A practice in the Birmingham area

5. Ms P complains about aspects of care and treatment her mother, Mrs D received from the Practice between 23 and 30 November 2022. In particular, she complains her mother was unable to contact the Practice when she called several times on 23 November and there was a delay in calling her mother back on 24 November.

6. She is also unhappy her mother was not given a face-to-face appointment and believes the diagnosis was incorrect (chest infection). Finally, she is unhappy with the delays in the handling of her complaint.

7. She says because of the Practice’s actions her mother sadly died, causing her and the family a great deal of distress and upset.

8. As an outcome she would like an investigation into the Practice’s actions to determine whether her mother’s death was preventable.

9. On 18 November 2022, Ms P has said her mother fell ill with a cold and flu-like symptoms.

10. On 23 November 2022, Mrs D was still feeling unwell, and she contacted the Practice to try and get an appointment. She said after 83 failed attempted she was unable to speak to anyone. Ms P says her mother subsequently emailed the Practice outlining her symptoms.

11. The following day Mrs D called the Practice again and an appointment was arranged for the same day. A locum GP spoke to Mrs D and diagnosed her with a chest infection and prescribed antibiotics.

12. On 30 November 2022, once she had completed her prescribed course of antibiotics, Mrs D contacted the Practice again as her symptoms had worsened. The Practice arranged for a call back the same day.

13. The Practice advised Mrs D to call for an Ambulance and attend the hospital for a chest X-ray.

14. Whilst waiting for the ambulance to arrive, Mrs D collapsed at home and became unresponsive. Sadly, when paramedics arrived, they were unable to resuscitate her, and she passed away.

15. The postmortem stated the cause of death was a Pulmonary Embolism (when a blood clot blocks a blood vessel in the lungs).

Mrs D’s contact with the Practice on 23 November 2022 and the consultation on 24 November 2022

19. Given the severity of the case and the tragic circumstances surrounding Mrs D’s death, we decided to obtain clinical advice from our Adviser to help us to understand whether the actions of the Practice were appropriate on 24 November 2022 and in line with the relevant clinical guidance.

20. Having assessed all the available evidence including Mrs D’s clinical records, we can see on 24 November 2022 the Practice assessed Mrs D over the telephone and took a history of her symptoms. it was documented, she had a high temperature, cough/sore throat and had no energy, lasting one week.

21. We can see these symptoms align with what Mrs D outlined in her email to the Practice on 23 November 2022 (a cough, sore throat, feverish, headache and aching).

22. The NHS website states the main symptoms of a chest infection are as follows:

• a chesty cough – you may cough up green or yellow mucus • wheezing and shortness of breath • chest pain or discomfort • a high temperature • a headache • aching muscles • tiredness

23. Our Adviser told us Mrs D’s symptoms were consistent with a chest infection. We can also see the Practice gave ‘worsening advice’ (what to do if Mrs D’s symptoms got worse), which is in line with GMC guidance.

24. Our Adviser also explained there was no indication a face-to-face appointment was required, given the symptoms Mrs D presented with. GMC guidance, Good Medical Practice states:

‘15 You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a. 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 b. promptly provides or arrange suitable advice, investigations or treatment where necessary c. refers a patient to another practitioner when this serves the patient’s needs.

25. Taking the guidance and our Adviser’s views into account, we are satisfied that the Practice acted appropriately.

26. Mrs D said she contacted the Practice 83 times on 23 November before being able to get through. The Practice has said it has reviewed its call log and can see Mrs D first connected to the phone system at 7.55am which was ‘out of hours’. The next call to connect was 8.07am but this call was ended after two minutes before staff answered.

27. The Practice has said there were no more records of Mrs D’s mobile number being connected to the Practice that day.

28. The Practice has said it receives an average of over 1400 calls each day and delays in answering calls remains an issue. It says its system can manage up to a maximum of 100 calls at a time, but when this is exceeded, all further incoming calls will fail to connect.

29. We fully appropriate the frustration Mrs D experienced in not being able to contact the Practice sooner and recognise that this is not ideal. We can see the Practice has explained the issues it faces, and we cannot say this is a failing in the circumstances and recognise that capacity is a big issue for many NHS organisations.

30. We are satisfied that the advice regarding Mrs D’s care would have been the same regardless on whether she was assessed on 23 November or 24 November, and as such, this had no impact on Mrs D’s sad subsequent decline (as the diagnosis would have been the same).

Consultation 30 November 2022

31. We can see from the records that Mrs D’s symptoms had worsened by 30 November, as she now was unable to complete a sentence due to shortness of breath. The records show the Practice advised her to ring an ambulance immediately and attend hospital.

32. Our Adviser explained it was clear Mrs D had worsened and the advice to call an ambulance was correct. This was again in line with GMC guidance on Good Medical Practice.

33. Given there was no previous indication of a PE, and Mrs D’s symptoms were consistent with those of someone who had a chest infection, we are satisfied the Practice acted appropriately. As tragic as the events that followed, based on the advice we have received and the relevant guidance, there is nothing to suggest the Practice should have done anything differently or that it failed to correctly diagnose Mrs D.

Complaint handling

34. The time taken to conclude the investigation took longer than both we and Ms P would have hoped. NHS complaints standards section 8.9 state;

‘For all other complaints, we will acknowledge them (either verbally or in writing/email) within three working days. We will also discuss with the person making the complaint how we plan to respond to the complaint’.

35. Section 8.10 states;

‘When we receive a complaint, we are committed to making sure it is addressed and resolved at the earliest opportunity’.

36. Ms P initially made her complaint in February 2023 and did not receive a final response until 14 March 2024. We understand this made an already extremely distressing situation much more difficult for Ms P and are sorry to learn of the impact these delays had on her.

37. When Ms P submitted her complaint in February 2023 and the Practice did not contact her until May 2023, it has explained the reason was due to the email unfortunately, going into its ‘junk’ imbox. Although, we appreciate this delay was unacceptable and extremely frustrating for Ms V, we are satisfied it has taken appropriate to put things right – in line with our principles of good administration, Putting things right.

38. This is because the Practice has apologised to Ms P for this error and has ensured steps have been taken to ensure the risk of this happening again have been reduced. It has done this by ensuring checking for any emails filtered as junk mail. As such, we are satisfied the Practice has done enough in respect to this issue.

39. Once the Practice acknowledged receipt (11 May 2023) of the initial complaint, a full response was not issued until 10 August 2023 and a final response in March 2024. We appreciate these were significant amounts of time for Ms P to wait for a response, especially given the serious and distressing nature of her concerns.

40. The NHS Complaints standards section 8.23 & 8.24 state;

‘We will aim to complete our investigation within the timescale shared with the person making the complaint at the start of the investigation. Should circumstances change we will:

• notify the person raising the complaint (and any staff involved) immediately • explain the reasons for the delay • provide a new target timescale for completion.

Unless we have agreed a longer timescale with the person raising the complaint within the first 6 months, we will inform them if we cannot conclude the investigation and issue a final response within 6 months. Our Responsible Person or a Senior Manager will write to the person to explain the reasons for the delay and the likely timescale for completion’.

41. We can see that the Practice contacted Ms P via email various times during this time, updating her on the progressing of the investigation and outlining reasons for the length of time it was taking. There are also various call logs to suggest the Practice was in contact with Ms P verbally during this time too.

42. There is no doubt there were delays in the Practice concluding its investigation(s) however, we are satisfied it updated Ms P throughout and made her aware of the issues it faced, in line with NHS complaints guidance. The Practice has also apologised for the delays and distress caused.

43. Finally, we hope our consideration of Ms P’s complaint gives her the explanations she is seeking and will help bring her some closure to this traumatic time.

1. We have carefully considered Ms P’s complaint about the Practice. We have seen no indication that the actions of the Practice were wrong or outside published guidance.

2. We understand this was a tragic experience for Ms P and appreciate the distress and upset she has been caused due to the circumstances surrounding her mother’s death.

3. From the evidence we have considered, we do not see anything to indicate the Practice incorrectly assessed Mrs D on 24 or 30 November. There were some delays in handling Ms P’s complaint, but we are satisfied the Practice has done enough to put things right.

4. For these reasons, we do not propose to investigate further. We know how important this complaint is to Ms P. We recognise the distress she has experienced, and we appreciate her kindly sharing these details for our consideration during an extremely upsetting time.