Blood tests
12. Mrs H told us the Practice prescribed Atorvastatin to Mr W and did not carry out regular blood tests to monitor the effects. Mrs H says this was neglectful and contributed to Mr W’s death.
13. The Practice said it discussed Mr W’s risk factors for cardiovascular disease (CVD) and fully counselled him about Atorvastatin including the benefits and unwanted side effects. It said follow up blood tests were requested but Mr W refused.
14. The Practice told us Mr W was advised on three occasions between May and October 2020 to have his blood tested but he declined.
15. The Practice went on to say it was faced with a dilemma when Mr W declined to have the appropriate blood testing. It said if it stopped Atorvastatin he would not get the risk-reducing benefit and on the other hand he may also be at risk of having side effects which include muscle aches or liver function disturbance (a rare side effect). It said Mr W never complained of muscle aches and showed no signs of liver derangement.
16. The Practice said it felt on balance, in view of Mr W’s high cardiovascular risk it was in his best interests to continue Atorvastatin.
17. We reviewed this matter with the help of our GP adviser using Mr W’s medical records.
18. NICE guidance for the management of cardiovascular disease risk states, ‘statins treatment should be offered for the primary prevention of CVD to people with an estimated 10 year CVD risk of 10% or more if lifestyle interventions have not proved effective. Atorvastatin 20mg a day is the recommended statin if the person decides to take drug treatment after an informed discussion about the benefits and harms, after having been provided with lifestyle advice, and if there are no contraindications.’
19. NICE guidance for prevention of CVD states ‘to assess the patient’s response to statins the clinician should carry out a blood test at 2 – 3 months and again at 12 months, but no further tests unless there is another reason.’
20. GMC guidelines state, ‘propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when you have adequate knowledge of the patient’s health and are satisfied the drugs or treatment will meet their needs.’
21. The Practice assessed Mr W in November and December 2019 and calculated his QRISK score to be 24.9%. A QRISK score is a tool used to estimate an individual’s risk of developing cardiovascular disease within the next ten years. It considers various factors such as age, sex, blood pressure, cholesterol levels, smoking status and medical history to categorise the risk as low, moderate or high. 20% or higher is classed as high risk.
22. In November and December 2019, The Practice gave Mr W advice about weight management and discussed opportunities for physical activity. The Practice discussed Mr W’s desire to give up smoking and referred him to a smoking cessation adviser.
23. The Practice prescribed Atorvastatin 20mg once per day on 17 January 2020. The Practice noted a blood test would be needed in six to eight weeks. The Practice requested a further blood test on 1 May 2020. There is nothing in the records to suggest these blood tests were carried out. The records show Mr W was not compliant with blood testing.
24. On 31 August 2020, Mr W had a telephone consultation with the Practice. The notes state Mr W declined to have his physical observations taken. The GP planned to check Mr W’s compliance with Atorvastatin the following week.
25. On 7 August 2020, the Practice discussed Mr W with a doctor at the rehabilitation facility. The doctor at the rehabilitation facility reported Mr W was not compliant with Atorvastatin and had advised Mr W given his risk factors, he was at greater risk by not taking Atorvastatin.
26. On 2 October 2020, Mr W declined a blood test.
27. The Practice noted Mr W ‘does not accept blood monitoring’ on 23 October 2020. There is nothing in the records to suggest Mr W lacked capacity to make this decision.
28. We have seen evidence the Practice assessed Mr W’s risk of developing CVD in the next ten years using the QRISK assessment tool and prescribed Atorvastatin in accordance with relevant guidance.
29. It is clear the Practice were aware of the requirement for follow up blood testing and offered this to Mr W which he declined. Faced with this situation, the Practice used clinical judgement to decide the benefits of taking Atorvastatin outweighed the risks to Mr W given his high risk for cardiovascular disease. We consider this was reasonable and in line with Good Medical Practice.
Blood pressure
30. Mrs H says the Practice did not adequately monitor Mr W’s blood pressure. She says on 15 November 2021 the Practice recorded raised BP readings showing hypertension. She says Mr H’s blood pressure readings were high in February 2022 and the Practice did not offer any intervention or plan to Mr W.
31. Mrs H also complains the Practice did not check Mr W’s blood pressure during an appointment on 31 January 2022.
32. The Practice said it was aware staff at the rehabilitation facility had measured Mr W’s blood pressure at 163/99 and 161/87 on 7 February 2022. It said at the time Mr W insisted this was because the blood pressure cuff was wrongly applied. It said following this, staff at the rehabilitation facility offered Mr W regular blood pressure checks.
33. Mr W consented to having his blood pressure measured on 8 February 2022 (systolic 143) and 10 February 2022 (systolic 145). Systolic is the top number in a blood pressure reading indicating the maximum pressure in the arteries when the heart is pumping. Diastolic is the bottom number representing the pressure when the heart is resting.
34. We reviewed this matter with the help of our GP adviser using Mr W’s medical records.
35. NICE blood pressure guidance states, ‘if blood pressure is between 140/90 and 180/120, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.’
36. NICE blood pressure guidance also states, ‘offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension.’
37. Stage 2 hypertension is classed as a clinic blood pressure of 160/100 or higher but less than 180/120 and subsequent daytime average of 150/95.
38. Mr W’s blood pressure was recorded in his Practice medical records on 9 August 2019 as 140/78, 7 January 2020 as 140/82, 23 October 2020 as 139/85 and 2 September 2021 as 139/85. We saw no evidence of a raised blood pressure reading on 15 November 2021.
39. Our GP adviser said these readings were satisfactory and there was no indication for ambulatory monitoring, or any type of intervention based on these readings.
40. We asked our GP adviser should the Practice have taken Mr W’s blood pressure on 31 January 2022 when he attended the Practice in person. Our GP adviser told us this consultation concerned back pain and eczema. There was no indication to check Mr W’s blood pressure as it had been normal only a few months prior to this consultation.
41. This was the last appointment Mr W had with the Practice before he sadly died on 1 April 2022.
42. We understand staff at the rehabilitation facility took Mr W’s blood pressure on 7 February 2022 and it was 163/99 and 161/87. Following this, staff at the rehabilitation facility planned regular blood pressure checks. This is in accordance with NICE guidance.
43. Staff at the rehabilitation facility checked Mr W’s blood pressure again on 8 February (systolic 143) and 10 February (systolic 145).
44. According to NICE guidance, Mr W did not fit the criteria for antihypertensive medication as he did not have stage 2 hypertension. It was therefore appropriate not to offer medication to Mr W.
45. We have seen no indications the Practice failed to manage Mr W’s blood pressure appropriately.
UTI referral
46. Mrs H told us the Practice did not refer Mr W to urology for persistent urinary tract infections (UTI’s). She says on 29 November 2019 Mr W was concerned his urine was discoloured following a UTI he had six weeks previously. She says a test showed he still had a UTI, and this was treated with antibiotics. She says the Practice showed no concern about this recurrent and treatment resistant UTI and took no further action.
47. Mrs H says UTI’s were recorded in October and November 2020. She says Mr W had been treated with several courses of antibiotics and had developed epididymo-orchitis (swelling of the testicles).
48. Mrs H said the Practice referred Mr W to urology at this time to rule out testicular cancer, but the Practice did not request investigation of his bladder or kidneys. She says had the Practice requested these tests then hydronephrosis may have been seen and treatment offered. She says Mr W experienced further UTI’s in October and November 2021 and again the Practice did not refer him to urology.
49. We reviewed this issue with the help of our GP adviser, using Mr W’s medical records.
50. NICE UTI guidance states, ‘refer or seek specialist advice on further investigation and management for people with recurrent lower UTI when the underlying cause is unknown.’
51. The GP notebook states, ‘recurrent UTI’s in adults is defined as repeated UTI with a frequency of two or more UTI’s in the last six months or three or more UTI’s in the last 12 months.’
52. Our GP adviser said it was important to note patients do not present with UTI’s. Patient’s present with symptoms which could be due to a UTI. The guidance refers to confirmed UTI’s.
53. Mr W presented to the Practice with symptoms of UTI’s in October 2019, September and October 2020 and October and November 2021. Not all of these suspected UTI’s were confirmed as UTI’s.
54. The suspected UTI’s in October 2019 and September 2020 were confirmed by laboratory testing and Mr W was on the correct treatment.
55. The suspected UTI in October 2020 was not confirmed, the testing came back as normal.
56. We have seen no evidence to suggest Mr W fit the criteria for referral in 2019 and 2020 as he had not had more than two UTI’s in six months or three UTI’s in 12 months.
57. The Practice referred Mr W to urology on 24 November 2020 for suspected urological cancer as he had presented with a swollen testicle. Mrs H believes had the urology team assessed Mr W’s bladder or kidney’s in November 2020, then hydronephrosis may have been seen and treatment offered. Mr W died on 1 April 2022 and hydronephrosis is listed on his death certificate.
58. Due to the time which elapsed between the urology appointment in November 2020 and Mr W’s death in April 2022, it would not be possible for us to know with any degree of certainty had Mr W’s bladder or kidney’s been investigated by urology, hydronephrosis would be seen at that time.
59. On 18 November 2021 Mr W had a telephone consultation and reported cloudy urine but with no clear symptoms of a UTI. The Practice prescribed a course of antibiotics and requested a urine sample for testing. The GP noted if a UTI was confirmed then Mr W would need a urology referral.
60. We have seen no evidence this urine test was carried out and do not know whether a sample was provided. There is no further evidence in the records to suggest Mr W complained to the Practice of urinary symptoms after this appointment and prior to his death in April 2022.
61. We have seen nothing in the records to suggest the Practice failed to manage Mr W’s urinary symptoms appropriately.
Summary
62. We are sorry to hear of the impact Mr W’s death had on Mrs H and her family. We recognise from conversations we have with Mrs H how difficult this has been for her. We have not identified anything went wrong in Mr W’s care and therefore we are not taking any further action on the complaints. We hope our decision provides some reassurance to Mrs H about the care and treatment Mr W received.