A practice in the Barnsley area

4. Mr A complains about the care provided to his late wife Mrs A by the Practice. He complains the Practice failed to thoroughly examine Mrs Aon 16 and 29 August 2023 and missed signs of an infection which required treatment.

5. Mr A considers this led to a delay in Mrs A receiving treatment for an infection, which in turn led to the infection progressing to such a severity it caused Mrs A to have a heart attack. The heart attack caused irreversible damage to Mrs A’s heart, and Mr A says this led to Mrs A’s untimely death.  Mr A tells us the loss of Mrs A has been devastating for him and his family.

6. As an outcome to the complaint, Mr A is seeking an acknowledgement of what went wrong. He would like the Practice to put service improvements into place, and to provide a financial remedy which reflects the impact of these events.

7. Mrs A had a history of recurrent urinary tract infections (UTIs) with hydronephrosis (the swelling of the kidney due to urine build up) and bladder/renal stones. She had a background of multiple sclerosis (MS), and an indwelling catheter. This meant she was more vulnerable to serious infections.

8. Mrs A had an appointment with her GP on 16 August 2023 due to concerns about low appetite, nausea, and weight loss. The GP carried out a blood test, and a plan was made to repeat the blood test in four weeks’ time.

9. Mrs A was seen at home on 29 August after reporting symptoms of loose stools and blood in her urine. Following the home visit on 29 August, the plan was for Mrs A to do a faecal immunochemical test (FIT) test (a test which looks for blood in the stool, which can be a sign of bowel cancer) and to have a blood test. Mrs A also provided a urine sample for testing.

10. On 30 August, the Practice were notified that the urine sample had been rejected due to insufficient volume, and a second sample was requested from Mrs A. On 31 August, Mrs A reported more blood in her urine.

11. On 1 September, Mrs A was admitted to a nearby hospital via ambulance. Upon triage, it was recorded that Mrs A had blood in her urine for a week and had been vomiting for four to five days prior. Mrs A also reported aching on her right side, a reduced appetite, loose stools, and that she felt generally unwell.

12. Once at the hospital, Mrs A was treated for a suspected kidney infection. She was given intravenous (IV) fluids, antibiotics, and medication to prevent vomiting.

13. On 2 September, Mrs A was moved to the acute medical unit (AMU) where further investigations were carried out. Overnight she experienced chest pain, and her blood test results along with an electrocardiogram (ECG) indicated her heart was under a lot of stress. Medications were given to manage this and to assist with her pain. A decision was made to transfer Mrs A to a different NHS Trust, who could provide specialist cardiology care.

14. Following transfer, Mrs A was diagnosed with a heart attack, secondary to urosepsis. This means that a severe urine infection had caused her to suffer a heart attack. Mrs A remained on IV antibiotics, and her clinical condition stabilised.

15. Following a period of care, on 14 September Mrs A was transferred back to the first hospital for ongoing treatment for heart failure, liver injury, low sodium levels, and anaemia (low levels of healthy red blood cells). She remained on antibiotic treatment for her infection but remained very unwell. Mrs A continued to deteriorate, and very sadly died on 17 September 2023.

16 August

19. Mrs A was seen by her GP on 16 August 2023. She reported symptoms of weight loss and a loss of appetite that had been ongoing for quite a while. It is recorded that she had been experiencing nausea, but had not been vomiting, and that she had not experienced any abdominal pain or dizziness.

20. The GMC’s Good Medical Practice guidance 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 provide or arrange suitable advice, investigations, or treatment where necessary, C- refer a patient to another practitioner when this serves the patient’s needs”

21. The medical records show us that the GP prescribed metoclopramide (used to treat nausea), carried out a blood test, and advised Mrs A to get back in touch if her symptoms worsened.

22. At this point, we understand it is likely the GP was suspecting the possibility of cancer rather than an alternative diagnosis such as a UTI or sepsis. We can see the GP carried out appropriate blood tests in line with this thinking, including tumour markers.

23. The blood results show Mrs A’s C-reactive protein (CRP) level was 96, which is raised considering a normal level would be 0-5. CRP is a protein produced by the liver in response to inflammation, a raised level can indicate infection.

24. The blood results were marked as ‘abnormal no action’. However, after reviewing the medical records with our GP adviser, we consider this is misleading as we can see that the GP did act upon these results. We can see from the medical records that the GP planned to repeat the blood test in one months’ time.

25. We have considered whether the GP should have reviewed Mrs A sooner, or suspected a UTI and taken a urine sample, given she had a raised CRP and a history of recurrent infections.

26. The NICE CKS for UTI explains a diagnosis of UTI should be suspected in women who; are experiencing dysuria (discomfort, pain, burning or stinging associated with urination), are passing more urine than usual, or are experiencing urgency to urinate. There may also be changes in urine appearance or consistency, such as appearing cloudy or with the presence of blood. Other symptoms can include passing urine more often than usual at night, and suprapubic (an area of the abdomen above the pubic bone) discomfort/tenderness.

27. It also explains that typical features can be absent in some patients, and UTI may be considered where a woman presents with generalised non-specific features such as delirium, lethargy, reduced ability to carry out their abilities of daily living, and anorexia.

28. Our physician adviser explained that some symptoms of a UTI such as blood in the urine, bladder spasms, and leakage/incontinence can occur in patients with a catheter, irrespective of whether they have a UTI. It is also worth noting that those with a catheter in situ would not experience dysuria, as they do not pass urine in the usual way because the tube continuously drains urine.

29. The CKS says a urine sample should be sent for testing in all women in whom a diagnosis of UTI is suspected on the basis of clinical features who; are older than 65 years, have recurrent UTI, have a urinary catheter in situ, have atypical symptoms, and who have visible or non-visible haematuria. Antibiotics should then be offered after taking account of the severity of symptoms, the risk of developing complications, previous urine culture and susceptibility results, and previous antibiotic use.

30. We understand that whilst Mrs A had a raised CRP, she did not have a raised neutrophil count. A neutrophil is a type of white cell, and our physician adviser explains that white cells go up with infection, and neutrophils go up with bacterial infection. We have not seen any evidence of this in Mrs A’s blood results. Our physician adviser also explained that although neutrophil counts may also be normal with bacterial infection, the absence of a raised neutrophil count may be regarded as further evidence of a lack of UTI.

31. Taking this into consideration alongside Mrs A’s reported symptoms, we consider Mrs A did not fully meet the criteria for a suspected UTI. For this reason, we consider it was reasonable for the GP to pursue the line of thinking of a possible malignancy based on the information known at the time of examination.

32. Overall, we have not identified clear signs of infection that required antibiotic treatment during this appointment. We consider the care provided to Mrs A was in line with the GMC’s Good Medical Practice as the GP took into consideration Mrs A’s symptoms and history, arranged suitable investigations, and had a plan to repeat the blood tests within an appropriate timeframe.

29 August

33. On 29 August, Mrs A was seen by her GP following a telephone call from Mr A. He requested a home visit due to his concerns about Mrs A’s presentation. The GP visited Mrs A and noted she had been experiencing ongoing diarrhoea.

34. The medical records say Mrs A did not report any vomiting episodes, and that she did not have a temperature or dysuria, but she did report there had been specs of blood in her urine. We can see the GP examined Mrs A, noting that her pulse and respiratory rate were normal, her abdomen was soft, and there were no other significant or concerning symptoms.

35. The GP requested further blood tests, a FIT test, a urine sample, and advised Mrs A to call back if she had any further concerns. Our GP adviser explained that whilst not explicitly documented, requesting the urine sample indicates the GP was considering the possibility of a UTI, and requesting the FIT test indicates the GP was still considering the possibility of an underlying malignancy.

36. We have also reviewed Mrs A’s blood results with our GP adviser. We can see her CRP continued to rise. Other than this, there was no deterioration in her blood results when compared to those from 16 August. We note there was no marked change Mrs A’s renal function, which can be a reassuring sign that Mrs A was not displaying signs of dehydration or acute kidney injury. Similarly, our physician adviser highlighted that the neutrophil count remained within a normal range.

37. We can see the blood results were marked ‘abnormal no action’ which we again consider is misleading. The GP had reviewed the blood results, and we understand from the Practice’s response to the complaint, a decision was made not to prescribe antibiotics until the urine sample results were obtained. This is because of the risk of resistance to treatment with frequent antibiotic use.

38. Both our GP and physician advisers highlighted that there is a careful balance between prescribing antibiotics too often and increasing the risk of antibiotic resistance. NICE guideline 113 explains that for patients with long term catheters, the longer a catheter is in place, the more likely bacteria is to be found (1.1.1), and it also recommends taking a urine sample before antibiotics are taken (1.1.4). We understand that prescribing the wrong antibiotics could do more harm than good and therefore waiting 24 hours for the urine sample to come back before prescribing antibiotics was unlikely to cause much of an impact.

39. Mr A was also concerned that Mrs A required hospital admission on 29 August. We have considered this with our GP adviser, and we have not identified any evidence that Mrs A required hospital admission.

40. The observations in the GP records from 29 August are incomplete as the GP should have noted Mrs A’s blood pressure, oxygen saturations, and temperature. However, in the absence of this information, we reviewed the observations taken by the paramedics on 1 September. Our GP adviser explained that Mrs A’s blood pressure was slightly low, but her pulse was within a normal range. There were no obvious signs from the observations recorded that Mrs A had sepsis at that point. On the balance of probabilities, it is more likely than not that there was no cause for hospital admission on 29 August.

41. We can see from the medical records that the urine sample was rejected on 30 August as it was of insufficient volume. The GP requested Mrs A provide a further sample for testing. We can see the GP then decided to prescribe antibiotics on 1 September whilst the results were pending, which appears to have been a bridging measure to mitigate against any further deterioration over the weekend. We understand this prescription was cancelled as Mrs A was admitted to hospital on the same day.

42. We can see a marked change in Mrs A’s symptoms from the paramedic’s documentation and hospital admission documents from 1 September. Mrs A reported symptoms of vomiting, pain around her catheter, blood in the catheter bag, right sided aching around the flank (which can be a sign of kidney infection), confusion, and feeling lethargic. Our physician adviser also highlighted that Mrs A had blood tests done upon admission which showed her neutrophil count had increased. We consider by this point, Mrs A was more unwell, and there was much more evidence suggestive of an underlying UTI.

43. Overall, we have not identified a service failure in relation to the actions of the GP on 29 August. Even though on occasion it has not been well documented, the actions in the medical records align with the Practice’s response to this complaint. We can see evidence that the GP was monitoring Mrs A and keeping an eye on the blood results and urine sample results before prescribing an antibiotic. We consider this was in line with the GMC’s Good Medical Practice guidance, NICE guideline 113, and the NICE CKS on managing a UTI.

44. Our final decision is that we do not uphold Mr A’s complaint.

1. Based on the evidence we have reviewed we have not seen any evidence that the GP missed the signs of an infection or failed to act upon them when Mrs A was seen on 16 and 29 August 2023. It is therefore likely we will not uphold Mr A’s complaint.

2. We will explain the reasons for our decision in this report. Complaints give us valuable insight into the organisations we investigate, so we would like to thank Mr A and his family for sharing their experience with us.

3. It is important to acknowledge that where we have not found failings in care, this does not diminish Mrs A’s experience, nor the impact this had on her and her family. We recognise the level of concern this caused for Mr and Mrs A, and it is evident Mr A did everything he could to seek medical help for Mrs A. We hope our findings provide some reassurance to Mr A about the care Mrs A received.