Telephone consultation 23 May 2023
18. Mrs H raised concerns about the decision of the Surgery not to refer her husband to a doctor or to the hospital when her husband had a telephone consultation on 23 May 2023.
19. The recorded evidence shows the telephone triage was conducted by an Advanced Nurse Practitioner (ANP). Mr J complained of loss of appetite over a two-week period, feeling nauseated, losing weight and changes in his bowel habit.
20. Our adviser explained given the symptoms had been present for over a two-week period there was no acute/immediate concern which would warrant a recommendation to attend the emergency department (A&E). Therefore, arranging a face-to-face consultation was appropriate.
21. Our adviser also explained there is no indication to suggest a doctor should have seen Mr J. ANPs work with a high degree of autonomy and complex decision making and our adviser explained there is no specific point at which guidance or advice should be sought from the GP. This will be based on the individual’s own competencies. As outlined in the Health Multi-professional framework for advanced clinical practice in England:
“Practice in compliance with their respective code of professional conduct and within their scope of practice, being responsible and accountable for their decisions, actions and omissions at this level of practice”
22. Whilst we find an ANP appears to have been an appropriate clinician to treat Mr J, our adviser explained that given his clinical history and presenting symptoms a more thorough review should have been carried out. Specifically, was Mr J drinking enough, could he be dehydrated, was he feverish, was he passing urine more or less frequently.
23. Our adviser went on to say ensuring there was no risk of dehydration was particularly important given Mr J was taking metformin. This is because individuals taking metformin, who are also dehydrated can develop serious side effects.
24. Our adviser explained given Mr J’s presenting symptoms he should have been seen the following day, and the Surgery should have advised him to stop taking metformin until he was assessed. This would help prevent lactic acidosis (excess buildup of lactic acid in the blood, leading to a life-threatening metabolic state).
25. Know Diabetes Sick day guidance of Type 2 Diabetes states:
‘If you are taking metformin…. and you have sickness and/or diarrhoea, you MUST STOP these drugs until you start eating and drinking normally again’.
26. NMC ‘The Code. Professional standards of practice and behaviour for nurses, midwifes and nursing associates’ states:
1.4 make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay.
13.1 accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care.
27. Furthermore, NMC Future nurse: standards of proficiency for registered nurse’s standards state:
5.5 identify, respond to and manage nausea and vomiting.
28. We find the Surgery should have arranged a face-to-face consultation sooner and should have advised him to stop taking metformin until he was seen. It also appears the Surgery should have carried out a more detailed history of Mr J’s presenting symptoms.
29. We will consider the impact of this potential failings further down in our report.
Consultation 26 May 2023
30. Mrs H has also raised concerns about the consultation the Surgery had with her husband on 26 May 2023.
31. The records show the Surgery saw Mr J in clinic. His symptoms were documented as, losing considerable weight over the last eight weeks, nauseated all the time (no abdominal pain) and is no longer eating.
32. The evidence shows the Surgery carried out a digital rectal examination (DRE) and an abdominal examination. The ANP felt a soft hard lump during the DRE and a hard mass to the left lower side of the abdomen. The ANP documented that the abdominal exam was difficult as Mr J was ‘tensing’ with palpation.
33. Our adviser explained it would be expected for the ANP to ask why Mr J was tensing, to understand whether this was causing him pain. However, it does not appear this was explored during the consultation and therefore the cause of the tensing was unknown.
34. Our adviser went on to say that given Mr J was not eating the ANP should have asked him, when he last ate something, if was he drinking, if he felt dizzy, weak or tired and if he was passing urine. The ANP should also have taken Mr J’s physiological observations (as a minimum; blood pressure, temperature, pulse, respiration rate) due to the symptoms he was displaying. It does not appear this was done. Again, in line with NMC ‘the code’ guidance as stated in paragraph 26.
35. The records show the ANP advised Mr J that the examination found a suspicious ‘mass’. The Surgery subsequently referred him under the two-week pathway due to a suspected colorectal cancer.
36. Our adviser explained the referral was appropriate as the examination led to a suspicion of a lower gastrointestinal cancer (the mass, the weight loss, nausea, and the change of bowel habits documented during phone triage).
37. However, our adviser stated a coexisting acute illness should also have been suspected due to Mr J not eating, tensing on abdominal exam and feeling nauseous. His physiological observations (as a minimum; blood pressure, temperature, pulse, respiration rate) should have been documented to assess for the severity of any acute illness. This would have helped establish the National Early Warning Score (NEWS2).
38. NEWS2 is a standardised scoring system used in healthcare to assess adult patients at risk of acute illness deterioration. It is built into the primary care system and can be used to guide the clinical response and can help ascertain whether a patient needs hospital admission.
39. Our adviser explained If after documenting physiological observations and taking a more thorough history, it was concluded Mr J did not need hospital admission, the ANP should have given safety netting advice in line with BMJ guidance which states:
• Safety-netting advice has since been defined as: “Information shared with a patient or their carer, designed to help them identify the need to seek further medical help if their condition fails to improve, changes, or if they have concerns about their health.”
• Safety-netting has become a widely used term to describe an array of activities both within the consultation and on systems levels. Within the consultation, safety-netting is considered best practice, and often an expected clinical standard, particularly in primary and emergency care.
40. Furthermore, our adviser once again explained that the ANP should have advised Mr J to pause his metformin until he started eating and drinking normally. Again, to help prevent lactic acidosis (excess buildup of lactic acid in the blood, leading to a life-threatening metabolic state).
41. From the evidence available, we found the ANP did not carry out any physiological observations or provided any safety netting advice to Mr J in line with the guidance we have referred above. An appropriate referral through the two-week pathway was made for suspected colorectal cancer.
42. Weighing up the evidence we found the Surgery should have taken a more thorough history of Mr J’s presenting symptoms and it should have taken his physiological observations to assess whether there was any coexisting acute illness (in addition to suspected cancer). This would have allowed the Surgery to establish whether hospital admission was required or whether safety netting advice was needed.
Impact
43. Mrs H told us the actions of the Surgery ultimately led to Mr J’s death, and she says had he been seen in hospital sooner he would not have died.
44. Very sadly, we can see three days after the consultation on 26 May 2023 Mr J was taken to hospital via an ambulance. On admission he had a high NEWS2 and had left sided chest pains.
45. Whilst in hospital, staff carried out several tests and scans to determine the cause of Mr J’s symptoms and the reason for his deterioration. During his admission, the hospital established he had developed sepsis.
46. Our adviser explained although there was a failure to consider whether Mr J had an acute illness during both consultations, it is not possible to conclude the Surgery failed to identify sepsis or any other acute illness or infection. This is because no observations were taken.
47. Furthermore, it is unclear from the evidence we have seen, when Mr J developed sepsis. Sepsis has a lot of possible symptoms. These include:
• Acting confused, slurred speech, or difficulty making sense, • Severe breathlessness or breathing very fast, • Blue, pale, or blotchy skin, lips, or tongue, • Feeling dizzy or faint, • Extreme shivering or muscle pain, and • Passing no urine (in a day).
48. From the evidence recorded, it does not appear Mr J had any of these symptoms at the time of either consultation. As such, we cannot say on the balance of probability, Mr J had sepsis at the time of either consultation.
49. However, we do appreciate had the Surgery carried out more observations this may have identified further symptoms. This in itself is an injustice that the Surgery has yet to put right. We found at it missed an opportunity to consider the appropriate treatment and potentially admit Mr J to hospital sooner.
50. We appreciate Mrs H will always have a degree of uncertainty about her husband’s tragic death and we understand the level of distress and upset this has caused her. Furthermore, we have no doubt the events which took place have significantly impacted Mrs H given the loss of her husband. It must have been shocking to see Mr J deteriorate so soon after his admission in hospital.
51. We cannot say the actions of the Surgery resulted in Mr J death, nor can we say it failed to identify sepsis. However, the surgery has not yet acknowledged its failure to carry out appropriate actions when Mr J attended the Surgery, or said what it might do in future to avoid this recurrence. We have set recommendations to the Surgery, to remedy this.