The GP Practice failed to visit Mr B following his discharge from hospital on 21 October 2022 until after he died on 1 December 2022
10. The GMC guidance states doctors must provide a good standard of practice and care. When assessing, diagnosing or treating patients, doctors 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
• promptly provide or arrange suitable advice, investigations or treatment where necessary
• refer a patient to another practitioner when this serves the patient’s needs.
11. The remote consultations guidance says remote consultations may be appropriate when:
• The patient’s clinical need or treatment request is straightforward • You have access to the patient’s medical records • You can give patients all the information they want and need about treatment options by phone, internet, or video link • You don’t need to examine the patient • You have a safe system in place to prescribe • The patient has capacity to decide about treatment
12. The records indicate Mr B was discharged from hospital to his care home on 21 October 2022. While in hospital he was diagnosed with terminal lung cancer. Following a review by its multi-disciplinary team the hospital concluded the only care available to him at this point was palliative care. Palliative care is aimed at making the patient as comfortable as possible by managing pain and other distressing symptoms when they have an illness that cannot be cured.
13. The records indicate Mr B was seen in the care home on 22 October 2022 by the Community Reablement Team (social care professionals from the local authority) who did an extensive assessment of the support he required. The care home was also contacted by the Community Adult Speech and Language Team (specialist therapists from the local NHS Trust) who provided advice and support for Mr B’s swallowing and diet. The Community Adult Speech and Language Team advised the care home to contact the GP Practice if they needed further assistance.
14. The records indicate Mr B was assessed by the District Nursing Team and the Community Palliative Care Team (specialist nursing and care providers from the local NHS Trust) on 25 October 2022. The records indicate the Community Palliative Care Team concluded Mr B had no complex symptoms and that his care could be provided by the District Nursing Team. The Community Palliative Care Team recommended the GP Practice prescribe end of life medication and the records confirm the GP Practice prescribed this medication the next day.
15. Our adviser said the records indicate the GP Practice were aware of the care interventions Mr B had received from the various teams in the days following his discharge from hospital. Our adviser said there is no evidence in the records of any clinical reason for the GP Practice to visit Mr B and no requests were made to the GP Practice to attend to him following his discharge from hospital. The records support the view Mr B was receiving the support he required at that time from the care home staff and the community multi-disciplinary team.
16. The records indicate Mr B’s care was being provided primarily by the care home staff and the District Nursing Team and our adviser said under such circumstances the GP Practice would only become involved when its input is needed and if clinically necessary. The records indicate Mr B was seen daily by the community multi-disciplinary team following his discharge from hospital, primarily the district nurses. All of his care interventions were entered onto a shared record which the GP Practice had access to and could review.
17. The records indicate the care home called the GP Practice for support on two occasions following Mr B’s discharge from hospital. The first occasion was on 14 November 2022 when the care home staff thought Mr B was suffering a chest and water infection. The records indicate the care home had reported cases of COVID in the home at this time and the GP Practice held a remote consultation with the Mr B and the care home staff. The record of the consultation indicates the GP Practice confirmed Mr B’s understanding of his illness and that he was terminally ill. The GP Practice prescribed a course of antibiotics to treat Mr B’s suspected chest and water infection.
18. Our adviser said the records indicate the action taken by the GP Practice on 14 November 2022 was consistent with the GMC guidance and the remote consultations guidance. There is no evidence in the records to indicate there is anything further the GP Practice could or should have done at this time. There is no evidence in the records to indicate the action taken by the GP Practice was detrimental to Mr B’s condition.
19. The second occasion the care home staff called the GP Practice for support was on 22 November 2022. The care home staff felt Mr B was deteriorating and the records indicate the GP Practice contacted the Community Palliative Care Team to visit and reassess Mr B. The Community Palliative Care Team assessed Mr B the same day and confirmed that his symptoms indicated he was approaching the end of his life. The Community Palliative Care Team confirmed Mr B’s end of life medication was in place for the care home staff to provide.
20. Following the assessment the care home called the GP and discussed Mr B’s end of life care. The records indicate the GP Practice discussed the advice provided by the Community Palliative Care Team with the care home staff and decided that a further visit was not required as all the necessary care, support and medication Mr B required was in place.
21. Our adviser said the records indicate the action taken by the GP Practice on 22 November 2022 was consistent with the GMC guidance and the remote consultations guidance. There is no evidence in the records to indicate there is anything further the GP Practice could or should have done at this time. There is no evidence in the records to indicate the action taken by the GP Practice was detrimental to Mr B’s condition.
22. Our adviser said palliative care is provided in the community by a multi-disciplinary team where the usual providers of care are the care home staff (if the person is in a care home) and the District Nursing Team. Other members of the multi-disciplinary team will provide input where necessary including the patient’s GP. The records indicate on this occasion the GP Practice provided appropriate care and advice in line with the GMC guidance when requested.
23. We carefully considered Mr A’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we have received. We found no evidence to indicate the GP Practice inappropriately declined to visit Mr B during this period.
24. We found no evidence to indicate Mr B did not receive the care and treatment he required at this time as a result of any action or decisions taken by the GP Practice. We found the GP Practice acted in line with the GMC and remote consultation guidance when it was contacted to review Mr B and provide care, treatment and support.
The GP Practice failed to record appropriate information when certifying Mr B’s death
25. Mr A says the GP Practice recorded malignant lung cancer as his brother’s cause of death rather than pneumonia. In its response to this complaint the GP Practice said:
‘I can now explain why the cause of death on the certificate was written as malignant lung cancer. (Mr B) was diagnosed with a metastatic lung cancer in September 2022. Metastatic means the cancer has spread outside of the organ where it's originated from which is a poor prognostic sign clinically speaking. He was discussed in the multidisciplinary lung cancer meeting, and we were instructed by the hospital team that he's not for any further treatment and should be managed in the community with best supportive care. What it means is that the cancer is not curable or treatable hence the aim of management is to keep the patient comfortable from there on.’
26. The DOH guidance states:
‘The cause section of the Medical certificate of Cause of Death (MCCD) is set out in 2 parts. The attending practitioner is asked to start with the immediate, direct cause of death on line a of part 1.’
27. Our adviser said the GP Practice’s explanation is appropriate and consistent with the information in Mr B’s medical records. It is clear he had been discharged from hospital to palliative care. In Mr B’s case the illness that was causing the deterioration in his condition was terminal lung cancer.
28. We carefully considered Mr A’s complaint. We also considered the information in the records, the guidance and the advice we have received. We found no evidence to indicate the GP Practice acted inappropriately when it recorded malignant lung cancer on the MCCD as the disease or condition directly leading to death.