Mr L’s capacity
20. Mrs L says the Practice wrongly claimed her husband did not have capacity when he simply did not always like to talk to other people. The Practice says her husband did have cognitive decline.
21. The relevant standards are Good Medical Practice and the GMC’s ‘Mental capacity: ethical topic hub’. Good Medical Practice says doctors must listen to patients and take account of their views (paragraph 31). The mental capacity hub says doctors should start by assuming a patient has capacity and not to assume that what happens on particular occasions means a patient always lacks capacity. A person is deemed to have capacity if they can understand, retain and use relevant information and communicate their decisions.
22. We asked our adviser about this. We can see from the records the Practice had recorded Mr L had some cognitive decline. We can also see that the Practice often spoke to Mrs L rather than her husband, because he often indicated he did not wish to speak to medical practitioners, or was not well at the time. This is in line with Good Medical Practice, as the Practice was taking account of Mr L’s views when it spoke to Mrs L instead.
23. But we cannot see in his records that the Practice thought Mr L did not have capacity. We can see times in the records when he was actively involved with discussions about his health. Our adviser said the records did not show any amended information on Mr L’s capacity even after his falls in summer 2022, when it also spoke to him about his DNACPR. Our adviser said this would have been a likely time for the Practice to have changed its records if it felt Mr L did not have capacity, but it did not do so.
24. We understand Mrs L has strong concerns about how the Practice interacted with her husband. We appreciate this upset her at the time and afterwards. We have not seen indications the Practice assumed Mr L did not have capacity. His records do not say this was the case. We have not seen indications the Practice did not act in line with either Good Medical Practice or the Mental capacity: ethical topic hub. We have not seen indications it got something wrong here.
Mr L’s DNACPR
25. A DNACPR is a ‘do not resuscitate’ medical order which says not to attempt cardiopulmonary resuscitation (CPR) if that person’s heart stops beating. It is usually put in place because medical professionals feel the risks around attempting CPR on certain patients mean they would suffer more than by letting someone die naturally. Mrs L says the Practice wrongly kept in place a DNACPR decision on Mr L. She also thinks this impacted on whether it decided to send him to hospital on 8 February 2023 (we discuss her concerns around what happened on that date later in this statement).
26. The Practice says her husband’s conditions and medical record meant the DNACPR order was rightly in place. It says it explained to her why it felt her husband was frail and why CPR would not necessarily have produced a positive outcome for him if it had been needed. It said its records show it agreed in January 2023 to review the decision again a few months later.
27. The relevant standard for this is the GMC’s Cardiopulmonary resuscitation(CPR) professional standards. This says medical professionals should consider whether giving a patient CPR will enable them to die in a dignified manner, or in their preferred place of death. It confirms that attempting CPR can prevent a person dying, but can also lead to poor clinical outcomes. Where a medical professional considers the latter to be the case, they can put in place a DNACPR order (paragraphs 134 to 138).
28. The professional standards say patients can challenge an order (paragraphs 47 to 49). Patients can ask for a second opinion. However, the NHS website confirms that nobody has the right to demand CPR and so a DNACPR decision may not change if there is a good clinical reason for it (‘Do not attempt cardiopulmonary resuscitation (DNACPR) decisions’).
29. We asked our adviser about this. The medical records confirm the DNACPR decision was made by the hospital in July 2022 after Mr L had falls in June and July. This was because it felt his various medical conditions and frailty meant giving him CPR should his heart stop was likely to cause him unnecessary suffering. Our adviser said the records show the hospital discussed this with Mr and Mrs L in July 2022.
30. Our adviser said the Practice discussed the DNACPR with Mr and Mrs L as soon as it was aware of it. We can see from the records it held a meeting with them and arranged for further follow-ups. In January 2023 the Practice said it would review the DNACPR order for Mr L. Unfortunately, it was not able to do this because of Mr L’s death.
31. We can see how upsetting Mrs L found the DNACPR order for her husband. We appreciate her concerns over what this might have meant had he been readmitted to hospital. We can also see the Practice did not put this order in place. It would have been wrong for the Practice to just change the DNACPR decision when Mr and Mrs L complained about it. We can see it did discuss this issue with them and planned to review it. When we weigh up the evidence, we think the Practice acted in line with the relevant standards here. We have not seen evidence it got something wrong.
Mr L’s records and medication
32. Mrs L says the Practice failed to record her husband’s atherosclerosis (a condition where arteries become narrow and hardened and can lead to complications such as strokes) as it should have done. She says it should have discontinued his prescription of midodrine because it worsened his other conditions, especially his blood pressure. She says it should have followed up about Mr L not being prescribed aspirin and reversed that decision.
33. The Practice said Mr L’s various medical conditions meant the risk of him taking aspirin outweighed the benefits. It says he needed to take midodrine because of the different things which were wrong with him.
Mr L’s atherosclerosis
34. The relevant standard is Good Medical Practice. It says records should be accurate and legible and should include relevant clinical information (paragraphs 19 and 21).
35. We asked our adviser about this. They said the term atherosclerosis is not specifically mentioned in Mr L’s records. But they said Mr L’s condition was instead listed under the name cerebrovascular disease (a disease which affects blood flow to the brain), which first appears in 2014. Our adviser said the records could arguably have been a little clearer on this, but the Practice had recorded what was wrong with Mr L and the treatments he was having for it. This appears to be in line with Good Medical Practice.
36. Our adviser also said it is not clear that specifically listing atherosclerosis in the records would have made any difference to the Practice’s care and treatment of Mr L. We can see the Practice was aware of his issues and needs related to those. Recording ‘atherosclerosis’ would not have impacted on his medication, for example, as that was decided based on other reasons (which we discuss next).
37. We understand Mrs J’s concerns that the Practice had not specifically recorded Mr J as having atherosclerosis. When we weigh up the evidence, we can see it was aware of his condition and how this related to his treatment. We have not seen evidence this impacted on his care or treatment. The evidence indicates the Practice acted in line with the relevant guidance on this issue. We have not seen indications something went seriously wrong here.
Mr L’s medication
38. The relevant standards are NICE guidance 61 (‘Orthostatic hypotension due to autonomic dysfunction: midodrine’) and NICE guidance ‘Low dose aspirin’. NICE’s midodrine guidance says it improves postural blood pressure (especially for those who have large drops in blood pressure) and therefore helps people who are a high falls risk (page 3).
39. The NICE guidance on aspirin says it can be given to people who have had strokes, but should not be prescribed where people have had intracranial haemorrhage (bleeding on the brain) or are at risk of increased bleeding. It says aspirin should be prescribed to elderly people with caution. It also says an adverse effect of aspirin is it can increase bleeding time and tendencies.
40. We asked our adviser about this. They said Parkinson’s disease can mean a person’s blood pressure can go up and down greatly. This can particularly be the case when someone stands up. The records also show Mr L was high risk for falls and had had a number of these during 2022. Some of these were serious: in July he had a fall which led to bleeding on the brain.
41. Our adviser said the records do not indicate there was a reason for the Practice to stop Mr L’s midodrine medication. The medication helps to prevent and reduce the risk of falls, which were a serious and ongoing problem for Mr L. He was therefore a risk of him having another bleed on the brain, which could have been fatal.
42. Our adviser said Mr L’s risk of a fall and possible further bleed on the brain was higher than that of him having a stroke, as he was very high risk for falls. We can see from the records the Practice did ask for a second opinion about whether Mr L could be prescribed aspirin again, but it did not get a response. It is possible the Practice could have followed up further on this, but we cannot say it had completed its review of whether to prescribe him aspirin again because Mr L died. Our adviser said the Practice’s decision to not prescribe him aspirin again was proportionate and related directly to Mr L’s actual condition.
43. The records show his falls risk was very high in 2022. The records indicate its decisions to maintain his midodrine prescription and not restart Mr L on aspirin were made in line with the relevant guidance. It did not prescribe him aspirin because of his previous bleeding on the brain and continued to prescribe midodrine because of his blood pressure and related fall risks.
44. We appreciate Mrs L’s concerns about her husband’s medication. When we weigh up the evidence, we can see the Practice had to balance Mr L’s different conditions and needs when prescribing his medication. We have not seen indications it got something wrong here.
The GP visit on 8 February 2023
45. Mrs L says the Practice failed her husband when it made a home visit on 8 February 2023. She says the GP did not assess her husband as it should have done, did not provide appropriate care or treatment and did not provide any guidance to her about what else she should do. She also thinks it may have not referred him to hospital because of the DNACPR order.
46. The Practice says the DNACPR order was irrelevant as to whether it referred Mr L to hospital. It agrees the GP did not record the blood pressure reading Mrs L had taken for her husband earlier that day, but otherwise says the GP followed the relevant standards. It says his condition did not indicate he needed referring to hospital. It also says Mrs L told the ambulance paramedics her husband had been ‘better’ the day before he died.
47. The relevant standards are Good Medical Practice, Playing it safe – safety netting advice and the National Early Warning Score (NEWS) calculator. The NEWS calculator produces a score based on various pieces of evidence which advises a doctor as to what further steps they may need to take for a patient. This is because it determines how ill a patient is and whether they need to be transferred for more specialised or intensive care.
48. Good Medical Practice says doctors should give patients information they need to know (paragraph 32) and take account of and respect patients’ wishes (paragraphs 31 and 47). Playing it safe says doctors should give appropriate advice to patients with unresolved symptoms, so they know how to get further advice.
49. We asked our adviser about this. We can see from the records the Practice has accepted its GP did not record the blood pressure recording Mrs L had taken earlier and confirmed this was the case with Mrs L.
50. We looked to see if the GP not recording Mr L’s blood pressure would have had an impact on a decision whether to send him to hospital. When you add the blood pressure reading and relevant sepsis score for the day, Mr L scored as low risk on the NEWS calculator. This would not indicate the Practice needed to send him to hospital. As the Practice has held an investigation into what happened, acknowledged what it got wrong about its visit and demonstrated how it will improve its service regarding that issue, we would not expect it to do anything else to resolve that point.
51. Our adviser said Mr L’s other conditions also indicated that sending him to hospital may have caused him other difficulties which could have made his condition worse. We can see from his records that Mr L had told the Practice he wanted to stay at home where this was possible. The Practice had respected Mr L’s views in line with Good Medical Practice.
52. There is no indication in the records that the Practice did not send Mr L to hospital because he had a DNACPR in place. A DNACPR would only be actioned if a patient’s heart stopped beating. It does not mean a hospital would not give a patient other treatments. We cannot say Mr L having a DNACPR had any impact on the Practice’s decisions on 8 February.
53. We understand Mrs L feels the Practice could have given her more information about her husband’s condition. We can see from the records the Practice informed Mr and Mrs L that either of them should contact it again if it felt Mr L’s condition was deteriorating. Our adviser says this met the safety netting requirements as set out in Playing it safe. When we weigh up the evidence, we have not seen indications it did not act in line with the required standards here.
54. This was a truly terrible time for Mrs L whose much loved husband died on 10 February. We would like to thank her for bringing this complaint to us, which has highlighted some points around record keeping which should improve further GP practice. We hope our statement provides her with the explanations and comfort she is looking for.