UTI
17. Mr G said the Practice did not do enough to treat his wife’s suspected UTI appropriately. He said staff prescribed her with antibiotics but when it was clear these were not working did not try anything else.
18. The Practice said that the outcome of Mrs G’s assessment at the frailty unit at the local hospital was age related decline, which would imply a general deterioration in health which is normally more permanent in nature.
19. The Practice said this assessment was a contributing factor to its own assessment as a team, along with observations it carried out once she was at home.
20. The Practice said following a urine sample on 5 April 2023, it prescribed antibiotics to Mrs G to treat her symptoms. It said it arranged a further course of antibiotics on 14 April as Mrs G had declined and was still suffering with a suspected UTI.
21. The Practice said when it became clear Mrs G may not recover from the UTI it began making arrangements for supportive treatment (palliative care).
22. GMC Good medical practice says good clinical care must include:
• ‘adequately assessing the patient’s conditions, taking account of the history (including the symptoms, and psychological and social factors), the patient’s views, and where necessary examining the patient • providing or arranging advice, investigations or treatment if necessary’.
23. Symptoms of a UTI in older or frail patients can include changes in behaviour, such as acting agitated or confused (delirium).
24. The records show the GP had noted Mrs G had been lethargic and had experienced behavioural changes. The GP noted Mrs G had significantly declined in the previous two weeks and was suffering with age related decline.
25. The GP suggested a urine sample to check if Mrs G’s symptoms were caused by a UTI. The GP then prescribed a 3-day course of antibiotics on 6 April and did the same on 11 April and 21 April. On each occasion, the Practice took a urine sample to send to the lab and check for an infection.
26. Our adviser said it typically takes two to three days for a result and each time, the lab results did not confirm an infection. Our adviser added that it is good practice to prescribe antibiotics whilst waiting for the result of a urine test, as a UTI is a treatable cause of deterioration, and further deterioration can occur during this waiting time. This is especially the case in a vulnerable and frail patient.
27. Our adviser added that the reason the antibiotics were not effective was because despite staff arranging the necessary investigations, Mrs G was not suffering with a UTI. The adviser said Mrs G’s confusion and delirium was likely due to her age-related decline, which would not necessarily show any abnormalities in tests.
28. The adviser added that Mrs G suffered no harm from taking the antibiotics, and these were stopped once the Practice moved towards a care package and anticipatory medication to relieve distressing symptoms near the end of her life.
29. We recognise Mr G’s concern that the Practice prescribed several courses of antibiotics which were ineffective in treating his wife’s symptoms. We appreciate the distress Mr G and his family experienced seeing Mrs G’s health decline without an obviously treatable solution.
30. We consider the Practice carried out the appropriate investigations based on Mrs G’s symptoms, in line with good medical practice.
31. Once it became clear the antibiotics were not effective and there were no further treatment options, the Practice moved towards managing Mrs G’s symptoms, which we explain in further detail below.
End-of-life care
32. Mr G said once his wife’s health began to worsen, the Practice did not do enough for her and did not refer her for hospital treatment when her symptoms worsened.
33. Mr G said prior to falling ill on 31 March 2023, his wife was quite well and was leading a somewhat normal life. He said she had started to slow down in the previous 12 months, but the family put that down to the onset of old age. Mr G said he did not consider that his wife was feeling weak or lethargic before this.
34. Mr G said he did not understand why the Practice was so quick to place Mrs G on end-of-life care, and not try other treatment options.
35. The Practice said that during the GP consultation of 5 April, despite the suspicion of a UTI, Mr G had said that Mrs G’s health had declined over the past 12 months. The Practice said Mr G had told staff that Mrs G had declined further over the preceding two weeks with symptoms of becoming weaker, more lethargic and little appetite.
36. It said for this reason, and following information given to it by the frailty assessment unit on discharge, it began making arrangements for an advanced care plan.
37. The Practice also said it discussed with Mr G that it would be appropriate for Mrs G to be treated at home and for her to have palliative treatment, should her treatment for the suspected UTI not work. It said at the time, the GP felt Mr G understood the plan but acknowledged she did not use the word palliative in these discussions. It apologised for this.
38. GMC guidance on treatment and care towards the end of life says:
‘As treatment and care towards the end of life are delivered by multi-disciplinary teams often working across local health, social care and voluntary sector services, you must plan ahead as much as possible to ensure timely access to safe, effective care and continuity in its delivery to meet the patient’s needs.
Patients whose death from their current condition is a foreseeable possibility are likely to want the opportunity (whether they are in a community or hospital setting) to decide what arrangements should be made to manage the final stages of their illness. This could include having access to palliative care and attending to any personal and other matters that they consider important towards the end of their life.
Even if there is a care plan in place, or the patient has made a decision in advance, you should still talk to them about the options available in case the options have changed or the patient has changed their mind.’
39. Mrs G was admitted to hospital on 31 March 2023. Although the Trust did not make a specific diagnosis, the notes advised she was suffering with general decline. Mrs G’s GP then visited her at home on 5 April. After examining Mrs G, the GP agreed that she was experiencing age-related general decline.
40. The records show the GP then discussed Mrs G’s understanding of DNACPR, completed a RESPECT form and also discussed further hospital admission, which the notes say Mrs G did not want, and her family had agreed to this.
41. We have not seen any evidence from the records that Mrs G lacked the capacity to make a decision about her treatment.
42. Our adviser said the Practice was engaging in early, sensitive discussion and planning how best to manage Mrs G’s care, in line with the GMC guidelines. The adviser added that Mrs G’s situation does not appear to have markedly changed since her hospital discharge, and there was no clear need to admit her to hospital at this time.
43. Mrs G was then readmitted to hospital via the NHS out of hours service on 25 April. Whilst at the hospital she had a set of blood tests which were normal and showed no sign of serious infection or other treatable cause for her decline. The notes from the Emergency Department show staff offered to admit Mrs G but she chose to discharge herself against medical advice. The records indicate Mrs G’s wishes on two occasions were to remain at home.
44. On 27 April the GP again saw Mrs G at home, and it was clear that she was frailer than when the GP had previously seen her. The GP notes document that Mrs G had been seen in the ED and had bloods taken. The GP discussed with Mr G and his family that Mrs G was likely in the palliative care phase of illness and that she would deteriorate further.
45. The Practice then arranged for a continuing healthcare (CHC) assessment and care package for nursing and care support and also issued anticipatory medication (medication prescribed to enable prompt symptom relief at whatever time the patient develops distressing symptoms).
46. The adviser said the Practice managed Mrs G’s symptoms in line with the guidelines, and there was no evidence in her records that showed she had distressing symptoms that needed to be managed in a hospital setting.
47. We recognise Mr G has found it difficult to understand why his wife’s health declined so rapidly. He said Mrs G had suffered from ulcerative colitis for 10 years before her death, but this had always been managed appropriately. She had then developed bowel cancer in 2019 and had a successful surgery to remove it. Mr G said his wife was very independent and they had even been on a Mediterranean cruise together only a few months before her death.
48. We have reviewed Mrs G’s GP records for the two years prior to her illness, to get an understanding of her general health. Our adviser said these records show that Mrs G was beginning to decline and was becoming frailer.
49. There is evidence from a GP appointment in November 2022 that Mrs G said she was feeling weak and described herself as unable to fully recover from her cancer diagnosis and surgery.
50. We acknowledge Mr G feels very strongly that his wife was in reasonably good health prior to her illness, and it was difficult to understand why she declined so quickly. The evidence we have seen shows her overall health was getting worse over the preceding years.
51. We consider the Practice acted correctly, in line with relevant guidelines, to manage Mrs G’s symptoms in her final weeks, and respected her wishes to die at home.
Conclusion
52. We understand that Mr G and his family felt that they had unanswered questions regarding the care and treatment the Practice provided to Mrs G in her final weeks. We have not identified any clinical failings from the Practice, and we consider its actions were in line with standards and guidelines.
53. We hope our findings on Mr G’s complaint will reassure him that the Practice acted appropriately to manage Mrs G’s condition and make her as comfortable as possible in her final weeks, taking into consideration the serious nature of his illness.