A practice in the Amber Valley area

5. Ms B complains a doctor at the Practice did not take her mother, Mrs A’s concerns seriously or refer her for further treatment when they discussed her health concerns on 17 March 2023. Ms B also complains the Practice should have done more to provide the treatment her mother needed in March 2023.

6. Ms B says her mother’s death could have been prevented. She says this has had a significant emotional impact on her.

7. Ms B would like the Practice to acknowledge what went wrong and make improvements to its service.

8. The following is a brief background to put our understanding of the complaint into context. We have limited the information to the key dates.

9. Mrs A was in her early sixties at the time of the events Ms B complained about. She suffered from anxiety and took venlafaxine (a medication used to treat depression and anxiety). In early March, Mrs A called the Practice to arrange a mental health review. Initially, the review was arranged for 17 April.

10. At the same time, Mrs A was suffering from symptoms of a urinary tract infection (UTI). On 26 March, she went to her local urgent treatment centre where a UTI was confirmed. She was prescribed antibiotics.

11. Mrs A called the Practice on 30 March and asked for her mental health review to be brought forward. The Practice arranged a telephone appointment for that day. The GP gave Mrs A some advice about managing her mental health and increased her dose of venlafaxine.

12. Very sadly, Mrs A died suddenly at home on 1 April. Her cause of death was confirmed by the coroner to be a pulmonary embolism (a blood clot in the lung).

13. Ms B complained to the Practice on 6 April and received a response on 8 June. She also sent her complaint to NHS England which asked Derby & Derbyshire Integrated Care Board (ICB) to facilitate an independent clinical review of the care Mrs A received in the month before she died. The ICB sent its response to Ms B in June 2024.

14. Ms B approached us with her complaint in full in July 2024.

Call on 17 March

18. To decide if we should conduct a detailed investigation, we first consider if there are reasons not to. These include if an investigation might not be practical or might not come to a satisfactory conclusion. We have considered this part of Ms B’s complaint and think we should not investigate it. We have not seen evidence to allow us to reach a robust view about what happened on 17 March.

19. Ms B complains a doctor at the Practice did not take Mrs A’s concerns seriously when she spoke to them over the phone on two occasions in March 2023. She says the doctor should have arranged an appointment sooner or referred Mrs A for further treatment.

20. Ms B says she witnessed the doctor calling Mrs A on her mobile phone on 17 March. She says she heard Mrs A telling the doctor she was experiencing a fluctuating temperature, coughing, dark urine, urgency to urinate, constipation, diarrhoea, shaking, and back and chest pain. She also says Mrs A told the doctor she was ‘losing consciousness’ when she sat down. We were sorry to hear Mrs A was experiencing so many distressing symptoms.

21. In its complaint response, the Practice said there was no record of a doctor calling Mrs A on 17 March. It said its phone records showed Mrs A called the Practice on this date, but the call was ‘abandoned’. It said this meant Mrs A ended her call before speaking to a receptionist.

22. Ms B told us the Practice did not have a record of these calls because the doctor called Mrs A from their personal mobile. Ms B told us that the text message screenshots and Mrs A’s diary excerpts show this call took place.

23. We can also see Mrs A wrote a letter to the doctor on 17 March. In this letter, she said she was experiencing a ‘urine infection’ and needed to speak to the doctor about her mental health.

24. It is important to explain our role is to make independent final decisions about NHS complaints in England. We make decisions by weighing up and considering all the available evidence. We then consider the likelihood that something has gone wrong with the service provided. As we are impartial, we must make robust decisions based on facts and evidence.

25. We carefully considered the evidence available to us. While we do not dispute Ms B’s version of events, we cannot agree that the screenshots and Mrs A’s diary excerpts show the call on 17 March took place. Furthermore, as we have seen, there is no evidence from the information the Practice provided that shows the doctor called Mrs A on this date.

26. Overall, we have not seen sufficient evidence to allow us to say the conversation between Mrs A and a doctor took place. For this reason, we consider it would not be practical to investigate this part of Ms B’s complaint in detail.

27. We recognise this outcome may be frustrating for Ms B. We are sorry we have not been able to investigate her complaint further or provide her with closure for her concerns. We would like to thank her for her time and effort in bringing this complaint to our attention.

Care and treatment prior to Mrs A’s death

28. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we cannot link the events Ms B complained about with Mrs A’s sad and unexpected death.

29. Ms B complains the Practice should have done more to treat Mrs A in the month prior to her death. She said the Practice should have arranged an appointment to see the doctor or referred her mother to another service based on her symptoms.

30. Ms B says if the Practice had done this, Mrs A’s death from a pulmonary embolism could have been avoided.

31. As we have seen, the evidence available to us shows Mrs A spoke to the Practice at the beginning of March to arrange a mental health review. She also had an appointment on 30 March. The records show during this appointment, she told the doctor she had experienced ‘throat issues’, a UTI, and anxiety.

32. The NHS website says symptoms of a pulmonary embolism include ‘difficult difficulty breathing that comes on suddenly, chest pain that's worse when you breathe in, and coughing up blood’.

33. We recognise Ms B’s account that Mrs A told the doctor on 17 March that she was experiencing chest pain. For the reasons outlined in paragraph 21, we have not included this conversation in our consideration of this part of Ms B’s complaint.

34. From the evidence available to us, we have seen no indication that Mrs A raised health concerns relating to symptoms of a pulmonary embolism. The evidence shows Mrs A raised concerns about unrelated conditions. Based on this, we do not see a link between what Ms B complains about and Mrs A’s sudden death. For this reason, we have decided not to consider this part of Ms B’s complaint further.

35. We fully empathise with how Ms B’s life has been affected by Mrs A’s sad death. We can see how much work she has put into understanding what happened and raising her complaint. Our decision is not intended in any way to diminish this or her experience. We hope our statement clearly explains the reason why we cannot consider the complaint further.

1. We thank Ms B for sharing her concerns about the care the Practice provided her mother, Mrs A. 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 Ms B and her family for their sad loss.

2. After careful consideration, we have not seen sufficient evidence to allow us to say the conversation on 17 March took place. This is because Ms B and the Practice have a different recollection of what happened, and we do not have evidence to help us determine what happened or what was discussed. For this reason, we have decided it would not be practical to consider this part of Ms B’s complaint further.

3. We have seen no indication that Mrs A raised health concerns relating to symptoms of a pulmonary embolism. The evidence shows Mrs A raised concerns about unrelated conditions. Based on this, we do not see a link between what Ms B complains about and Mrs A’s sudden death. For this reason, we have decided not to consider this part of Ms B’s complaint further.

4. We thank Ms B for the effort she has gone to in bringing us her complaint and sharing information with us. We recognise our decision not to consider her complaint further may be disappointing.