25. Before we decide whether we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong with regards to most issues Mrs A has brought to us. Where we have seen indications that something has gone wrong, we think the organisation has done enough to put right the impact of its’ actions. We explain our decision relating to each part of Mrs A’s complaint below.
The Practice
Telephone consultations
26. Mrs A says the Practice carried out telephone consultations and Mr A was prescribed antibiotics twice without physical review or further investigations which delayed his AML diagnosis and subsequent treatment. The Practice says Mr A was treated only once without physical review, during the first telephone consultation. The medical records show there were three telephone consultations, the first consultation on 21 December 2021 was the only telephone consultation which did not result in a physical review of Mr A. Physical reviews were carried out following the telephone consultations on 10 January 2022 and 13 January 2022.
27. We have therefore based our consideration of Mrs A’s concerns on the first consultation as this is the only one which did not lead to a physical review. We have considered this appointment in line with the NICE guidance, ‘Cough (acute): antimicrobial prescribing’. This says doctors should consider an immediate antibiotic prescription (preferably after a face-to-face clinical examination) for patients who have an acute cough and are at higher risk of complications.
28. Mr A would be considered at higher risk as he was over 80 years old at the time of the consultation. We therefore have not seen indications of failings in the decision to prescribe antibiotics at this time.
29. Next, we considered that Mr A did not have a face-to-face appointment. In line with the above guidance, it is preferable that a patient has a clinical examination in person.
30. We can see from the records the GP offered to see Mr A in person during the telephone consultation, but Mr A preferred to have antibiotics prescribed over the telephone. There is nothing to suggest Mr A did not have capacity to make this decision about his own care, in line with the ‘Mental Capacity Act 2005’. Our GP adviser also notes it is common practice to prescribe antibiotics without a face-to-face appointment.
31. With this in mind, have seen no indications of failings in the prescribing of antibiotics over the telephone. We consider this was in line with the NICE guidance.
Chest infection diagnosis
32. Mrs A is concerned Mr A’s AML was misdiagnosed as a chest infection. She says the AML diagnosis may have been made sooner if he had been seen by the GP when he first presented to them with a persistent cough, along with his recent history of cancer. She says Mr A was diagnosed with AML shortly after he went to hospital in an ambulance on 13 January 2022, following months of infection. She is particularly distressed that he was diagnosed in an emergency setting and said it came as a complete shock to her and her family. We do not underestimate the family’s distress at receiving this diagnosis following Mr A’s emergency admission on 13 January 2022.
33. The NICE guidance ‘Suspected cancer: recognition and referral’ provides information about when leukaemia should be suspected. This says:
‘Leukaemia in adults 1.10.1 Consider a very urgent full blood count (within 48 hours) to assess for leukaemia in adults with any of the following:
• pallor • persistent fatigue • unexplained fever • unexplained persistent or recurrent infection • generalised lymphadenopathy (swollen lymph glands) • unexplained bruising • unexplained bleeding • unexplained petechiae (tiny purple, red, or brown spots on the skin • hepatosplenomegaly (swelling of the liver and spleen).’
34. Our GP adviser said during the first consultation on 21 December 2021, Mr A’s symptoms did not meet any of the criteria listed in the above guidelines. The records of this consultation show Mr A reported he had a tickly cough for six weeks which was not clearing, a constantly blocked nose and pain in the left side of his chest when he coughed which was not related to exercise. He felt there was some phlegm in his chest, but he was unable to bring it up. The symptoms were worse at night. He was also eating, drinking and passing urine.
35. At the second consultation on 10 January 2022, which was face-to-face following a telephone consultation, Mr A was examined and all his observations were within normal levels. The ongoing cough was the main symptom which had not improved. We have not seen anything which would prompt the GP to suspect AML, in line with the above guidance.
36. We have also considered whether additional tests should have been carried out given Mr A’s symptoms. Our GP adviser told us there was nothing to suggest the clinician should have arranged a blood test to check for AML and we have not seen anything to suggest other additional tests were required. It may be helpful to know that even if a blood test had been done on 10 January 2022, the results would have been received on 11 January 2022. This unfortunately would not have made any difference to what happened to Mr A. He would have been diagnosed two days earlier at most, which would not have resulted in a more favourable outcome. We hope this provides some reassurance for Mr A's family.
37. We fully appreciate Mrs A’s concern that her father’s AML could have been diagnosed sooner. Overall, we have not seen indications of failings in the consideration of Mr A’s symptoms and have not seen evidence to suggest AML should have been suspected during this time.
Consideration of squamous cell carcinoma
38. Mrs A told us Mr A was diagnosed with squamous cell carcinoma in 2021 and subsequently had a growth removed in September that year. This is a type of skin cancer, which forms in the middle and outer layer of the skin. This causes red nodules, scaly, red patches on lips or inside the mouth, open sores, or wartlike sores. Mr A developed his persistent cough around four weeks after this procedure. Mrs A feels this diagnosis was not taken into consideration and finds this particularly concerning.
39. Our GP adviser said there is no mention of squamous cell carcinoma in the records we have been provided. He said the records show Mr A was diagnosed with basal cell carcinoma. This is a type of skin cancer which develops in basal cells, a type of cell within the skin which produces new skin cells. This causes a pearly white, skin-coloured or pink bumps on the body especially on the face and ears.
40. Basal cell carcinoma is a different type of cancer to AML and there is no link between these two cancers. Therefore, the basal cell carcinoma diagnosis was not relevant to Mr A’s AML symptoms. We can also see the GP noted Mr A had a skin cancer removed eight weeks earlier, which would suggest they were aware of this and had reviewed Mr A’s records during the appointments.
41. Overall, we have not seen indications of failings in relation to the consideration of Mr A’s previous cancer diagnosis of basal cell carcinoma.
EMAS
Categorisation of emergency calls
42. Mrs A complains Mr A had to wait seven hours for an ambulance due to the initial call being incorrectly triaged because his septic marker and AML diagnosis were not taken into consideration.
43. Ambulance trusts categorise how quickly they respond to 999 calls based on urgency. Category 1 is immediately time critical, for example a cardiac arrest; Category 2 is emergency, for example a patient having a stroke or a seizure; and Category 3 is urgent, for example a patient going into labour.
44. The initial call to EMAS was categorised as Category 3 (urgent). This was later re-categorised to Category 2 (emergency) following the call at 7.16pm. Mrs A feels the initial call should have been a Category 2.
45. Our paramedic adviser explains calls are categorised using a telephone triage system. This uses algorithm flowcharts that the call handler goes through and usually the way a call is triaged is down to how certain questions are answered. The key questions that are considered are whether the patient is conscious and breathing. We note Mr A was conscious and breathing at the time of both the calls.
46. Sometimes the triage will identify that further input is needed from a clinician. This happened in Mr A’s case and a clinician called him to discuss his symptoms further. The clinician noted Mr A’s NEWS (national early warning score) was 2. This is likely to have been used to categorise the sepsis markers and high temperature, and this led to the call categorisation being upgraded to a Category 2 during the call at 8.05pm with a clinician from the Clinical Assessment Team.
47. EMAS aims to respond to Category 2 calls within an average time of 18 minutes and in at least nine times out of ten, within 40 minutes. The ambulance arrived at the scene at 9.35pm which is 30 minutes from when the call was upgraded to category 2 and therefore within the timescales it works towards. We have reviewed the records and EMAS’ responses and consider the Trust did what it could to ensure an ambulance was sent as soon as practically possible.
48. Our adviser told us Joint Royal Colleges Ambulance Liaison Committee (JRCALC) are the guidelines that apply to everything paramedics do and there is nothing in JRCALC about triage or wait times. If there was less demand on the service at the time, Mr A might have received a quicker response, but beyond this, unfortunately there was not much the service could have done to dispatch an ambulance quicker to Mr A.
49. We have not seen indications of failings in the initial categorisation, in line with the triage system, and consider the call was appropriately upgraded following the clinician’s review of Mr A. We therefore have not seen indications of failings in how the ambulance was dispatched.
Consideration of symptoms and paracetamol
50. Mrs A complains the ambulance crew did not take into account that Mr A had paracetamol, which would have masked his high temperature.
51. The JRCALC says paracetamol should not be given solely for a high temperature, it should be given for pain with high temperature. This is because paracetamol may mask normal physiology and therefore treatment opportunities for sepsis might be missed. In essence, paracetamol can disguise that an individual is unwell.
52. NICE guidelines on ‘Suspected sepsis: recognition, diagnosis and early management’ say a high temperature is not the sole predicter of an unwell patient and to consider other factors too. We have considered the actions of the paramedics with this guidance in mind.
53. The JRCALC says ambulance crews should maintain ‘a high index of suspicion… particularly in a patient who has recently undergone chemotherapy and has an increased temperature’. Such patients may have an increased risk of ‘deteriorating rapidly’ and may not necessarily have a raised temperature.
54. We also note Mr A had received chemotherapy in the past month. This would have put him at higher risk of contracting neutropenic sepsis.
55. The records show the ambulance crew identified Mr A was on an end-of-life pathway and had anticipatory medications in place. These are medicines prescribed in advance to manage symptoms likely to occur in the last days of life.
56. The ambulance crew took Mr A’s observations which were recorded as ‘no bleeding’ in relation to catastrophic haemorrhage, the airway is recorded as ‘patent’ (open and unobstructed), ‘C-spine cleared’ is recorded, Mr A’s breathing was adequate and in terms of circulation, Mr A’s pulse is recorded to be ‘present’. In relation to disability, it is noted that Mr A was alert to time, person, situation and place.
57. These observations were noted to be within the normal parameters. Therefore, although his temperature may have been masked by the paracetamol administered, there were no other clinical markers indicating severe infection at that point. Mr A was noted to be alert, stated he had no pain and felt well in himself. With this in mind, we consider the assessment and observations undertaken by the crew were in line with the NICE guidelines and JRCALC guidance. This is because the ambulance crew considered all of Mr A’s symptoms appropriately and took note of his medical history.
58. Therefore, we have not seen any indications of failings in the assessment of his symptoms and observations taken by the ambulance crew.
Decision not to go to hospital
59. Mrs A says the ambulance crew did not inform Mr A of the severity of his condition for him to make an informed decision not to go to hospital. She said he was exhausted by the time the ambulance arrived and he said he did not want to go with the crew. She is concerned the paramedics accepted his decision, despite seeing and hearing how unwell he had been and with knowledge of his medical history and AML diagnosis.
60. Informed consent is at the heart of decision making. The ‘Mental Capacity Act 2005’ (the MCA) is central to this and covers patient decision making. Principle 1 of the MCA states that every adult has the right to make his or her own decisions and must be assumed to have capacity to do so unless it is proved otherwise. This means you cannot assume that someone cannot make a decision for themselves just because they have a particular medical condition or disability.
61. The ambulance crew were happy that Mr A’s observations were within the normal parameters, and he seemed well in himself. We have not seen anything to suggest he did not have capacity to make a decision about his care.
62. JRCALC also includes guidance on end-of-life care. This mentions establishing care based on a patient’s preferences and in a holistic manner. It says ‘unlike conventional areas of pre-hospital care which are to save life and rely on algorithms, end-of-life care seeks to provide supportive care using a holistic approach tailored to each individual’.
63. Our paramedic adviser said the decision making when considering a terminally ill patient is based more on establishing what their wishes are. We can see Mr A had a Recommended Summary Plan for Emergency Care and Treatment (RESPECT) form and the ambulance crew considered it and discussed Mr A’s wishes.
64. We have not seen indications of failings in the actions of the ambulance crew. We consider they appropriately took Mr A’s observations and then made a plan based on his wishes. We have not seen indications of failings in the decision to allow him to manage his symptoms in the community. We consider this was in line with the MCA and JRCALC guidelines.
The Trust
Communication and updates
65. Mrs A complains about the lack of communication and updates from the Trust.
66. The NMC guidance ‘The Code’ provides information about communication. This says nurses ‘must take reasonable steps to meet people’s language and communication needs, providing, wherever possible, assistance to those who need help to communicate their own or other people’s needs.’
67. The records show there were frequent communications between the Trust and Mr A’s family, particularly with Mrs A. There were various types of communication used including emails and telephone calls with many members of the ward staff including the medical team at various points of the day and in the evening. This was well documented.
68. Mrs A lives in New Zealand meaning the time difference is significant. She telephoned the ward and requested daily updates and the ward was unable to comply fully with this. We consider this is reasonable considering the time difference.
69. The nursing notes say communications by email were offered and used as a method of communication to help mitigate the complications of the time difference. There is no professional guidance to say that communications to family that lives abroad should be different to communications with family within the UK.
70. Consent from the patient to share information with family members is always required and this was obtained from Mr A in order for the Trust to communicate with Mrs A. He said he wanted written communications to be sent to Mrs A and he would also communicate with her. The Trust followed Mr A’s preferences.
71. In relation to respecting people’s right to privacy and confidentiality, ‘The Code’ says, ‘to achieve this you must share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand’.
72. Our nurse adviser told us the Trust adhered to this guidance as it shared information regularly with Mrs A throughout Mr A’s care in a patient sensitive way.
73. The evidence and records indicate the Trust provided updates and communicated regularly with Mrs A’s family and Mrs A in particular, and this is in line with ‘The Code’ as explained above. Whilst we have not seen indications of failings in relation to this issue, we recognise what a difficult time this will have been for Mrs A.
Communication of discharge/discharge summary
74. Mrs A complains the Trust did not tell Mr A’s family he was being discharged on 28 February 2022, leaving him sat in the discharge lounge alone for hours. She also complains that on 25 May 2022, the Trust did not communicate Mr A’s discharge to her or how this decision was reached.
75. Our nurse adviser told us the original planned discharge date was 25 February 2022. The nursing notes say Mrs A was updated by a member of staff at the Trust on 25 February 2022, therefore the discharge was communicated appropriately as Mrs A appears to be the spokesperson for the family. At 3.15pm on 25 February 2022, there is a nursing record which says, ‘medical plan- not for home today, discharge cancelled’.
76. The communication to Mrs A on 25 February 2022 is the only one about discharge that has been recorded. Our nurse adviser says Mrs A will have therefore been aware that Mr A’s discharge was going to happen on this day. However, the discharge happened three days later, on 28 February 2022.
77. There were also clear communications with Mr A about his needs on going home. On 4 February 2022 his medical records document that he was asked if he had any worries about going home, he said he had no worries other than getting into hospital for his treatment and he was reassured that transport would be booked. Mr A said he had facilities downstairs and that his wife would support him. He was reassured that a stairs assessment would be done before he went home.
78. We considered whether The Trust should have provided the discharge summary to Mrs A. The Trust’s internal discharge policy does not say the discharge summary needs to be given to family members when a patient has capacity and is going home by hospital transport.
79. The discharge summary was provided to Mr A and a copy was sent to his GP; this is in line with the Trust’s discharge policy. As such, we have not seen any indications of failings in relation to this concern.
Anti-sickness medication/food in the discharge lounge
80. Mrs A complains Mr A was not provided food or anti-sickness medication before his chemotherapy, leading him to vomit in the discharge lounge on 28 February 2022.
81. In terms of the anti-sickness medication, our nursing adviser said Mr A was prescribed ondansetron (used in prevention or treatment of sickness associated with chemotherapy, radiotherapy or surgery), but this was not signed for on the drug chart. As it was not signed for, we would have to assume it was not given to Mr A.
82. In line with the BNF guidance, ondansetron should have been given one to two hours before Mr A’s chemotherapy treatment. As Mr A vomited in the discharge lounge and the ondansetron had not been signed for, we consider it is more than likely that ondansetron had not been administered. This means it appears the Trust did not act in line with this guidance.
83. With this in mind, we considered whether the Trust has acknowledged and addressed this concern. The Trust’s response of 1 December 2022 said there was no documentation to state whether anti sickness medication had been given to Mr A before his chemotherapy and, because he vomited, it might indicate it was not given. It apologised for this.
84. Based on the evidence, it appears likely that ondansetron was not given to Mr A which caused him to vomit in the discharge lounge. Whilst this will have been unpleasant, we can see the Trust has explained what happened and apologised.
85. We consider this is in line with our ‘Principles of Good Administration’ which say, ‘when mistakes happen, public bodies should acknowledge them, apologise, explain what went wrong and put thing right quickly and effectively’. We consider the Trust has done enough to put right the impact of this concern and do not see indications to suggest further action is needed.
86. We also considered if Mr A was given food in the discharge lounge. Mr A arrived in the discharge lounge at 11.32am and regular checks were completed thereafter. Further details about the timing of when he was offered food and drink are set out below:
• 11.32am- refused • 1pm- declined • 2.20pm- declined • 4pm- tea.
87. The evidence suggests Mr A was offered food and drink therefore we can see no indication that something went wrong in relation to this issue.
Communication about IV antibiotics – May admission
88. Mrs A complains that on 25 May 2022, the Trust did not communicate the decision to stop Mr A’s IV antibiotics and his subsequent discharge to her or how this decision was reached.
89. Our general physician adviser told us there are documented discussions in the records with Mr A and his family members during visits by the haematology and palliative care clinical nurse specialists. The discussion on 19 May 2022 included details about there being no current requirement for discharge to a hospice and that the plan was to discharge home with support in place. The discussion on 20 May 2022 included reference to the infection and antibiotic treatment that was in place at that time.
90. There are no documented discussions between the medical team and family when Mr A had completed the course of IV antibiotics and was to be discharged home. However, there is no reason to believe from the information in the records that Mr A did not have capacity to understand and make decisions relating to his medical care at that time.
91. NICE guidance ‘Patient experience in adult NHS services’ quality statement 5 about ‘preferences for sharing information’ says, ‘People using adult NHS services have their preferences for sharing information with their family members and carers established, respected and reviewed throughout their care’.
92. We can see Mr A’s family was kept up to date in general. We can also see that Mr A had capacity for making decisions so we cannot say there are any failings in not discussing every medical decision with his family.
93. The GMC guidance ‘Good medical practice’ also includes guidance for doctors around communication. This says, ‘you must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’. We consider this happened in Mr and Mrs A’s case, and this is demonstrated by the discussions with different family members that are documented in Mr A’s clinical records.
94. With this in mind, we have not seen evidence of failings in the Trust’s communication with Mrs A and Mr A’s family.
Discharge decision
95. Mrs A says the decision to discharge Mr A on 25 May 2022 was a mistake because he was not well enough to go home. She feels she was not given an opportunity to challenge this decision.
96. Our general physician adviser told us the clinical records show Mr A was reviewed by a consultant and the medical team on the day of his discharge. His observations showed no cause for concern. He was therefore considered to be medically suitable for discharge. A plan for support at home was also discussed with Mr A and his sons.
97. We consider the above assessment and decision for discharge was in line with GMC guidance ‘Good medical practice’. This says doctors ‘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 account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient’.
98. The Trust’s complaint response also refers to an occupational therapy assessment where Mr A demonstrated being independent with daily activities and that Mr A voiced a wish not to be discharged to respite care. There is no indication from the clinical records that a 24-hour care environment was required on discharge.
99. Whilst the decision to discharge Mr A was appropriate and in line with guidance, we can see how Mrs A would have been upset at not being able to discuss her concerns about his decision.
100. In the Trust’s response dated 1 March 2023, it acknowledged and apologised for the distress caused to Mrs A due to not having the opportunity to discuss her concerns relating to Mr A’s discharge. We consider this to be in line with our ‘Principles of Good Administration’ which says, ‘when mistakes happen, public bodies should acknowledge them, apologise, explain what went wrong and put thing right quickly and effectively’. We consider the Trust has done enough to address this concern and do not consider further action is needed.
101. Based on the evidence we have seen, we have not seen indications of failings in the decision to discharge Mr A, and where there was a lack of communication with Mrs A, we see the Trust has already addressed this.
Switch from IV to oral antibiotics
102. Mrs A says Mr A was switched to oral antibiotics without these being trialled before his discharge. She says Mr A did not respond to oral antibiotics and therefore needed to be readmitted to the Trust.
103. We can see Mr A received IV antibiotics for nine days to treat neutropenic sepsis. Our general physician adviser explains this is a prolonged course of treatment, and clinically Mr A appeared to improve as a result of this. The NICE guidance ‘Neutropenic sepsis: prevention and management in people with cancer’ does not include any advice for patients to have a trial of oral antibiotics whilst in hospital. Rather, it highlights the risk of hospital acquired complications, especially in light of Mr A’s advanced disease and his prognosis. The oral antibiotic prescribed on his discharge was appropriate in line with this guidance.
104. The NICE guidance further says to ‘offer discharge to patients having empiric antibiotic therapy for neutropenic sepsis only after the patient’s risk of developing septic complications has been reassessed as low by a healthcare professional with competence in managing complications of anticancer treatment using a validated risk scoring system and taking into account the patient’s social and clinical circumstances and discussing with them the need to return to hospital promptly if a problem develops’.
105. Mr A met all this guidance in relation to his discharge.
106. Our general physician adviser said Mr A had AML which was no longer treatable, so a holistic approach to his treatment and care was appropriate, which would include a timely discharge from hospital.
107. We have therefore not seen indications of failings in the decision to switch Mr A from IV antibiotics to oral antibiotics. This decision appears in line with his symptoms, circumstances and the guidance above.
Conclusion
108. With regard to the apparent failure to give Mr A the anti-sickness medication and lack of communication with Mrs A, we consider The Trust has already done enough to put right the impact of this. In respect of the rest of Mr A’s care, there is no indication that anything went wrong and his treatment was in line with the relevant guidelines. We are therefore taking no further action on the complaints. We are sorry to hear how Mr A’s death impacted Mrs A and her family and we understand why Mrs A had questions about the care provided to her father. We hope that our explanations provide some reassurance to Mrs A and her family.