The Practice
21. Mr A told us the Practice made a wrong diagnosis and denied him a necessary test. He said the Practice based its conclusion on a previously incorrect diagnosis made at Trust’s ED.
22. We looked at the records of the first Practice appointment on 14 March, to see if it was in line with guidance. This was a telephone appointment as Mr A felt too unwell to attend the Practice in person.
23. The GMC guidance says: ‘You 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 • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.’
24. We consider the telephone consultation was in line with this guidance. Our GP adviser explained the doctor took a good history and assessed Mr A’s condition. Mr A declined to attend the Practice for a face-to-face appointment and so the doctor was not able to physically examine him. The Practice carried out the assessment in line with the symptoms Mr A described. There is no evidence the Practice based its conclusion on the diagnosis made the previous day at the ED.
25. We recognise Mr A declined to attend the Practice as he felt too unwell, and as there was no suggestion he did not have capacity to make this decision it was reasonable for the doctor to follow the relevant steps in the GMC guidance on remote consultations. This says a remote consultation is appropriate when you can give the patient all the information they want and need about treatment options.
26. The Practice also gave Mr A advice on what to do if his condition worsened. This was in line with the MDU guidance on safety netting that says doctors should give specific advice on what to do if a patient’s condition worsens. We can see from the records this happened.
27. The appointment on 17 March was also compliant with the requirements of the guidance outlined in paragraph 23. The doctor carried out a comprehensive assessment, took a detailed history and carried out a thorough examination.
28. Our GP adviser explained that resolving gastroenteritis was a reasonable diagnosis for the doctor to make, based on the examination and history. Mr A’s temperature and blood pressure were normal, with only his pulse rate being raised (this can happen in clinical situations due to stress).
29. Mr A had bowel sounds, a soft and non-tender abdomen, and no stomach distension. He reported the pain was better than it had been. The doctor also gave excellent safety netting advice, as outlined in the MDU guidance.
30. The GP phoned Mr A later to clarify some additional points, such as Mr A passing wind and not having had previous surgery to cause adhesions (bands of scar tissue that form between tissues and organs. They can cause these tissues and organs to stick together, which can lead to complications such as pain and obstruction. They are a risk factor for bowel obstruction). Our GP adviser said this was an example of good and thoughtful practice, as the doctor was actively considering the possibility of a bowel blockage and wanted to make sure they had all the information they needed.
31. Our GP adviser said that on the balance of probabilities, it is reasonable to assume Mr A did not have bowel obstruction at this point, as this would usually present with a distended abdomen, and a lack of wind.
32. Mr A said the Practice had denied him a necessary test that had been ordered by the hospital. We can see the hospital requested the Practice undertake a test for Helicobacter pylori (H. pylori, a type of bacteria that infects the stomach), in the discharge letter, received by the Practice late on 13 March. The records also show Mr A completed an online consultation questionnaire on 17 March saying he wanted a ‘test to understand what virus or bacteria’ was causing his symptoms.
33. We have not seen any evidence the Practice denied Mr A the test for H. pylori. Our GP adviser explained a practice will not review a hospital letter immediately, unless they require an immediate urgent response. There is nothing to show this was the case in either the hospital letter or the online consultation request.
34. A test for H. Pylori requires preparation as the patient must provide a stool sample, which is then sent off for assessment. It is not an urgent or immediate test.
35. Our GP adviser further explained it is not possible to carry out a test for H. pylori until two weeks after a patient has been taking a PPI (omeprazole). As the records suggest Mr A was given a PPI in hospital on 12 March, it would not have been useful to carry out the tests at this point. We can see the Practice contacted Mr A on 21 March and offered the tests at this point. This is in line with the GMC guidance which says:
‘If you assess, diagnose, or treat patients, you must work in partnership with them to assess their needs and priorities. The investigation or treatment you propose, provide, or arrange must be based on this assessment, and on your clinical judgement about the likely effectiveness of the treatment options.’
The Trust
36. Mr A said the Trust made the wrong diagnosis and gave the wrong care and treatment when he attended on 12 March.
37. The medical records show that on 12 March Mr A presented with an acute onset of abdominal pain, nausea and vomiting after consuming a sausage roll. The Trust assessed and managed his symptoms, and carried out blood tests, which were all within the normal range.
38. Our ED adviser said the overall management was in line with the GMC guidance, as outlined in paragraph 23.
39. The Trust carried out a full examination as required by the GMC guidance and took a detailed history. The records note his abdomen was not distended, was soft and there were normal bowel sounds. Our adviser said in these circumstances gastritis was a reasonable diagnosis to make and there was no reason to suspect bowel obstruction.
40. The NHS webpage that explains the treatment for gastritis says to treat with medicines to control stomach acid. We can see this is the treatment the Trust gave Mr A.
41. Mr A presented again on 13 March. He told us the Trust would not carry out a reassessment. On this date an ED consultant reviewed Mr A and formulated a management plan. This was in line with the RCEM guidance which says patients that return within 72 hours of discharge with the same condition should be reviewed by a consultant.
42. Our adviser said there is no evidence to support the view that the Trust would not carry out a reassessment. The records again note Mr A’s abdomen was soft and non-tender. On both occasions his symptoms were noted to be improving. The Trust followed the guidance in paragraph 26 and gave safety netting advice. For these reasons we did not see any indications of failings.
LAS
43. LAS has acknowledged it omitted to record details of a hands on physical gastrointestinal assessment on 14 and 17 March. It has apologised and arranged feedback and reflection with the ambulance crew. These are indications of possible service failings.
44. We carefully considered whether we could link the impact Mr A claimed in paragraph five to these omissions on 14 and 17 March. We did not consider we could make this link.
45. The medical records show that when the Trust diagnosed a bowel obstruction on 18 March, it found this was due to adhesions. Adhesions can cause some of the loops in the small intestine to stick together, which can result in abdominal pain and occasionally obstruction in the gut.
46. Our GP adviser said this can come on quickly, sometimes within hours. They said Mr A did not have clear symptoms of bowel obstruction when examined by the GP on 17 March. Instead, Mr A had the physical symptoms that ruled out bowel obstruction on 17 March, as outlined in paragraph 31. It is therefore reasonable to assume, on the balance of probabilities he did not have clear symptoms of bowel obstruction earlier, on 14 March, at the first ambulance attendance.
47. We do not know when these symptoms developed, or whether they would have been observable if Mr A had been physically examined by the ambulance crew later on 17 March.
48. We cannot say, even on the balance of probabilities, whether Mr A had a bowel obstruction at this point. We do not know whether the ambulance crew would have reached a different decision if they had carried out a physical examination. We cannot say LAS would have made the decision to transport Mr A to hospital, rather than taking the action it did - advising him to make his own way to the UCC if he continued to be concerned.
49. Our ED adviser agreed that we could not say whether a physical examination by the ambulance crew would have changed the decision about transportation. They added that even if LAS had taken Mr A to hospital in the early hours of 18 March we cannot say whether the operation would have been completed sooner, because of such issues as the availability of staff and operating theatres.
50. Even if Mr A had been taken to hospital in the early hours of 18 March, rather than at 11.34am when he arrived, we cannot say he would have had all the assessments, investigations, surgical opinions and preparation much sooner. Our ED adviser said on the balance of probabilities he would have needed the same operation. We cannot say he had a more invasive operation than would have been necessary otherwise.
51. Taking into account the views of our ED adviser we could not reach the conclusion about the impact that Mr A outlined in paragraph five of this statement.
52. We have seen that LAS has taken the correct action having identified indications of failings, as outlined in paragraph 43. We do not consider there is anything further we need to recommend.
53. We were sorry to hear about how difficult Mr A found his experience and the ongoing impact this had on him. We hope we have explained in this statement the reasons we have decided not to take further action on his complaint.