16 February consultation
19. Mrs H explains her daughter did not receive a thorough assessment from the nurse practitioner when she attended the Practice on 16 February. She is also concerned the nurse practitioner was unsupervised and there was no input from a GP.
20. Mrs H tells us her daughter’s symptoms where not fully explored, and this led to her avoidable death less than 24 hours later.
21. We recognise this tragic loss understandably continues to cause Mrs H and her family a great deal of distress.
22. The Practice says its nurse practitioner thoroughly examined Miss G, took a good history of her symptoms and recommended a salbutamol inhaler trial to see if this improved her condition.
23. The Practice says this course of action was reasonable based on Miss G’s symptoms. It adds that its nurse practitioners have ready access to GP input if they need support.
24. NICE PE guidance and NICE PE risk factor guidance set out the symptoms commonly associated with PE and the factors which may increase the risk of PE.
25. NMC guidance sets out how nurses can provide good care. Sections 1.4, 2.1 and 7.5 say nurses must ensure they communicate effectively, listen to patients under their care and provide treatment without delay.
26. Miss G attended the Practice on 16 February with a cough and tachycardia (high pulse rate). A normal pulse rate is between 60 and 100 beats per minute. Miss G had a pulse rate of 102 beats per minute.
27. NICE PE guidance lists a cough and tachycardia, among other symptoms, as being a possible indicator of PE. Miss G was also on the combined oral contraceptive pill. This is among the risk factors listed in NICE PE risk factor guidance.
28. We can see the nurse practitioner took a good medical history from Miss G and noted her temperature, respiratory rate and oxygen saturations were normal.
29. The nurse practitioner also reported Miss G’s chest was clear with no wheeze or crackles. Wheeze or crackles could be a sign of a narrowing airway, infection or fluid on the lungs.
30. We can also see the nurse practitioner provided Miss G with safety netting advice should her symptoms worsen. Safety netting advice ensures the patient knows what to do if their condition fails to improve.
31. Our nursing adviser notes Miss G’s presentation was of a well person with mild respiratory symptoms which are within the scope of a nurse practitioner and there were no worrying symptoms which would trigger escalation to a GP.
32. While Miss G did present with a cough and tachycardia (which are among the symptoms listed in NICE PE guidance), we do not think these two symptoms alone should necessarily have necessitated further exploration around possible PE in the absence of more serious or obvious symptoms.
33. We also acknowledge Miss G was on the combined oral contraceptive pill which is listed as a risk factor for PE. We are not persuaded, however, that this should have altered the nurse practitioner’s thinking at the time.
34. This is because Miss G’s symptoms were not clearly indicative of PE, so use of the oral contraceptive pill would understandably not have factored into their decision making at this time.
35. Having carefully considered the available evidence, we think the nurse practitioner correctly assessed Miss G in line with NMC guidance and there is nothing to suggest they should have escalated her care to a GP.
36. For the reasons set out above, we have decided to take no further action in this part of Mrs H’s complaint.
37. We understand Mrs H has been through a great deal and it is clear her bereavement has deeply affected her. Although our decision may be disappointing, we hope she is assured that we have carefully considered her concerns.
Complaint handling
38. Mrs H tells us it took the Practice nine months to respond to her complaint and it did not update her during this period. She says she received the Practice’s response, dated 24 October 2024, nearly six weeks later on 7 January 2025.
39. We can see Mrs H complained to the Practice on 22 April 2024. She received an acknowledgement letter from the Practice on 26 April which confirmed it would investigate her concerns.
40. Mrs H wrote to the Practice again on 10 August asking for an update but received no reply. She wrote to it asking for an update on 23 September but again received no reply.
41. As described above, she received the Practice’s response on 7 January 2025.
42. We asked the Practice why it did not respond to Mrs H between 26 April 2024 and 7 January 2025. The Practice says it did not respond as it thought it was about to issue its response around the time it received Mrs H’s letters in August and October.
43. It agrees this was the wrong approach and it should have responded to Mrs H regardless of where it was up to with her complaint.
44. It also says there were additional delays in posting out its response to Mrs H. It appears the response was largely complete around October, but further delays meant it did not send the letter until a few months later.
45. The Practice also appears to have forgotten to amend the date on its complaint response before sending it. This likely explains why the letter Mrs H received in January 2025 had an October 2024 date.
46. NHS complaint regulations say that if an organisation cannot respond within six months it must write to the complainant and set out its reasons for the delay.
47. Our complaint standards say public bodies should keep the complainant regularly informed about progress and the reasons for any delays.
48. We can see the Trust did not write to Mrs H in October to set out why it was going to take more than six months to respond to her complaint.
49. The Practice also did not respond to Mrs H’s letters in August and September and caused additional confusion by forgetting to amend the date on its letter before issuing it.
50. Overall, we can see an indication something went wrong with the Practice’s complaint handling as its actions are not in line with NHS complaint regulations or our complaint standards.
51. We recognise Mrs H was already mourning the loss of her daughter at the time so the Practice’s lack of contact will have added unnecessary upset and frustration at an already difficult time.
52. Mrs H experienced additional upset and frustration as a result of these delays for around nine months until she received the Practice’s response on 7 January 2025.
53. We consider Mrs H is at level two on our severity of injustice scale. This scale is set out in our remedy guidance and contains six different levels of injustice that a complaint could fall into, which increase in severity.
54. A level two injustice will typically arise where a relatively low impact has been caused by what went wrong. It will often result in a degree of distress and can also include instances where an injustice was more serious and lasted for several months.
55. We understand Mrs H wants the Practice to acknowledge its mistakes, apologise for them, improve its service and to pay her a financial remedy.
56. As set out above, we contacted the Practice and discussed Mrs H’s concerns about its complaint handling.
57. It agreed to write to Mrs H to acknowledge its mistakes and to apologise for them. We have seen a copy of this letter and can see it also includes service improvements.
58. The Practice says it has since tightened its complaints process which it hopes will mean complaint responses are issued much more quickly.
59. It also says it is actively considering the recruitment of a patient liaison role to provide a clear point of contact. It says this should ensure patients receive timely updates and reassurance at every stage of its complaints process.
60. Having carefully considered this in line with our remedy guidance, we think the explanation we have set out alongside the apology and service improvements the Practice describes are appropriate to put right the upset and distress caused to Mrs H. We do not think it is proportionate for the Practice to pay a financial remedy under these circumstances.
61. For the reasons set out above, we have decided to take no further action in Mrs H’s complaint.
62. We understand the events described in our statement have been very distressing to Mrs H and her family and appreciate their experience continues to affect them. We hope we have been able to provides some reassurance that we carefully considered Mrs H’s concerns, and we thank her for bringing this complaint to our Office.