A practice in the West Suffolk area

3. Miss F complains a GP at the Practice failed to recognise that her friend, Mrs G, needed emergency care during a telephone consultation on 28 July 2023. Mrs G died at home on 29 July, and Miss F says her death could have been prevented had the GP acted as they should have done.

4. Miss F says the Practice has failed to recognise that the failing led to Mrs G's death. She says she feels angry that it has not taken responsibility for what happened.

5. Miss F would like the Practice to make service improvements.

6. Mrs G called NHS 111 at around midday on 28 July 2023. She complained of abdominal pain, vomiting, and diarrhoea. She also reported breathlessness at rest. NHS 111 referred her to the Practice which arranged a telephone appointment for that afternoon.

7. In the afternoon, Mrs G discussed her abdominal pain, diarrhoea, and breathlessness with the GP. The GP prescribed Gaviscon to help with the feeling of acid Mrs G reported in her stomach.

8. Mrs G called 111 later that evening and she was advised to go to A&E. Miss F says this was not straightforward for Mrs G because she suffered from anxiety and agoraphobia and would have needed a family member to drive her to hospital. Miss F reports Mrs G did not wish to wake them, so she slept downstairs. Very sadly, Mrs G died during the night. The cause of her death was described by the coroner as bronchopneumonia.

9. Miss F complained to the Practice on 3 August 2023, and it responded on 25 October. It held a meeting between Miss F, the Practice Manager, and the GP on 20 March 2024. Miss F brought her complaint to us on 1 May.

13. The NICE guideline on breathlessness sets out how doctors should assess and diagnose this symptom. It says for people experiencing breathlessness, doctors should examine the person and assess their blood pressure, pulse rate, respiratory rate, temperature, level of consciousness, and oxygen saturation (the percentage of oxygen in their blood).

14. It also says doctors should take a medical history of the breathlessness, including asking about how long the patient has been experiencing breathlessness, anything that make it worse or better, its impact on daily activities, and any associated symptoms like chest pain, dizziness, or coughing.

15. The guideline says doctors should arrange additional investigations, depending on the person’s presentation, the doctor’s examination, and the suspected underlying cause.

16. During her appointment on 28 July 2023, Mrs G explained to the GP that she ‘could not get around the house very well’ and needed support to get down the stairs. She said she felt like she was ‘panting’ at times. Mrs G explained to the GP she had borrowed an asthma inhaler, and this had helped her breathing. Mrs G also described her chest as ‘tight’.

17. The records show the GP suggested Mrs G’s breathlessness was ‘likely to be anxiety related’. They advised her to focus on breathing calmly and suggested she stop using the inhaler she had borrowed.

18. Our adviser said although Mrs G had a long history of anxiety, her breathlessness did not appear to be related to this. They noted Mrs G had not complained of anxiety related breathlessness at any other time.

19. Our adviser noted Mrs G described breathlessness which became worse when she moved around her home and breathlessness which was relieved by an asthma inhaler. They said both these factors suggest a physical cause for Mrs G’s breathlessness.

20. Our adviser said the GP should have arranged to examine Mrs G that same afternoon. They explained this would have allowed the GP to consider if she needed emergency treatment. Our adviser also said the GP should have asked Mrs G about any other symptoms that occurred alongside her breathlessness.

21. We consider the evidence shows the GP did not act in line with the NICE guidance on breathlessness. They did not assess or arrange to examine Mrs G, and they did not take a detailed medical history. We consider this an indication of a failing and we have looked at the potential impact this had on Mrs G.

22. We think it is impossible to know what would have happened if the GP had arranged to examine Mrs G on 28 July. Our adviser said given Mrs G died of bronchopneumonia, it is likely she would have been admitted to hospital if she had been examined. Even if this happened, we cannot know if Mrs G would have survived. Equally, Mrs G may have preferred to attend the Practice for an examination the following day. These are just two amongst many possible scenarios.

23. While we cannot say Mrs G’s death could have been avoided, we think what went wrong represents potentially a missed opportunity for her to have received better care and to be better informed about the serious nature of her breathlessness. We can therefore understand Miss F’s anger and frustration at what happened to her friend. We think it likely the uncertainty of the events surrounding Mrs G’s death has made Miss F’s bereavement more difficult to cope with.

24. Our NHS Complaints Standards set out how organisations providing NHS services should approach complaint handling. They say organisations should ‘promote a learning culture’ by having appropriate governance structures in place so that senior staff regularly review information that arises from complaints. They also say organisations should look at what action will be taken to learn from a complaint to continuously improve services.

25. We considered what the Practice has done to put things right. In its complaint response, the Practice acknowledged the GP had not given Mrs G advice on what to do if her symptoms deteriorated. It said it has a new triage system in place, and this will make sure appointments are allocated to those whose who most need them. It also said the GP had reflected on the importance of agreeing with patients what to do if their symptoms get continue or worse.

26. We approached the Practice and explained our view that the service improvements it has made do not fully address what went wrong. We explained what we had found so far during our primary investigation and asked it to consider taking action to address the potential failing and impact set out in this report.

27. The Practice shared with us an updated action plan with the service improvements it has made in relation to Miss F’s complaint. This includes a review of the NICE guideline on breathlessness during its clinical governance meetings. The Practice Manager explained to us these meetings are attended by the majority of its clinical staff and are the best way for the Practice to learn from the events like Mrs G’s sad death.

28. We have shared a copy of this action plan with Miss F.

29. We consider the information the Practice sent us shows it has acted in line with our NHS Complaints Standards. It has undertaken further work to ‘identify suitable ways to put things right’. It has made wider service improvements to support its staff to minimise the risk of similar mistakes happening in the future.

30. As this was the outcome Miss F told us she wanted from her complaint, we are satisfied we do not need to take any further action. We would like to thank both parties for their time and effort during this process.

1. We thank Miss F for bringing her complaint to us. We recognise how important the complaint is to her and the effort she has made to share her experience with us. We would like to offer our sincere condolences to Miss F and Mrs G’s family for their sad loss.

2. In its response to Miss F’s complaint, the Practice acknowledged it did not get some things right during Mrs G’s appointment. As part of our process, it has shared the action it has taken to reflect, learn, and make service improvements to prevent the same thing happening again. We consider this to be enough to put things right and we will therefore take no further action.