The Practice
30. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indication that something has gone wrong in relation to part of the complaint.
General declining health
31. GMC ‘Good medical practice’ says doctors must adequately assess a patient’s conditions, taking account of their history and promptly provide or arrange suitable advice, investigations or treatment where necessary.
32. The NICE CKS on chest infections explains pneumonia is usually caused by bacteria and needs antibiotic treatment. In contrast, most other acute respiratory conditions are not bacterial and usually do not require antibiotic treatment.
33. Our GP adviser explained Mr G’s deteriorating health was largely due to heart failure. In May, he was coughing up green sputum and more short of breath. Based on his symptoms, our GP adviser said he was appropriately treated with antibiotics on 17 May 2022. The Practice acted in line with the NICE CKS on chest infections in managing Mr G’s condition.
34. In June, Mr G’s heart failure was found to be worsening with symptoms of increasing leg swelling and shortness of breath. The NICE CKS on chronic heart failure says diuretics (water tablets) should be used to relieve symptoms such as fluid retention. The Practice gave Mr G water tablets, which was in line with this.
35. Mr G’s CRP, which is an infection/inflammation marker, was slightly raised but was being managed with antibiotics. Cellulitis is a bacterial infection and the NICE guidance NG141 says people who have it should be offered antibiotics. In line with this, the Practice gave Mr G antibiotics for possible cellulitis. He was also on antibiotics for a chest infection as set out above.
36. The Practice increase the dose of Mr G’s water tablets in August as his leg swelling was still an issue. It offered a referral back to cardiology or admission to hospital which Mr G was not keen on.
37. GMC ‘Good medical practice’ says doctors must respect a patient’s right to reach decisions about their treatment and care. Our GP adviser said given Mr G did not want to go into hospital, increasing his water tablets was sufficient in line with the GMC guidance.
38. In September, Mr G’s leg swelling was still increasing. The Practice arranged repeat blood tests in order to consider starting another water tablet (spironolactone) to help his symptoms. This was in line with the NICE CKS on chronic heart failure. These blood tests then showed considerable abnormalities which Mr G was reviewed in hospital for.
39. As we have explained, it appears the Practice’s actions were in line with what we would have expected.
Blood test results
40. Mrs U is concerned the Practice did not act on Mr G’s blood test results relating to his kidney function. Our GP adviser explained eGFR is the important blood test to check for the kidney, not urea and creatinine. Urea and creatinine are usually raised when the eGFR drops and just a sign of kidney failure.
41. GMC ‘Good medical practice’ says the investigations or treatment a doctor provides or arranges must be based on the assessment they and their patient make of their needs and priorities. The doctor must also use their clinical judgement about the likely effectiveness of the treatment options.
42. Mr G’s eGFR (a measure of kidney function) was 37 in September 2021. This is low but was recorded as ‘stable results’ implying this was not a sudden drop compared to previous results. This remained stable when it was checked a couple of weeks later. In December 2021 the eGFR had decreased to 28 and therefore rechecked after one month which showed an improvement to 46. We are referring to these earlier results to provide context.
43. In May 2022 Mr G’s eGFR result was 32 which was lower than before was still relatively stable considering his previous results. It had lowered further to 24 in July but the Practice did not make a plan to repeat this. The consultation on 25 July acknowledges ‘CKD’ (chronic kidney disease) but gives no further explanation.
44. Point 40 of the GMC guidance on ‘Treatment and care towards the end of life’ says the benefits of a treatment that may prolong life, improve a patient’s condition or manage their symptoms must be weighed against the burdens and risks for that patient. The doctor had to consider this before they can reach a view about whether it could be in their interests.
45. Our GP adviser said it is difficult to say if the eGFR test should have been repeated by the Practice. In a deteriorating patient, it may not be appropriate as the result would be unlikely to change the Practice’s actions.
46. If the eGFR result had lowered further, Mr G would likely need a hospital admission which he had said he did not want. The water tablets could have been causing his decline but were also needed for his symptoms. This is where advanced planning could have been started, as the Practice has acknowledged.
47. If the eGFR result had remained the same, there would likely be no changes in Mr G’s care. The complaint response letter says the Practice made decisions based on the fact he did not want a hospital admission, and the main aim was symptomatic control.
48. Based on the available information and the advice we have received, we are unable to say Mr G did not receive the care he should have in relation to his kidney function.
Swollen scrotum
49. NICE CKS on scrotal pain and swelling says doctors should assess a hydrocele (fluid accumulation around the scrotum), consider possible underlying causes and arrange a referral or ultrasound scan based on their assessment. If the person has a large, symptomatic hydrocele the doctor should consider arranging a referral to a urologist.
50. We can see the Practice acted in line with this. The testicular swelling was felt to be a possible hydrocele and the Practice arranged an ultrasound scan. Out adviser said this initial plan was appropriate. The swelling was worsening so Mr G went to A&E.
51. The Practice managed Mr G in the way it should have done. We have seen no indication something went wrong in relation to this but we know there was an issue with the referral.
52. GMC ’Good medical practice’ says doctors must share all relevant information with colleagues involved in their patients’ care within and outside the team. This did not happen.
53. Our Principles of Good Administration say when mistakes happen, organisations should acknowledge them, apologise, explain what went wrong and put things right quickly and effectively.
54. The Practice has acknowledged that when it referred Mr G for the ultrasound scan, it did not mark the ‘urgent’ box. This contributed to Mr G being unable to have the scan at the time it was originally planned to take place. His mobility issues were also a factor.
55. Before we decide if we should conduct a detailed investigation of a complaint, we also look at whether there are signs the events complained about had a negative effect which the organisation has not put right.
56. Our GP adviser said even if the scan was done sooner, it is unlikely it would have resulted in a different outcome. Mr G’s fluid was being treated with water tablets and he would not have been a candidate for surgery. While we cannot change her father’s experience, we hope this helps Mrs U.
Co-ordination of care
57. Our GP adviser continuity of care in primary care is desirable but not always achievable. It was clear the Practice was responding to Mr G’s needs with telephone calls, home visits, blood tests and referrals for investigations. Essentially it was more reactive than proactive and in hindsight could have been better managed. The Practice acknowledged this.
58. It was clear Mr G was deteriorating and was making multiple contacts. Having one clinician dealing with him may have been ideal but having some advanced care planning discussions would also have helped. This could have involved discussing his preferences if he was to deteriorate further such as hospital admissions, palliation, and doing further blood tests. It is also important to involve family members.
59. The Practice has provided information to explain it has taken appropriate steps to correct this. It says it identified areas for improvement, including the lack of an end of life care plan when Mr G deteriorated, and as put a protocol in place to improve the continuity of care even when a patient’s primary GP is absent.
Conclusion
60. In summary, we can see there were issues in relation to the co-ordination of Mr G’s care and the referral for the ultrasound scan. The Practice has acknowledged these issues but Mrs U does not feel she has had appropriate apologies or evidence of improvements.
61. We raised what we had seen with the Practice. It told us it was happy to send a letter of apology to Mrs U. The Practice has shared this letter with us and we will send it to Mrs U. It has reflected its standard operating procedure was updated to reinforce the requirement to mark referrals as ‘routine’ or ‘urgent’. It has also taken steps to improve care co-ordination.
62. Having considered how the issues affected Mr G and looking at the Practice’s actions since, we have decided it has now done enough to put right the impact of these events. We consider its letter an appropriate resolution in the circumstances, in line with what our NHS Complaint Standards about taking action to put things right.
The treatment centre
63. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong in relation to the treatment centre.
64. Our Principles of Good Administration say organisations should be customer focused. This means they should do what they say they are going to do. If they make a commitment to do something, they should keep to it, or explain why they cannot. They should meet their published service standards, or let customers know if they cannot.
65. We understand the treatment centre holds appointments at various locations run by other healthcare providers (GP Practices) with differing facilities. Not all of these locations hold all mobility aids and this is why there is a minimum level of mobility required.
66. The ultrasound referral form says patients with mobility impairments must be able to get on and off the examination couch. During local resolution, the ICB explained the treatment centre was not aware of Mr G’s mobility needs until he arrived. We can see this is correct. Unfortunately, this meant the scan could not go ahead.
67. The ICB explained to us that when the treatment centre is made aware of mobility issues on referral forms it contacts patients to find out if they can self-transfer onto the treatment couch. In its complaint response it also explains it can try to accommodate needs ahead of time if it is warned.
68. We can also see that if the treatment centre cannot accommodate a person, it will write back to the referrer to let them know and an appointment will instead be made for a location that can accommodate them. This is what happened when the scan could not go ahead in September.
69. Based on the available information, we are satisfied the treatment centre’s actions were in line with our Principles of Good Administration. We have seen no indication anything went wrong in relation to this.
The Trust
70. 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 complained about with the negative impact Mrs U has claimed.
Categorisation
71. As Mrs U complains the Trust should have sent an ambulance sooner, we started by considering the Trust’s assessment that Mr G needed a category 3 response.
72. The Ambulance Response Programme guidance sets out four categories of call (1 to 4). Category 1 calls, from people with life-threatening illnesses or injuries, are the most serious and should receive the fastest response. Category 4 calls relate to a non-urgent problem.
73. NHS Pathways is a clinical tool used for assessing, triaging and directing the public to urgent and emergency care services. It involves using a set of pre-triage questions to identify those patients in need of the fastest response. Non-clinical health advisers are presented with a series of questions asked in a clinical hierarchy. Life-threatening questions are asked early in the call, progressing through to questions about less urgent symptoms.
74. The NHS Pathways system is broadly divided into three modules (0, 1, 2) with the system taking a symptom-based approach, rather than a diagnostic one. If the answers given to the symptoms assessed in Module 0 are sufficiently serious, the questions will trigger the dispatch of an emergency ambulance. No further questions or considerations of conditions are needed at this point.
75. Module 0 rules out some, but not all, life-threatening conditions. Once these have been ruled out, the health adviser reaches Module 1. Module 2 is only accessible to trained in-house clinicians.
76. In its complaint response, the Trust said it was experiencing extreme pressure and had had implemented its Surge Management Plan when its 999 service received the request for an ambulance. The Trust was unable to confirm whether it took other actions outlined in its surge management plan but told us it had implemented its emergency rule on call answering.
77. This, in effect, covers Module 0 of NHS Pathways. It means the call is answered as normal, but if life threatening symptoms can be ruled out the call is exited, and a category 3 ambulance is arranged.
78. Our adviser explained the ‘emergency rule’ that the Trust implemented is not a national approach and is something that it has used as a local workaround. While this approach does not reflect the national guidance, the Trust’s staff followed its local guidance.
79. Because the NHS Pathways assessment was terminated before it was fully completed and before all category 2 dispositions have been ‘cleared’ it is not possible to say definitively that the Trust appropriately categorised the calls as a category 3. We recognise Mrs U may still feel some uncertainty around this.
80. From what we have seen and what our paramedic adviser said, even if a full NHS Pathways assessment had been completed past module 0, it seems very unlikely Mr G would have received a category 2 response. We hope this reassures Mrs U.
Response time
81. Performance targets for the ambulance service are set out in the addendum to the Handbook to the NHS Constitution. The standard says 90% of category 3 incidents should be responded to within two hours.
82. The AACE report show nationally for September 2022, 90% of incidents were being responded to within 6 hours 51 minutes and 31 seconds. Other categories of incidents also did not meet the performance standards. This represents that all ambulance services were in a position where demand was outstripping resources.
83. The Trust has provided further information that illustrates the operational pressure it was under at the time. The response time for 90% of category 3 incidents for 29 September was just under 8 hours 20 minutes. For 30 September, it was just over 8 hours 23 minutes.
84. The response to Mr G was significantly above that and is an outlier. This does not in itself mean that there was an earlier opportunity to dispatch an ambulance. The Trust has confirmed it has reviewed all category 3 incidents that were held and none received a quicker response than Mr G aside from those that were upgraded.
85. As Mr G did not receive a call back, this limited the opportunity for him to receive an upgrade to his response. Our paramedic adviser explained had Mr G received a call back from a clinician, based on the available information, there is no indication that he would have been upgraded to receive a category 2 response.
86. Our adviser noted Mr G was able to converse normally on the final call and there is no suggestion of a rapid deterioration or other concern that would indicate a category 2 response. When the ambulance arrived, he has a NEWS2 of 3 and in line with NICE MIB205, indicated he was a ‘low risk’ patient.
87. There are no specific national guidelines or standards stating welfare calls should be performed but the Trust has an internal standard. It did not comply with its own relevant policies around providing patient welfare call-backs and review in relation to Mr G.
88. Despite this, given the severe operating pressures it was experiencing, it was also not realistic or reasonable to expect them to be able to do so. This is why we have not identified any indication of a failing here.
89. The Trust confirmed while Mr G was waiting for an ambulance, it carried out a review at 3.12am. Mr G’s final call occurred after this review so we cannot say the Trust considered the information provided then to decide if the category 3 response was still appropriate.
90. Our paramedic adviser explained that had a welfare call been completed, it is likely that the response would have remained a category 3. This means Mr G received an ambulance at the first opportunity.
91. While we cannot say Mr G should have been taken to hospital sooner, we do not wish to detract from what must have been a particularly challenging time for him and Mrs U.
92. Overall, we have seen no reason to investigate the concerns Mrs U brought to us further. We would like to thank her for bringing the complaint to us and we hope we have reassured her about the changes now in place.