A practice in the Dorset area

4. Ms R complains that on 7 December 2023 the Practice’s triage and assessment of her mother, Mrs T, were inadequate.

5. She says the Practice should have visited her mother urgently to physically assess her, or contacted an ambulance for her. She says the Practice delayed contacting her mother. She says it did not take seriously that her mother was panicking about her breathing and that she had difficulty breathing throughout the previous night.

6. Mrs T says this delayed her mother’s admission to hospital and meant her mother suffered and struggled at home during the day. She says her mother would not have died if she had been admitted to hospital sooner. She says her family have suffered greatly due to these events and her mother’s death.

7. In bringing this complaint Mrs T wants an apology and honesty from the Practice, a change in practice relating to their response to elderly people and financial remedy.

8. Mrs T was in her late 80s. She contacted the Practice early on 7 December 2023 requesting antibiotics as she thought she had a chest infection. The receptionist arranged for her to have a telephone call with a physician associate (PA) that afternoon.

9. At around 4pm that day, the PA telephoned Mrs T, assessed her and prescribed antibiotics. That evening, Ms R contacted 111 regarding her mother’s condition. The 111 call handler arranged an ambulance for Mrs T and she was admitted to hospital. Doctors diagnosed her with heart failure and pneumonia. Sadly Mrs T died a few days later.

13. 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.

14. Where we see signs the organisation has got something wrong, before we decide if we should conduct a detailed investigation of a complaint, we also look at whether there are signs the event complained about had a negative effect which the organisation has not put right.

Complaint about appointment booking call

15. The Practice’s Triage Aid sets out how staff triaging calls to the Practice should deal with some conditions or symptoms. It explains it is not an exhaustive list and if there is any doubt then staff should ask a doctor what to do.

16. The triage aid includes those conditions or symptoms which should be treated as a life-threatening emergency, those which are an emergency (but not life threatening), those requiring urgent face to face appointments and those which could be dealt with by a pharmacy.

17. Mrs T spoke to a receptionist when she called the Practice on the morning of 7 December. Mrs T said she was panicking a bit, thought she had a chest infection and would like antibiotics. The receptionist asked Mrs T if she was able to come into the Practice but she said she could not drive and could not get anyone to take her.

18. The receptionist therefore offered Mrs T a call that afternoon. Mrs T asked about the antibiotics and whether they could be sent to the pharmacy for her. The receptionist explained someone would need to speak to her first.

19. During the call, Mrs T did not mention any symptoms which would have prompted a same morning face-to-face appointment, in line with the triage aid. In any event, Mrs T had declined to come into the Practice to be seen in person. In doing so, there was no suggestion she was housebound due to ill health and needed a home visit.

20. The receptionist taking the call is not medically qualified. We recognise Mrs T said she was panicking, and the receptionist did not ask the reasons for that. Mrs T did not tell the receptionist that she was panicking about her ability to breathe or shortness of breath.

21. Having listened to the call and from our lay perspective, there was nothing within it to cause concern about Mrs T’s health and welfare. However, we would also like to reassure Ms R that on listening to the call recording, our adviser said that even from their medical perspective, there was nothing to indicate Mrs T was particularly unwell at that time.

22. We have seen no indication the Practice did anything wrong in how it dealt with Mrs T’s call and therefore we will not take any further action here.

Complaint about telephone appointment

23. Mrs T’s telephone consultation was with a PA. Although the PA was not a doctor, the consultation was delegated to them by a GP and they were working under the supervision of a GP.

24. GMC guidance says when delegating the care of a patient to a colleague, doctors must be satisfied the person providing care has the appropriate qualifications, skills and experience to provide safe care for the patient. The PA also discussed Mrs T with a GP who prescribed antibiotics, as PAs are not permitted to prescribe. Therefore, we consider GMC guidance is relevant in this case.

GMC guidance says to assess the patient’s condition adequately, taking account of their history and examining the patient where necessary. NICE guidance sets out how NHS services should assess someone by telephone call when they report signs and symptoms of an acute respiratory infection.

25. It says to arrange or refer the person for a face-to-face assessment if they have another condition that an acute respiratory infection could make worse, such as frailty. Any decision regarding the urgency and location of the face-to-face assessment should be based on the severity of symptoms and rate of deterioration.

26. The record shows when the PA spoke to Mrs T she had a wet sounding cough. She felt short of breath on exertion, was able to do her activities of daily living but felt breathless when walking up the stairs. She did not have a fever but felt hot and sweaty. She initially had symptoms of a cold, but these had improved

27. We can see the PA asked Mrs T about her symptoms, breathlessness and assessed her ability to speak in sentences. The PA has documented Mrs T was talking in full sentences. Our adviser said this and her breathlessness only when walking upstairs indicated her breathlessness was not severe.

28. The PA obtained as much information as was possible for a telephone consultation. Our adviser said there were no features at that point which suggested Mrs T was very unwell. There was nothing to suggest she needed hospital admission at this stage.

29. Ms R spoke to her mother shortly after the telephone consultation. She was concerned about her mother’s breathing and that her mother was frightened, so made a 100-mile journey to her house. We acknowledge that by almost 11pm that evening, Mrs T’s shortness of breath was such that 111 arranged an ambulance for her.

30. Ms R’s concern over her mother’s health at 5pm is understandable. She knew her mother best and would want to help and support her when unwell. We are unable to conclude that her understandable concern and an ambulance being arranged several hours later indicates one should have been arranged by the PA at 4pm.

31. However, our adviser said that despite not needing hospital admission at that stage, Mrs T was at risk of sudden deterioration due to her age. In its complaint response, the Practice noted Mrs T was frail. Ms R disputes her mother was frail, saying she was fit, independent and in good health.

32. In our view, if the Practice believed Mrs T was frail then it would have been in keeping with the NICE guidance for the PA to arrange a face-to-face assessment. This would have allowed a physical assessment and observations of Mrs T’s heart rate, oxygen saturation levels, temperature and blood pressure.

33. In line with NICE guidance, the PA would have considered the urgency of such an assessment. Our adviser said considering Mrs T’s presentation, a next day face-to-face appointment would have been reasonable.

34. We are aware Mrs T had initially declined to attend the Practice due to transport difficulties. However, the PA is a clinician and could have encouraged Mrs T to attend. We think it is likely Mrs T would have attended an appointment the following day.

35. We have seen no indication in the records or Practice response that the PA thought about the need for a face-to-face assessment. We consider this was not in line with NICE and GMC guidance. It is a sign the Practice got something wrong.

36. Ms R is concerned her mother’s admission to hospital was delayed, and that she was alone and may have been struggling and frightened during the day. We acknowledge this causes her a lot of upset.

37. Mrs T was admitted to hospital very late on 7 December. If an in-person assessment had been arranged for 8 December, Mrs T would not have been admitted to hospital any sooner than she was. Therefore, we have not found these events caused any delay.

38. Mrs T’s circumstances would have been the same during 7 December. If the PA had, on speaking to Mrs T, arranged a face-to-face assessment for the following day, it is likely Mrs T would still have spoken to her daughter shortly after, and her daughter would have travelled to her house.

39. Therefore, we cannot link Ms R’s upset about her mother’s experiences at home during the day to the events she has complained about. That is not to say we do not appreciate why she is upset but we cannot see it is the result of the Practice’s actions.

40. Overall, we have seen no reason to investigate Ms R’s concerns further. We would like to thank her for giving us opportunity to consider and address her concerns.

1. We have carefully considered Ms R’s complaint about her mother’s call to the Practice and the telephone consultation on 7 December 2023. We know how important this complaint is to Ms R and these events continue to cause her distress.

2. Having considered the complaint, we have decided we will not take any further action. This is because we have seen no indication anything went wrong in how the Practice handled Mrs T’s initial call.

3. Where something did go wrong with how the Practice dealt with the telephone consultation, we cannot link it to a delayed hospital admission or the distress Ms R has experienced.