Malling Health

4. Mrs S complains Malling Health failed to take appropriate action when her father, Mr T, did not answer the calls it made to him on 29 and 30 April 2020.

5. She says it should have recognised something might be wrong and taken steps to ensure he received medical care or a welfare check. She says it should not have discharged him.

6. Mrs S says if these mistakes had not happened, her father may have received treatment, and he may have survived. She says because of the mistakes; her father was not given the best possible chance of survival.

7. She says the uncertainty around what might have happened had her father received timely and correct care caused extreme distress and made the grieving process harder to deal with.

8. Mrs S wants Malling Health to acknowledge the failures and their impact, to apologise and pay her a financial remedy.

9. Mr T had a telephone consultation with his GP on 28 April 2020. He had been suffering with a cough for over three weeks. The GP prescribed antibiotics to Mr T and referred him to the COVID monitoring service (CMS), which is run by Malling Health.

10. The CMS was to make daily contact with Mr T to monitor his condition. The GP advised Mr T to contact his GP, 111 or 999 if his condition deteriorated.

11. That evening, Mr T contacted out of hours (111) due to feeling unwell, faint and suffering with chest pains. They referred him to the out of hours GP who advised him to continue taking the antibiotics. Mr T contacted his GP practice on 29 April, who advised him to stop the antibiotic and prescribed him a different one.

12. On 30 April, Mr T contacted 111 again. They referred him to Malling Health for a call back within six hours.

13. The CMS attempted to contact Mr T on 29 and 30 April, and 1 May. When there was no answer, the CMS discharged him from its service.

14. On 4 May, Mr T’s mother phoned him and he was confused, before the phone line went dead. She rang 999 and when they arrived Mr T was found on the bed, where sadly, he had died.

18. Malling Health provided us with its guidance for call handlers. Unfortunately, it has been unable to confirm which copy of the guide was in place at time of these events. However, we can see on each version, there is guidance around the process for failed contacts with patients.

19. Each version of the guidance for call handlers says after the third unsuccessful attempt to contact a patient, the call handler should leave a voicemail with the patient to advise them to contact 111 if they need further assistance.

20. It says there should be some investigation, such as checking phone numbers and hospital admissions. They should then make a clinical decision about whether the patient is low or high risk. If they are high risk, such a being elderly, living alone, suffering from cardiac symptoms, then the call handler is to decide if a welfare check should be carried out.

21. In a complaint response to Mrs S, Malling Health acknowledged that when it could not contact Mr T, it should not have discharged him from the service without a review by one of its GPs. It said it should have arranged a welfare visit or contacted Mr T’s GP to ask if they held other contact details or those of his family.

22. There are very limited records from Malling Health, as it did not have any contact with Mr T. However, they show attempts to contact Mr T and no further action being taken when he did not respond.

23. Considering Malling Health’s own guidance, the records, and its acknowledgement it made a mistake, we have found that not taking action to ensure Mr T’s welfare is a failing.

Impact of this failing

24. We tried to understand what the sequence of events may have been if the failing had not happened.

25. Malling Health said it may have contacted Mr T’s GP to ask if they had any other contact details for him or his family. We therefore contacted his GP Practice, who checked the records and confirmed it did not have any other contact details for Mr T or his family.

26. We also asked what the Practice would have done if it was informed by a service that it could not contact a patient it had been asked to monitor. The Practice explained that after checking the records for contact numbers, it would then forward the matter to a GP to consider what action should be taken.

27. We asked our GP adviser what would happen in those circumstances. They said a GP would need to consider if a welfare check was indicated. A welfare check generally involves a clinician going to the patient’s home address or requesting the police do so. As this was during the COVID-19 pandemic, home visits were done by the COVID-19 visiting service.

28. Our adviser says based on the circumstances of this case; the GP would likely have arranged a welfare visit for Mr T. We asked about the timing of this, and they said it would be necessary that same day (1 May). They said the welfare check was likely to have been done by the COVID-19 visiting service, who dealt with home visits during the pandemic.

29. We have considered if we can say what would have happened if a welfare check had been carried out on 1 May.

30. Mrs S told us she believes that if a welfare check had been done, this would have resulted in an ambulance being called for her father. Knowing that her father sadly died a few days later, we understand why Mrs S has this view.

31. We do not know why Mr T did not answer the calls from the CMS. We do know he did not answer calls from the CMS on 29 or 30 April, despite having telephone contact with his GP practice and 111 on those days. Therefore, we cannot conclude he was too unwell to answer the CMS calls on those days.

32. On 1 May, we know the CMS tried to contact Mr T but the call was not answered. However, Mrs S told us that between 1 and 4 May, she and her sister were both in contact with their father. We do not know why Mr T did not answer the call from CMS.

33. Mrs S understands that during that time her father had been sick and fainted a few times. She says he had previously been decorating downstairs but had to stop this because of how he was feeling. She says he was spending time in bed because the downstairs was not suitable. It is clear Mr T was feeling quite unwell at this time.

34. When considering how a failing altered the course of events, we would usually look to the medical evidence to consider how someone’s condition progressed. However, as Mr T died at home without any direct contact with medical staff, we have no medical evidence about his condition on 1 May, or how it progressed over the next three days.

35. We do not know if or to what extent he was breathless, what his heart rate was, or his oxygen saturation levels (the amount of oxygen in his blood to ensure organs and tissues do not become damaged). We do not know if he was confused or had reduced urine output. He did not have any X-rays or blood tests.

36. This means we do not know what his clinical condition was from 1 to 4 May. In the absence of such information, we are unable to say what, if any, intervention or treatment he would have needed.

37. We acknowledge it is possible that a welfare check on 1 May, could have led to an ambulance being called and admission to hospital. Equally, it is possible that monitoring would have continued. We also cannot say if Mr T had been admitted to hospital as early as 1 May, that he would have survived his illness.

38. There is so little information, and so many variables for what might have happened. This means we are unfortunately unable to conclude that Mr T would have survived if the failure by Malling Health had not happened.

39. The failure was a missed opportunity to ensure Mr T’s welfare was checked, and his condition was reviewed by medical staff. This has caused uncertainty for Mrs S about whether there could have been a different outcome for her father. We can see this has caused distress to Mrs S and added to her grief.

40. We can see that during the complaints process, Malling Health acknowledged and apologised for its failure. However, it did not acknowledge the impact the failure had on Mr T or Mrs S.

41. We have set out below recommendations have made to Malling Health to put right the impact to Mrs S.

1. We have considered Mrs S’ complaint about the care provided to her father, Mr T, a few days before his sad death. We were sorry to hear of her concerns and the distress they caused her.

2. We uphold this complaint. This is because we found Malling Health failed to arrange a welfare check when it could not contact Mr T. We found this was a missed opportunity to ensure a medical review of his condition. This has caused uncertainty and distress to Mrs S as her father died a few days later.

3. Malling Health has not done enough to put this right and therefore we are have made recommendations for it to acknowledge and apologise for the impact of this failure and pay a financial remedy to Mrs S.

42. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. Our Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

43. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

44. In line with this we recommend that by 14 February 2025 Malling Health writes to Mrs S to acknowledge that its failure meant Mr T missed out on medical review of his condition. It should apologise for the uncertainty and distress this has caused to Mrs S.

45. To decide on a level of financial remedy, we review similar cases where the person has experienced similar injustice, along with our severity of injustice scale. Following this review, we recommend that by 14 February 2025, Malling Health should pay Mrs S £800 in recognition of the uncertainty and distress this failing caused her.