Chest infection
14. Mrs A says the Practice did not recognise or treat her father’s chest infection early enough. She says hospital staff later told her the infection had been present ‘for months’, which she feels contradicts the GP’s view that it was new. We are sorry to hear how upsetting and confusing this has been for her, especially during such a difficult time.
15. NICE guidance on chest infections says antibiotics are not routinely needed and should only be prescribed when someone is systemically unwell or at higher risk of complications. If symptoms get worse, the person should be reassessed to rule out pneumonia. For pneumonia, hospital admission should be considered when symptoms suggest a more serious illness or are not improving with treatment. Decisions about treatment or referral should be based on the person’s symptoms, observations, and overall condition.
16. The GMC guidance says in providing clinical care you must adequately assess a patient’s condition, taking account of their history and symptoms and carry out a physical examination where necessary. It also says to promptly provide (or arrange) suitable advice, investigation or treatment where necessary.
17. On 23 February, the Practice conducted a home visit to Mr B. The appointment was requested due to concerns about his congestion and breathing. The GP examined Mr B and concluded this was normal. It is noted Mr B had mucus and a cough. The GP felt there were no signs of a chest infection at that time.
18. On 18 May 2023 the Practice conducted another home visit as the family felt Mr B’s symptoms were worsening. An examination was performed which found nasal mucus, a cough, and crackles on the chest. His oxygen saturations and heart rate were normal. An antibiotic was prescribed. The GP felt hospital admission was not required based on the examination findings.
19. The Practice conducted a further home visit on 31 May 2023. The GP performed an examination which showed Mr B still had a cough, and crackles were again heard on his chest. His oxygen and heart rate were normal. A second course of antibiotics was prescribed, and blood tests were arranged. The tests showed a normal white cell count and only a mildly raised CRP (is a signal in your blood that tells doctors if your body is dealing with inflammation). The GP felt these results did not indicate a serious infection or the need for hospital admission.
20. On 11 June, the Practice conducted a further home visit after the family raised concerns about Mr B’s ongoing cough and congestion. His observations were normal, and his chest was clear. The GP felt there were no signs of infection, so antibiotics or admission were not needed.
21. On 21 June, Mr B’s carers reported a cough and wheeze. A telephone consultation took place with the Practice who prescribed antibiotics.
22. On 4 July, the Practice conducted a home visit to Mr B again for his persistent cough and tiredness. The GP performed an examination which showed his oxygen levels and heart rate were normal, and his chest was clear. Blood tests were arranged, and a sputum sample was taken. The BNP test (is a test that helps doctors see if someone’s heart is under pressure or not working as well as it should) suggested worsening heart failure, and the sputum sample showed no bacterial infection.
23. Our GP adviser said the Practice assessed Mr B appropriately at each contact. They said, in line with the NICE guidance on chest infections, antibiotics were appropriately prescribed when there were signs of a chest infection and not prescribed when examinations were normal. Our GP adviser also said that the decision not to arrange a hospital admission at any stage was reasonable, as Mr B’s symptoms and observations were stable on every review. Our GP adviser said the Practice managed Mr B’s chest symptoms appropriately between February and July.
24. We consider the Practice appropriately examined Mr B during each home visit in line with the GMC guidance, and conducted appropriate investigations, such as blood tests and listening to his chest, to assess Mr B’s condition. As Mr B was systemically unwell so at a higher risk of complications, the Practice prescribed antibiotics, in line with the above NICE and GMC guidance, when Mr B showed signs of a chest infection. We have not seen any indications the Practice did anything wrong in how it assessed or managed Mr B’s chest symptoms.
25. We appreciate how distressing this situation has been for Mrs A. Based on the clinical records, the guidance, and the advice we received, we have not seen any indication anything went wrong in how the Practice assessed or managed Mr B’s chest symptoms. As such, we will not consider this part of her complaint any further.
Indapamide prescribing and communication
26. Mrs A says the GP prescribed indapamide during a period of very hot weather without explaining what the medicine was for or the risk of dehydration. She believes this made her father more unwell, contributed to kidney injury, and played a role in his death.
27. In its complaint response, the Practice explained indapamide was started on 12 July for fluid overload linked to heart failure, following discussion with its heart failure nurse. It accepted it did not inform Mrs A when prescribing it and apologised for this. The Practice said Mr B had taken indapamide before for over a year without problems, so it did not expect significant side effects.
28. The GMC guidance says doctors must give patients information about their care and treatment in a way they can understand. This includes listening to patients, taking account of their views, and explaining what a medicine is for and any important risks.
29. We have not seen any evidence in the records that the Practice explained the indapamide prescription to Mr B or his carers to explain what is was for or any important risks. This is not in line with the GMC guidance and we consider this is an indication of a failing.
30. NICE guidance on chronic heart failure says treatment decisions should follow evidence-based recommendations. It also explains how patients taking diuretics should be monitored. Diuretics (often called water tablets) help the body get rid of extra fluid by increasing urine. Thiazide-type diuretics, such as indapamide, are a specific group of these medicines.
31. Our GP adviser explained that indapamide is licensed for treating high blood pressure, but it is not recommended for treating heart failure in the NICE guidance on chronic heart failure. On 11 July 2023, the Practice prescribed indapamide to treat Mr B’s heart failure, which our GP adviser said was not appropriate and was not in line with this guidance. As this prescription was not in line with the NICE guidance, we consider this is an indication of a failing.
32. Mrs A says if she had been told about the risks of this medication then she would have stopped it sooner. She also says the inappropriate prescription caused kidney failure, placing strain on his heart, and resulting in his death in August 2024. As we identified indications of failings, we then looked at what impact these indicated failings had and whether these led to a worsening of Mr B’s condition, resulting in his death as Mrs A claims.
33. Our geriatrician adviser explained indapamide is a mild diuretic that helps the body get rid of extra fluid by increasing how much you urinate. It is usually used for high blood pressure, not heart failure. As indapamide is only a mild diuretic, our geriatrician adviser said it is unlikely to have contributed to any dehydration or kidney injury. In their view, the indapamide played no meaningful role in Mr B’s decline.
34. Our geriatrician adviser explained that the main cause of Mr B’s deterioration was a severe and unusual bloodstream infection called Streptococcus dysgalactiae, which was confirmed in his blood cultures on 28 July. This type of infection is known to be particularly dangerous in older, frail people and can directly damage the kidneys. Our geriatrician adviser said this type of infection often starts when bacteria enter through broken skin, such as chronic wounds or areas of skin irritation.
35. The records show that community nurses had been treating several skin wounds in the weeks before Mr B’s admission, and our geriatrician adviser said these were the most likely source of the infection.
36. Our geriatrician adviser said Mr B’s blood pressure was low at times during the first three days in hospital, which can happen with sepsis, dehydration or worsening heart failure. His kidney function continued to worsen until 31 July, and a blood test that shows inflammation in the body (called an inflammatory marker) rose sharply in early August. This pattern shows the infection not the indapamide was the main cause of his decline.
37. The records also show that chest imaging during his admission showed no chest infection, only fluid related to heart failure, which confirms he did not die from a chest infection but from this severe infection.
38. Therefore, we have seen no evidence that the inappropriate prescription or the lack of communication around this had an impact on Mr B, or led to, or contributed to, his decline or death.
39. While we have seen indications of failings in the prescribing of indapamide and the communication around this, we cannot say that this contributed to Mr B’s deterioration or death. As these indications of failings did not lead to any impact we will not consider this part of the complaint any further.
40. We appreciate how upsetting and worrying these events have been for Mrs A. We hope the explanations from our geriatrician adviser provide some reassurance that her father’s sad death was not linked to the indapamide or a chest infection.