A practice in the Dorset area

4. Mrs T complains the Practice denied her husband’s request for a home visit on 19 July 2023, instead arranging a telephone consultation for 8 August with an unacceptable wait of 20 days for GP care. Mrs T complains the Practice then failed to arrange a home visit, despite agreement from the GP on 8 August that Mr T should be seen face-to-face.

5. Two days after his request for a home visit, on 21 July, Mr T was admitted to hospital with sepsis, and discharged home on 25 July. Nine days after the Practice agreed to arrange a home visit, on 17 August, Mr T was readmitted with sepsis. He sadly died in hospital on 24 September.

6. Mrs T questions whether the Practice’s lack of care may have contributed towards her husband’s early death and whether this could have been prevented, had he been seen by a Practice GP sooner. Mrs T is left a widow at a young age and is still coming to terms with her loss. She says she cannot fully explain the significance of the impact on her life.

7. Mrs T would like the Practice to acknowledge its failings and apologise for their impact. She seeks improvements, for lessons to be learned and changes made in how they manage home visit requests and the timeliness of their actions for other patients in a similar position. Mrs T also seeks a financial payment in recognition of the impact of these failings.

8. On 19 July 2023 Mr T called the Practice to request a GP home visit. Mrs T told us her husband had a complex medical history, he was a wheelchair user and was housebound, unable to physically get to the Practice building. The Practice contacted Mr T the next day, 20 July, confirming having booked a routine telephone consultation for Mr T for 8 August.

9. On 21 July, Mr T was admitted to hospital. Hospital records note he had sepsis of an unspecified source, thought likely urinary in origin. He was given intravenous antibiotic treatment and he was discharged home on 25 July.

10. Mr T’s GP telephone consultation took place as arranged, on 8 August. Earlier that same day he had a home visit from the diabetic nurse for his annual review. During the telephone consultation, the GP agreed Mr T should have a home visit and said he would make the necessary arrangements.

11. Having not heard further, 8 days later, on 16 August Mrs T emailed the Practice to chase up the appointment and to raise her concerns with these recent events. The Practice replied to Mrs T’s email the next day, 17 August, to acknowledge receipt and to say her concerns would be reviewed the next working day.

12. Mrs T emailed the Practice later that same evening on 17 August, to advise that Mr T had been readmitted to hospital with likely sepsis. Very sadly, Mr T died in hospital on 24 September. The hospital discharge summary records he had sepsis of unspecified origin.

Arranging an initial home visit 16. Mrs T told us when her husband called the Practice on 19 July requesting a home visit, he reported feeling ‘unwell’ and ‘empty’. She said he had not seen a GP for some time. Practice records show the reception team documented Mr T gave ‘no real reason’ for the home visit request. They note he was: ‘asking only in the fact he hasn’t seen a GP for a while [and] has a lot of health issues and feels he needs to be seen’.

17. Practice policy says home visit requests are at its discretion to agree and depend upon their clinical necessity. It says the Practice will consider whether alternative ways of assessing the patient are appropriate, such as by telephone consultation. Practice policy contains a flow diagram, illustrating the process to follow for home visit requests.

18. Considering what we understand Mr T said when he called, from both Practice records and Mrs T’s account, we think it reasonable the Practice felt his request could be managed by telephone. We consider this decision was in line with the Practice policy flow diagram, and in line with GMC consultation guidance, which 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.’

19. From the information we know, it does not appear Mr T reported any specific or acute symptoms. Our adviser says there is no indication he reported anything of acute concern to have warranted a face-to-face assessment, or any urgent GP involvement outside of a routine process. They say it appeared to be a routine request for GP input, with no information imparted to suggest telephone consultation was inappropriate.

20. Mrs T is concerned the Practice did not complete its own triage process when Mr T called on this occasion. Information on the Practice website, under the heading ‘Urgent (‘Triage’) Appointments’, says:

‘For all urgent matters, please telephone the Surgery between 8.30am and 12pm when you will be asked to briefly outline your symptoms. If appropriate, you will be added to the triage list for a doctor or Nurse Practitioner to call you back that morning. If they cannot help you over the telephone, you will be directed to the most appropriate healthcare professional. This could mean prescribing medication over the phone or asking you to attend the Surgery at short notice’.

21. This makes clear the triage process applies to urgent matters only. We do not see that Mr T reported any symptom or concern that would be considered clinically urgent. As such, we do not consider this triage process applied.

22. We understand Mrs T’s view, that a home visit should have been arranged considering her husband’s disability, complex illness and medical history. We know this has given even greater cause for her concern. It does not appear any of these were reasons given by Mr T for why he was calling for a home visit. We think the clinical reasons given, of feeling empty and unwell without specific symptomatic concern, met the above criteria and meant arrangement of a telephone consultation was appropriate.

Timeliness of the telephone consultation 23. Mrs T complains about the timeliness of the telephone consultation arrangement. Our adviser explains whether a home visit, face-to-face appointment or telephone consultation, the urgency for the arrangement depends upon the clinical matters reported by the patient.

24. Practice records note the telephone consultation was arranged on a routine basis. From the information we know Mr T reported, our adviser describes it as a low priority requirement and says it was reasonable his request was managed as routine.

25. Our adviser explains there is no guidance that stipulates what timeframe should be met for routine appointments. They explain the timeliness of such an arrangement would depend on the Practice’s own internal process, the availability of its GP resource, and what the Practice itself considers timely.

26. This leaves the matter of timeliness at the discretion of the Practice. Without specified guidance and with discretion involved in these arrangements, we are not unduly critical. We do not find that this falls so far below an expected standard, to indicate a service failure. It remains that we recognise the time to wait has only added to Mrs T’s concern and distress, considering the events that later happened.

27. Whilst there is no specific guidance, general GMC guidance advises that doctors must: ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’. A 20 day wait for telephone consultation in this instance does not appear duly prompt, and we highlight this to the Practice for its future consideration.

Arranging a second home visit 28. The accounts we have from both Mrs T and the GP align, that during the telephone consultation on 8 August, the GP said Mr T should be seen face-to-face. The records further support this as the GP wrote Mr T needed a review, noting that he would liaise with Mr T’s own GP on this.

29. We cannot see that anything was done. This is not in line with GMC guidance, which advises doctors must: ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’, and ‘refer a patient to another practitioner when this serves the patient’s needs’.

30. We consider this indicates a service failure. The Practice should have done what it said it would do, in making an appointment for Mr T and letting him know the date for the home visit. We think it should have taken this action promptly, which we consider should have been before the time Mr T was readmitted to hospital, nine days later.

31. Whilst we think the arrangement should have been made in that period, we cannot say Mr T would have had a home visit conducted in in that time, nor can we say that he should have.

32. Considering what we understand was said during the call, from both Practice records and Mrs T’s account, it appears the home visit was agreed for a check on Mr T’s general wellbeing. Our adviser says even with discussion of his recent admission, Mr T had received treatment in hospital and had been discharged home without instruction to the GP for any additional action. The home visit arrangement was therefore appropriate to make under a routine process.

33. General GMC guidance advises doctors must act ‘promptly’ in this circumstance. The Practice policy flow diagram also applies. This time, the flow moves down the line to say this request cannot be managed by telephone, the patient is housebound, the condition is not acute, and the outcome is to: ‘Arrange a timely home visit’.

34. As we have explained, the timeliness of when the home visit should have been made is at the Practice discretion and in considering and accommodating their resources. We cannot say it would have, or should have, happened before Mr T was readmitted to hospital.

35. We know this may leave Mrs T concerned with the thought of what might have happened, if the visit had taken place in that period. We hope to provide her with reassurance, by explaining that even had the home visit occurred in those nine days, we cannot say it would have identified or prevented any deterioration in Mr T’s health. This is because of what we know of his clinical circumstances.

36. The UK Sepsis Trust gives the following as possible warning signs of sepsis: slurred speech or confusion, extreme shivering or muscle pain, passing no urine in a day, severe breathlessness or sleepiness, a feeling you are going to die or pass out, mottled or discoloured skin, an extremely high or very low temperature, repeated vomiting, seizures, a rash that does not fade when a glass is pressed against it.

37. Mr T was seen face-to-face at home on 8 August by a diabetic foot nurse. The nurse made a detailed note of Mr T’s presentation, the discussion they had with Mr T, and documented his physiological observations which were all within normal parameters. Our adviser confirms nothing within this entry indicates any apparent signs or symptoms of sepsis.

38. Hospital records then note Mr T’s presenting complaint on 17 August was of chest pain. The nurse documents Mr T had no chest pain on 8 August, and our adviser explains chest pain typically comes on within hours.

39. We cannot say Mr T would have presented with chest pain or any apparent symptoms of sepsis that would have warranted additional action, such as hospital admission, even had he been seen at a GP home visit between 8 and 17 August.

40. Whilst we consider the lack of home visit arrangement an indication of a service failure, we do not see that this had any impact on the subsequent course of events or the very sad eventual outcome. We remain very sorry to have learned about Mrs T’s concerns and we thank her for bringing her complaint for our consideration.

1. From the evidence we have carefully considered, we do not see anything to indicate a failure with the Trust’s initial decision on 19 July to arrange a telephone consultation. Whilst the time to wait was not ideal, we do not see this indicates a service failure, considering the Practice’s discretion and as Mr T’s request indicated a routine, low priority requirement.

2. We think the Practice should have acted soon after the telephone consultation on 8 August, to arrange the agreed home visit and tell Mr T the planned date. This action was not taken, and this indicates a service failure. We do not see that the home visit should have taken place before Mr T was readmitted to hospital. We do not see that the indicated failure would have changed the course of events or the very sad outcome of Mr T’s death.

3. For these reasons, we do not propose to investigate further. We know how important this complaint is to Mrs T. We recognise the distress she has experienced, and we appreciate her kindly sharing these details for our consideration.