16. The family raise concerns that despite Ms S having a fall at home in December, the GP did not carry out any review of her living situation or how she was coping at home alone. Further to this, they are concerned that because the GP carried out Ms S’s appointments over the phone, they were not aware of her circumstances at home.
17. In response to the complaint, the Practice explained that Ms S was given treatment and advice following her fall at home. It noted she reported her back pain was improving in early January, and so they discussed the importance of treating osteoporosis to try and prevent fractures.
18. The Practice explained that following the paramedic assessment for leg ulcers, the district nursing team were seeing and assessing Ms S, and the integrated care team were involved. They had been discussing further support for Ms S regarding self-care and a cleaner, as well as a referral to social services. Ms S had said she would prefer to arrange this herself.
19. The Practice explained that there is an entry from the district nurses (separate service) dated 25 February 2023, which notes Ms S was referred to a community support worker for occupational therapy and physiotherapy services to help with her mobility. Ms S became critically unwell before her situation was able to be further reviewed.
20. Ms S had a telephone appointment with her GP on 20 December 2022. She reported that she was experiencing back and hip pain, after sneezing and falling off her chair onto the hard floor the week prior. Ms S explained she could weight bear by holding onto furniture and was taking paracetamol and ibuprofen to control her pain. The GP prescribed co-codamol, and advised Ms S of red flag symptoms and to get back in touch if she had any further deterioration or could not tolerate the medication.
21. The NICE CKS for lower back pain advises clinicians to exclude an underlying cause and assess for prognostic indicators to help guide management. This includes asking about the site and type of the pain, any red flag symptoms which indicate a serious underling cause, the impact on daily functioning. It also includes examining the person to assess their gait, posture, and spine for deformity, palpate for localised spinal tenderness and decreased range of movement. An examination should also assess for any red flag signs which may indicate a serious underlying cause.
22. The CKS explains that where a person presents with low back pain following an assessment, an emergency hospital admission or specialist referral should be arranged if there are red flag symptoms or signs suggesting a potentially serious underlying cause, or if another underlying cause for symptoms is suspected.
23. Potentially serious conditions causing back pain, such as a spinal fracture, can present with the following red flags:
• A sudden onset of severe central spinal pain which is relieved by lying down • A history of major trauma, minor trauma, or even just strenuous lifting in people with osteoporosis • Structural deformity of the spine • Point tenderness over a vertebral body
24. The patient should be offered advice on sources of information and support and offered reassurance and advice on self-management strategies. Examples of this include encouraging the person to keep active and consider the short-term application of local heat, as well as offering referral or self-referral to physiotherapy.
25. Clinicians should advise on drug treatment options for symptom relief if needed, and if needed, patients should be advised to use an over-the-counter nonsteroidal anti-inflammatory drug such as ibuprofen. If an anti-inflammatory medication is contraindicated, not tolerated, or ineffective, codeine can be used short-term.
26. If symptoms persist or are worsening after three to four weeks, the patient should be advised to seek urgent medical review if there are red flag symptoms or signs suggesting a potentially serious underlying cause.
27. When the patient is reviewed, the clinician should again consider emergency hospital admission or specialist referral (depending on urgency) if red flag symptoms are present. They should reassess the patient for an underlying cause for symptoms and assess their adherence and response to self-management strategies and drug treatments.
28. The GMC’s Good Medical Practice guidance states:
“You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must:
• Adequately assess the patient’s conditions, taking into account their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • Promptly provide or arrange suitable advice, investigations, or treatment where necessary • Refer a patient to another practitioner when this serves the patient’s needs”
29. Based on the notes from this appointment, we consider Ms S had red flag features of a spinal fracture. She had suffered a minor trauma (falling of the chair), had known osteoporosis (which was not yet being treated), and severe pain following the minor trauma.
30. Because of this, we consider Ms S should have been seen face-to-face so that she could have been examined to determine if she had point tenderness over a vertebral body, or a structural deformity. Our adviser added that consideration should also have been given to arranging an X-ray.
31. For this reason, we consider there are indications of a service failure as Ms S was not adequately assessed in line with the NICE CKS and GMC guidance. We cannot see from the records that any consideration was given to the possibility of a spinal fracture, and Ms S was therefore not examined in person or referred on for further investigation. We will address the impact of this later in our report.
32. On 30 December, Ms S reported her pain had improved slightly. She did not report any other red flag symptoms. Ms S was advised to take naproxen instead of ibuprofen and increase her dosage of co-codamol. The GP also provided safety netting advice regarding where to seek medical attention out of hours and advised Ms S to make a physiotherapy appointment in the new year. We consider the advice given in this appointment was in line with the guidance outlined in the NICE CKS on lower back pain which is detailed above.
33. Ms S had an appointment on 13 January to discuss medication for her osteoporosis. She reported that the naproxen was helping her back pain, but it was still difficult to mobilise. The GP advised that if the back pain was not improving or remained sore in six weeks’ time to call for a review, as she may need an X-ray.
34. We can see that by 16 January, the pain had intensified. Ms S told her GP she was unable to leave the house and was mobilising by holding onto furniture. Ms S also reported that the friend who would normally come and help her out was no longer able to do so. Based on this information, this indicated a deterioration in her presentation with regards to pain management and mobility.
35. The GP prescribed additional pain relief and made an appointment with the physiotherapist for three weeks’ time. Ms S was advised she would need to attend the Practice for an examination if her pain was worsening.
36. Based on the information provided in the appointments on 13 and 16 January, we consider the GP should have arranged a home visit to carry out an examination of Ms S’s back pain. This was approximately four weeks on from the initial minor trauma, and there had been a worsening in symptoms. From the information she provided it was evident she was struggling to mobilise without support, and that it would have been difficult for her to attend the Practice.
37. We consider this was a service failure, as the GP did not carry out an adequate assessment or examination of Ms S’s presentation in line with the GMC’s Good Medical Practice guidance. We consider this indicates a further missed opportunity for intervention.
38. On 10 February, Ms S had a telephone review with her GP. She reported ongoing back pain, and described how this was affecting her mobility. She explained she was unable to leave the house and was using a rail to mobilise around her house. Ms S also reported that she had developed ulcers on her calves as a result, but otherwise felt okay. It is noted that although she lived alone and had no contacts nearby, she was able to shop online and was managing to wash and dress herself.
39. The GP booked a paramedic home visit, made a further physiotherapy referral for Ms S’s mobility, and planned to make a district nurse referral for leg dressings (if needed). Ms S was seen by the paramedic for a home visit on the same day.
40. We cannot comment on the actions of the paramedic during this home visit as this was a service run by Primary Care Sheffield as part of additional winter pressures provision, and this organisation is not part of our investigation.
41. The paramedic reported that Ms S had ulcers on her legs and had been experiencing yellow discharge. There was no pain on palpitation, and she had no signs of blisters. The paramedic recorded that they gave worsening advice and contacted the GP to arrange a course of antibiotics.
42. We consider some of the actions taken by the GP following this appointment were in line with the NICE CKS for lower back pain, as Ms S was referred again to the physiotherapy team. However, there was no review of Ms S’s analgesia despite her reporting ongoing back pain and that she was unable to tolerate naproxen, and she had still not had a physical examination of her spine despite reporting a worsening of symptoms. We consider this indicates a further missed opportunity for intervention.
43. Ms S had a telephone appointment on 21 February 2023 and reported to the GP that she had been unable to tolerate the antibiotics. Ms S thought she had been referred to the district nurses but had not been seen by them. The GP recorded there was no referral in the notes. Ms S also advised she was able to mobilise around the house by holding on to furniture, and she was still unable to leave the house. The GP prescribed alternative antibiotics and referred Ms S to the district nursing service.
44. The referral to the district nursing service was to address the ulcers on Ms S’s legs and we consider this referral was in line with the GMC’s Good Medical Practice guidance. No action appears to have been taken in response to Ms S’s back pain, however, we recognise she was awaiting a physiotherapy appointment and so specialist support had been arranged in line with the NICE CKS guidance. Despite this, there had still been no physical examination of Ms S’s spine, which we consider was a missed opportunity to assess her injury.
45. Ms S was seen by the district nursing team on 24 February. It was noted that Ms S was unable to attend to her bathing needs as she could not access her shower, and consequently she had not washed or changed her clothes for weeks. Ms S agreed to contact social services for a care package and advised she would arrange a cleaner. The district nurses also reported that there was dog faeces on the floor in the house.
46. The records also show us that the district nurses made a request to the GP to contact Ms S regarding a visit to assess her therapy needs so she could regain some independence and they also made a referral to the integrated care therapy team. We are unable to comment on the actions of the district nurses as they are provided by a separate organisation and are not involved in this complaint.
47. Ms S received a letter from the community therapy team on 26 February advising that she had been placed on a waiting list for therapy in her home environment.
48. A second referral was made to the integrated care team by the GP on 27 February 2023. The referral form details that the district nursing team had been visiting her, but as her ulcers had healed/dried they were no longer required. The GP explained Ms S’s recent history of falls and reduced mobility, and the difficulties she was having with activities of daily living. An appointment with the team was booked for 8 March 2023.
49. We consider the GP acted in line with the GMC’s Good Medical Practice guidance by making this referral, as Ms S was referred on to a service which was best placed to meet her additional needs at that time.
50. Overall, we have identified service failures in relation to missed opportunities to thoroughly assess Ms S’s lower back pain. We consider due to her level of pain, her reduced level of mobility and lack of social support, this should have prompted the consideration of a home visit.
51. The first instance was the appointment of 20 December. Ms S had red flag symptoms of a possible spinal fracture and should have been examined in person or referred for further investigations. We also consider home visits were indicated during the appointments of 13 and 16 January, in the next review with the GP on 10 February when Ms S’s condition had not improved and her mobility continued to be significantly reduced, and lastly when Ms S reported a similar situation in the appointment on 21 February.
52. We will address the impact of this in the next section of our report.
Impact
53. Our adviser has confirmed that even if Ms S had been seen face-to-face and an X-ray had shown a spinal fracture, the treatment Ms S received would not have changed. She would have been managed in the community with pain relief and physiotherapy, in the same way as she was treated for her pain. For this reason, we are satisfied that the missed opportunity to examine Ms S face-to-face did not have an impact on the management of her lower back injury.
54. However, we consider if home visits had taken place to assess her back pain, the GP may have become aware of Ms S’s living situation sooner than the district nurse referral on 24 February.
55. It is difficult to determine exactly how long Ms S had been struggling for at home based on the information in the records.
56. The GP notes from 10 February detail that Ms S was managing to wash and dress herself independently. Ms S had been reviewed by the paramedic home visit team on 10 February and no concerns were detailed in the notes from this visit.
57. However, the district nurses report from 25 February details that Ms S had not been able to wash or change her clothes for weeks, which indicates that this had been an ongoing issue.
58. The referral to the integrated care team details that Ms S had suffered from two falls, one in December 2022 and one in January 2023. Since those falls, Ms S had been unable to go upstairs. She had explained that she was unable to use her own bathing facilities and was struggling to dress/undress without being in pain.
59. The ambulance report from 3 March details that paramedics had suspicions of months of self-neglect, and it was reported that her sofa was “sodden” with blood and/or faeces. Additionally, a report from Ms S’s dog walker/friend stated she had been declining for a few months.
60. Based on this information, it would appear Ms S had been struggling since the time of the fall, and this had continued to worsen as time went on, particularly in the time between the paramedic visit on 10 February and the district nurse visit on 24 February.
61. We consider that if home visits had been carried out sooner, and as early as 20 December, this may have led to the GP having a discussion with Ms S about what support could be offered or put into place with her, like the conversation prompted by the district nurses on 24 February.
62. We consider it is important to take into consideration that when the district nurses suggested making referrals for assistance at home, Ms S reported she was happy to do this herself. This indicates she had the capacity to contact the relevant organisations to request help, and we consider she likely would have made the same agreement with the GP to contact them herself.
63. However, we consider Ms S would have been referred to the integrated care team sooner than she was, meaning she would have been seen by this service prior to her death. This may have meant she had some additional support in place to assist with her activities of daily living.
64. We have discussed this with our adviser, and we do not consider this would have had an impact on the eventual outcome of the case, as Ms S suffered from a gastrointestinal bleed of an unknown cause which would not have been prevented by additional social support in the community.
65. Despite this, we recognise that there was a missed opportunity for Ms S to have additional social support. We consider that, upon learning of Ms S’s death and living circumstances, this would have provided the family with more reassurance that her care providers were aware of her living situation and were taking steps to put the appropriate support into place for her.
66. In response to the complaint, with regards to telephone appointments, the Practice explained that by January 2023 patients were given the choice of what type of appointment they preferred. It agreed that it is unfortunate to not always know firsthand knowledge of people’s personal circumstances and that seeing patients directly is more effective than a phone call. The Practice explained it has moved almost completely back to face-to-face appointments as they are more effective.
67. Whilst the Practice’s response acknowledges the benefits of face-to-face appointments and explains it has moved almost completely back to seeing patients in this way, we cannot see that there has been any acknowledgement of the service failures we have identified in this report, nor the impact they have had on Ms S and her family.
68. For this reason, we are making recommendations to the Practice to put things right and address this.