15. Mr B was 88 years old. He had a history of type-2 diabetes, atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate), previous stroke and high blood pressure. He had also been using an intermittent catheter since 2015, which he managed himself.
16. At the beginning of July 2023, he had an elective transcatheter aortic valve implantation, which is a procedure to replace a diseased aortic valve via a minimally-invasive approach. He was discharged home on 2 July. We understand why his family would be concerned that he died so soon after that.
17. When a patient is discharged from hospital, doctors send information to their GP with information and if necessary, a request for follow-up care. We saw that in the hospital discharge notice they did not identify any additional need for Mr B when he returned home. However, someone from the Practice phoned Mrs B on 3 July to check up on her husband. We consider this was good practice. At that time, Mrs B said they had everything they needed.
18. Mr B developed a problem with his vision on 6 July. He was seen by a GP at the Practice, who referred him for a same-day assessment by the ophthalmology team. Our adviser says there is no indication this was related to a urinary tract infection (UTI) or urosepsis. (Sepsis is a life-threatening reaction to an infection. It happens when the immune system overreacts to an infection and starts to damage the body's own tissues and organs. If it is caused by a UTI, it is called urosepsis.)
19. On 11 July Mr B had a consultation in person with a practice nurse. There were several things wrong; he was feeling generally unwell, had diarrhoea for the last few weeks (which he thought was due to medication), and was weak and dizzy. At that point there were no symptoms of UTI. He was examined and had normal observations (temperature, heart rate, blood pressure, blood oxygen levels). The nurse advised him to take Imodium for the diarrhoea and said she would phone him on the Friday (14 July). Although this consultation was done by a nurse, we consider it was in line with Good Medical Practice, which says
‘If you assess, diagnose or treat patients, you must adequately assess the patient’s conditions, taking account of their history (including symptoms and psychological, spiritual, social and cultural factors)…
Promptly provide or arrange suitable advice, investigations or treatment where necessary.’
20. Our adviser says there was no indication at the time that Mr B had an infection. The record noted that he mobilised from wheelchair to bed (for examination) slowly, but there was no report of recently reduced mobility.
21. The nurse phoned three days later as arranged. Mr B’s abdominal symptoms had now improved, but he now had haematuria (blood in the urine), which was a significant development. The nurse noted he self-catheterised. There were previous urology investigations a few years earlier when he was diagnosed with an infection. He was now also experiencing lethargy. The nurse thought he had a UTI and prescribed antibiotics, nitrofurantoin, which the BNF states is indicated for UTIs. She advised that if his symptoms worsened over the weekend, she should go to the Emergency Department at hospital.
22. There was a plan to send a urinary culture but there is no evidence it was done. The NICE guidance for UTIs in men says the diagnosis should be made by urinary culture. We saw no evidence this was done, so it was an omission. We saw no indication it would have changed management as he was given an antibiotic for a UTI anyway.
23. Mrs B spoke to the out of hours service over the weekend.
24. On 17 July, Mr B had a consultation at the Practice with a doctor. He had ongoing haematuria and increased frequency of urination, which is also a symptom of UTI. The doctor planned to have a urine sample tested (although our adviser explains it is better to do this before the patient takes antibiotics). A blood test was also arranged.
25. We recognise that the situation was complicated. This was now the third day of the course of antibiotics and Mr B was still passing blood, although his confusion appears to have resolved. An ambulance had attended on the Friday night and the paramedics did not see any indication he had sepsis. The consultation of 17 July was appropriate and in line with Good Medical Practice.
26. The result of the urine sample soon after was ‘mixed growth’. In essence, this means it was inconclusive. Usually, it is because bacteria from the skin have contaminated it. This was the last entry in the records until 28 July.
27. On 25 July one of the Practice’s patient navigators called Mrs B. The patient navigator referred to the fact Mrs B had spoken to one of her colleagues the previous day. (There is no audio recording or written record of that.) The colleague had spoken to one of the Practice doctors, who said Mr B needed to be seen. Mrs B said she did not think she could get her husband to the Practice. Our adviser said that if a GP decided Mr B needed to be seen, an appointment should have been generated. However, we saw no record of the doctor’s consideration.
28. The patient navigator said that if Mrs B felt her husband was deteriorating quickly, he could be seen in the urgent care clinic. Mrs B did not think she could get him there; his mobility was the most important problem at that time. She explained the difficulty she had in getting him to his recent ophthalmology appointment.
29. The patient navigator said there was only one doctor in that morning. Mr B’s usual GP had been on sabbatical and would be back the following afternoon. (We recognise Mr and Mrs B did not know the doctor who had been allocated as his usual GP.)
30. Therefore, it appears one of the GPs said on 24 July that Mr B needed an appointment but there is nothing in the records about this. Regarding the return of Mr B’s usual GP, our adviser says that asking a GP to deal with a potentially urgent matter when they are returning from an extended period of leave is not good practice.
31. When Mrs B said she would not be able to get her husband in, a clinician should have spoken to her to assess how urgently he needed to be seen, including the relevance of the reported worsening mobility. It should have been passed to the duty doctor to triage; that was the only safe action the Practice could take at that point. It appears the issue of his declining mobility was seen to be a social care need rather than a possible indication of deterioration due to a medical problem. A possible deterioration in mobility after Mr B’s attendance at recent appointments was not considered.
32. The NHS England Patient Safety Alert says:
‘When a request for a home visit is made, it is vital that general practices have a system in place to assess: • whether a home visit is clinically necessary; and • the urgency of need for medical attention.
This can be undertaken, for example, by telephoning the patient or carer in advance to gather information to allow for an informed decision to be made on prioritisation according to clinical need. In some cases the urgency of need will be so great that it will be inappropriate for the patient to wait for a GP home visit and alternative emergency care arrangements will be necessary.’
33. The patient navigator, who was not a clinician, was triaging a potentially urgent case. It was considered the day before and a doctor was consulted but there is no record of this or why it was decided Mr B did not need a home visit or other urgent action such as an ambulance.
34. During Ms B’s call on 27 July, she requested a home visit as her mother had done two days before. Again, this should have been passed on to the duty doctor to triage. If that had been done, the doctor would have spoken to Mr or Mrs B to see whether it could wait or whether he needed to be seen (either by a GP or paramedics) that day.
35. When Mr B’s usual GP returned on 28 July, she contacted and then visited Mr B and recognised he needed to be admitted to hospital.
36. Mr B died in hospital the early hours of the next day. His death certificate showed the cause of death to be i. Urosepsis, ii. Heart Failure.
37. We cannot say with any certainty what would have happened if a GP had done a phone assessment with Mr and Mrs B or visited between 24 and 27 July. On the balance of probabilities, his reduced mobility was evidence that he was deteriorating. A doctor may have arranged a home visit, called an ambulance or referred Mr B to hospital for further investigation. There may have been a chance to treat him with antibiotics (the first course having finished). It is likely that some action would have been taken because the evidence suggests his condition was deteriorating.
38. Therefore, there was a lost opportunity to have taken action sooner and arranged for treatment. It is possible they may have treated Mr B in the community (with antibiotics) or arranged for hospital admission. (We also recognise that a doctor may have decided no immediate action was needed, but in the absence of any recorded consideration, we cannot say this would have been reasonable.)
39. It is not possible to say if Mr B would have lived longer. He had a number of comorbidities and was at high risk of sepsis due to recent surgery, his age and frailty. The failure to deal with those calls denied him the opportunity of at least a consideration of what treatment he needed. The home visit requests were not triaged properly by the Practice. He may have succumbed to this illness even if everything possible had been done in a timely manner. However, we cannot rule out the possibility that a timely tirage may have led to earlier treatment which would have enabled him to have survived. An earlier recognition of his deterioration would have given more time for Mr B and his family to come to terms with the fact he may have been approaching the end of his life and for his symptoms to be better managed. We recognise that Mr B’s family will continue to have this uncertainty and associated distress.
40. We considered what action the Practice has taken since these events. We noted in its first response to Ms B’s complaint, they acknowledged this system was not safe and it had taken action;
‘During the Significant Event review, we discussed your father’s medical record and the difference between a routine and urgent home visit request. We could see that there was confusion about the nature of the home visit request for your father i.e., was it a new medical deterioration, for a catheter change or for social home care. From this review we have instructed the Patient Navigators to put any home visit requests on the Duty Doctor rota, who will then assess the urgency of the request.’
41. In response to our proposal to investigate this complaint, the Practice said that it had implemented a system called Total Triage. All GP requests are now reviewed by a GP with over 90% being dealt with within two hours by a GP phone call, appointment or home visit being offered depending on the urgency. The requests are reviewed by a GP and if necessary a GP will telephone to ask further questions if it appears urgent, or message for further information.
42. In this regard, we consider the Practice has put things right in terms of acknowledging weaknesses in the system and making changes to improve. It is in line with the NHS Complaint Standards, which say organisations should use learning to improve their services. As such, we do not identify any need for us to recommend the Practice change its current procedures.
43. However, while the Practice acknowledged shortcomings in the system at the time, it did not acknowledge there was a failure in the way it dealt with the requests for home visits, nor the impact this could have had and consequently, the uncertainty Ms B and her family will be left with the uncertainty of not knowing what might have happened.
44. We therefore uphold the complaint.