15. 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 follow an open and fair process of reaching an independent and impartial decision in the work that we do. We are unbiased in reaching that view and to do so, when we look at a complaint, we first use relevant standards and guidance to inform us what should happen.
16. We then look at all accounts of events to establish what did happen. We do this by taking the complainants’ account and the organisation account into consideration. Following this, we look at whether the care and treatment fell below the relevant standard to such an extent as to be considered a failing. We have done this and have not found any indications that the practice failed to provide appropriate care and treatment to Mrs K.
17. Mr K complains that the practice failed to investigate and treat his mother, Mrs K during home visit appointments on 14 August, 29 August and 18 September 2024.
18. He told us he felt the practice should investigated her symptoms more urgently and arranged further follow ups which could have prevented her admission to hospital.
19. In the response of 28 November 2024, the practice explained it arranged a number of follow up investigations and an urgent referral which it felt was appropriate. It said there was no indication at the time to escalate her care further through an immediate admission to hospital.
20. We sought input from our GP clinical adviser to help inform our decision. We acknowledge that the first two home visits on 14 and 29 August were carried out by a community paramedic. However, these clinicians were acting under the supervision of a registered GP, and we therefore consider advice from a GP is suitable for this case.
21. From our advice we understand there are no specific clinical guidelines on the management of generalised vomiting. However, our adviser referred to the General Medical Council’s guidance on good medical practice as relevant to the complaint. Point 15 of the guidance explains clinicians must ‘provide a good standard of practice and care. If [they] assess, diagnose or treat patients, [they] 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 patientb) promptly provide or arrange suitable advice, investigations or treatment where necessaryc) refer a patient to another practitioner when this serves the patient’s needs’
22. Mr K has raised concerns about the practice’s actions at each of the three appointments. We will consider each of these in turn.
23. At the appointment on 14 August, Mrs K reported vomiting intermittently for a period of around three weeks. The paramedic recorded her observations as within the normal range and noted she reported eating well and no change in her bowel habits.
24. The community paramedic recommended that Mrs K monitored the episodes of vomiting to try and establish a pattern and review this as required. Having sought input from our adviser, we understand this was an appropriate plan to adopt moving forward. Our adviser explained there was no evidence to indicate that Mrs K required admission to hospital or further investigations at this stage. We can see in line with GMC guidance the clinician adequately assessed the patient’s conditions, took account of their history and provided or suitable advice going forward, including investigations or treatment where necessary.
25. The practice carried out a second home visit on 29 August. This followed a request submitted by Mr K on 28 August explaining that Mrs K’ symptoms had not resolved. At this visit Mrs K reported continued vomiting and difficulty swallowing. The community paramedic again recorded her observations in line with GMC guidance as within acceptable ranged and documented normal bowel movements and urine passing.
26. The paramedic took bloods at this visit which showed slight indications of anaemia. From advice sought we recognise this does not mean immediate treatment or a hospital admission was required. After a discussion with the supervising GP, the practice also started Mrs K on a proton-pump inhibitor (PPI), a medication for stomach acid reflux. We understand both taking bloods, and commencing a PPI are appropriate steps to have taken based on Mrs K’s symptoms and are in line with the GMC guidance identified above.
27. Following the discussion with the community paramedic, the supervising GP also initiated a referral to gastroenterology under the two-week wait suspected cancer pathway. This is consistent with section ‘c’ of the GMC guidance to refer to another practitioner (specialist). Our adviser also referred to the National Institute of Health and Care Excellence’s guideline NG12 on suspected cancer: recognition and referral (NICE NG12) as relevant guidance for this part of the complaint.
28. Section 1.2.1 of NICE NG12 explains clinicians should refer people using a suspected cancer pathway referral for oesophageal cancer if they have dysphagia (difficulty swallowing) or are aged 55 and over, with weight loss, and they have any of the following: upper abdominal pain; reflux or dyspepsia.
29. Mrs K’s symptoms as documented in the clinical records met the criteria outlined above. It was therefore appropriate for the practice to make a referral under the two-week pathway.
30. The practice arranged for a third home visit to be carried out on 18 September. This was conducted by one of the practice GPs in response to an online request sent by Mr K.
31. By this point, Mrs K reported continued difficulties with vomiting for several weeks. The GP did not record any symptoms which would indicate a requirement for an urgent admission to hospital at the time of this visit.
32. From independent advice sought we understand the most relevant follow-up to offer at this appointment would have been a referral under the two week wait but this had already been made. The clinician also prescribed anti-sickness medication which our adviser said was a reasonable and appropriate decision to take based on the symptoms she was experiencing. This was also in line with GMC guidance on good medical practice.
33. Mrs K was admitted to hospital via ambulance on 20 September, two days after the last home visit by the practice. This followed an ambulance visit for an unwitnessed fall. We appreciate this must have been a difficult and worrying time for Mr K.
34. As we have explained above, having sought advice we consider the treatments and investigations offered at each of the home visits in question were appropriate and in line with the relevant clinical standards. The practice prescribed appropriate medication, carried out blood tests and safety netted Mrs K. The practice also referred her to gastroenterology for follow-up under the two-week pathway in line with guidance.
35. Having reviewed the available relevant evidence, we have seen nothing to suggest that the symptoms Mrs K was experiencing required urgent treatment or escalation through a hospital admission on each of the three occasions (14 August, 29 August and 18 September).
36. Based on this, we consider we have seen no indication that the practice failed to act in line with the relevant guidance. We are therefore not intending to look into the complaint further. We appreciate this decision will be received with disappointment by Mr K but seek to reassure him we have carried out an independent consideration of his complaint.