Dorset Healthcare University NHS Foundation Trust

5. Mrs F complains that when her grandmother, Miss R, attended an appointment at the Trust’s Out Of Hours (OOH) Treatment Centre on 19 August 2023, the doctor did not physically examine Miss R or take her observations, failing to identify her infection or need to attend the accident and emergency department (A&E) for admission.

6. Tragically, Mrs F found her grandmother deceased at home the next day. Mrs F says her grandmother died avoidably, as a direct result of these failings in her care. Mrs F has been deeply affected, needing to seek counselling for post-traumatic stress disorder.

7. To resolve her complaint Mrs F would like the Trust to acknowledge its failings, apologise for their impact, and ensure action is taken so these failings do not happen again. She also seeks a financial payment in recognition of the impact of these failings.

8. Miss R called 111 on the morning of 19 August 2023. She reported symptoms of nausea, weakness, diarrhoea and loss of bowel control for the past six days. Miss R was 77 years of age and had a known diagnosis of metastatic ovarian cancer (cancer originating in the ovary that has spread to other parts of the body).

9. Miss R was assessed over the phone by a 111 clinician. They noted that Miss R reported a frequent urge to pass urine, incontinence when mobilising, and she was struggling to eat due to her nausea. The 111 service arranged a face-to-face appointment for Miss R at the Trust’s OOH treatment centre for later that morning. The 111 clinician’s notes were sent to the GP at the OOH centre prior to Miss R’s appointment.

10. Miss R attended the appointment along with Mrs F and Mrs F’s father. The GP noted Miss R was unwell with urgency to pass urine, and only passing a small amount. The GP noted Miss R had left loin pain (around the belly button and the left side of the body), no fever, that she had nausea, was unable to eat and felt sick after drinking water.

11. The GP tested a urine sample which was positive for urinary tract infection (UTI). The GP treated Miss R’s symptoms as a UTI, prescribing antibiotics and anti-sickness tablets to help her nausea. The GP noted giving safety netting advice, advising Miss R to go to the hospital’s A&E if her symptoms did not improve.

12. After the appointment, Miss R returned home. Mrs F visited the following morning and very upsettingly, found Miss R deceased. A post-mortem was performed and found the cause of her death was peritonitis due to her cancer. Peritonitis is an inflammation of the peritoneum, the tissue that lines the abdomen, caused by injury or infection.

13. Mrs F complained to the Trust. In its response to the complaint, the Trust said considering Miss R’s symptoms, an abdominal examination and a full set of observations were clinically appropriate. It explained the actions the GP did take, confirming these actions were not done. Remaining unhappy with this response, Mrs F asked for our further consideration.

17. Mrs F complains that the OOH GP did not physically examine Miss R or take her observations. At the point Mrs F brought this complaint to us, the Trust had already accepted these as failings.

18. When we spoke with Mrs F, she told us she was accepting of the acknowledged wrongdoing with these aspects of her grandmother’s care. She said she remained of the strong view that had her grandmother’s infection and her need to attend A&E for admission been identified, her grandmother would not have died.

19. We have focused our consideration on this remaining concern. Having considered this very carefully, we cannot say that Miss R would not have died, if the acknowledged failings had not happened. This is because we cannot say that taking observations and a physical examination would have led to a different management plan or outcome.

20. We spoke about this with our advisers and carefully considered the information we have from Miss R’s post-mortem. Our advisers all agree that even with post-mortem information, we have no way of knowing what Miss R’s observations would have been at the time of the OOH appointment. We cannot know whether these would have been within the normal range or not.

21. Even had they been outside of the normal range, Miss R had tested positive for a UTI and she had a known metastatic cancer. Our Lead Clinician said if abnormal findings had been made on observation, these could reasonably have been ascribed to these known conditions. These alone would not necessarily have changed the management plan. We cannot say that taking Miss R’s observations would have resulted in her peritonitis infection being identified or any need for A&E admission, as Mrs F suggests.

22. In terms of a physical examination, we know from the post-mortem that Miss R had a large tumour on her left ovary. Our GP adviser says it is likely this would have been felt had Miss R been physically examined. Miss R’s cancer diagnosis was known, and therefore even had this been felt, our GP adviser says this alone would not have required the GP to have directed Miss R to A&E or suggested the need for hospital-based care.

23. We note Miss R reported left loin pain and we have considered this carefully. We cannot know how Miss R would have reacted to physical examination, in terms of whether she would have reported mild pain, moderate pain, or severe pain.

24. From the evidence, our Lead Clinician suggests there is little doubt that Miss R’s abdomen would have been painful. We therefore think it likely she would have reported some pain had she been physically examined. Yet, it remains we cannot know exactly where this would have been located or how severe Miss R would have reported it to be.

25. We also cannot know how any report of pain would have been interpreted by the doctor. This is important, considering the known cancer diagnosis and finding of UTI. Our Lead Clinician explains that palpating (touching with hands) the area where the ovarian tumour was could have caused pain, simply because of the tumour itself. Further, UTI can also cause lower abdominal pain. Had Miss R reported pain on palpation, this could reasonably have been considered the result of her cancer and/or her positive test of UTI.

26. The GP treated Miss R’s symptoms as UTI, supported by the positive test result, prescribing antibiotics and giving safety netting advice. Whilst we know the GP failed to perform observations and physical examination, it is apparent from the information considered and the urine test done, the GP did not think Miss R was so unwell that she needed hospital care. Our Lead Clinician explains it is widely acknowledged that unless necessary, it is best for older people not to go into hospital, as there are risks associated with hospital admission in itself.

27. We are left not knowing whether findings on observation and physical examination would have changed anything in terms of Miss R’s onward management. It is possible that the decision for Miss R to return home may have remained appropriate, even had observations and a physical examination taken place.

28. We recognise this leaves Mrs F not knowing, and we acknowledge the distress this has caused. We must acknowledge there are other uncertainties that form part of our consideration, including not knowing the course or timing of events, even had A&E attendance been advised.

29. Very sadly, mortality rates from peritonitis can be up to 60%. Miss R’s peritonitis on post-mortem was described as severe, meaning it would have been advanced even at the point of her OOH attendance. Our surgical adviser says this means sadly in her case, this would have carried a higher mortality risk.

30. We recognise there are many unknowns. It remains we cannot say anything different would or should have happened, if the acknowledged failings had not taken place. We cannot say Miss R would not have died when she did, had her observations and a physical examination been done.

31. We are satisfied the Trust has taken sufficient action in response to the acknowledged failings in line with Our Principles. We are left without indications of any unremedied injustice.

32. We recognise how important this complaint is to Mrs F. We recognise the intense emotional distress Mrs F has and continues to experience following these events and we in no way diminish how impactful this has been. We thank her for bringing her complaint for our consideration.

1. We have carefully considered Mrs F’s complaint about whether her grandmother, Miss R, died as a direct result of failings in her care at an appointment on 19 August 2023. We extend our sincere condolences to Mrs F as we recognise the loss of her grandmother in these circumstances continues to cause her considerable upset and distress.

2. Before coming to us, Mrs F complained to the Trust, and it accepted where things had gone wrong with Miss R’s care. We focused our work by considering Mrs F’s outstanding concern, of whether Miss R’s death was a direct result of the accepted failings in care.

3. We have carefully considered this concern, and do not find any clear indication this was the case. For this reason, we do not propose to investigate further.

4. We know from the information Mrs F sent us and from speaking with her, how important her complaint is and how much this experience has had an impact on her. We were very sorry to hear about her distress and we appreciate the details she kindly shared with us.