Initial GP appointment on 7 January 2025
21. Ms E told us that in her opinion, if the doctor had prescribed antibiotics on January 7 2025 she may not have been so ill. Ms E said that she found out her temperature on January 7 was 38.2 and this as well as the symptoms she reported should have meant she was prescribed antibiotics to stop her condition deteriorating.
22. In its complaint reply the Surgery told Ms E: ‘On 7 January 2025, we agree a full, complete examination was carried out and there was good documentation of all observations with safety netting in place. Your symptoms and examination did not indicate a bacterial infection and antibiotics were not indicated, in line with clinical guidelines’.
23. We understand that Ms E feels strongly that if the doctor prescribed her antibiotics on her first attendance her health would not have deteriorated to the extent it did. We are sorry to hear about how sick Ms E became and that she was admitted to hospital with serious health concerns.
24. To consider if the doctor completed the appointment on 7 January 2025 in line with the relevant standards and guidance we have considered the guidance contained in the NICE guidance ‘Influenza – seasonal’.
25. This guidance sets out that if you are treating a patient for influenza you should only consider prescribing antibiotic if the person is in an at-risk group.
26. An at-risk group would be people aged over 65 years, children aged under 6 months, pregnant women, and people with any of the following conditions: • chronic respiratory disease, including: chronic obstructive pulmonary disease, chronic bronchitis and emphysema, bronchiectasis, cystic fibrosis, interstitial lung fibrosis, pneumoconiosis, and bronchopulmonary dysplasia.
• asthma that requires continuous or repeated use of inhaled or systemic corticosteroids or with previous exacerbations requiring hospital admission.
• chronic heart disease • chronic kidney disease • chronic liver disease • conditions in which respiratory function may be compromised • diabetes mellitus, including type 1 diabetes and type 2 diabetes • immunosuppression due to disease or treatment, including • people undergoing chemotherapy (or radiotherapy) leading to immunosuppression • morbid obesity (body mass index of 40 or more).
27. Ms C is not an at-risk group. We have asked her if she suffers from any of the conditions listed above and she confirms she does not. As this is the case the guidance confirms the doctor should not have prescribed antibiotic as Ms E thinks they should have.
28. This is also in line with NICE Antimicrobial prescribing guidance, that says: ‘Viral infections should not be treated with antibacterials. However, antibacterials may be used to treat secondary bacterial infection (e.g. bacterial pneumonia secondary to influenza)’. This guidance also confirms it was correct to not prescribe antibiotics on this first appointment, but to prescribe them on the second appointment, which we will explain further below.
29. Our adviser indicated that the history taking, examination, observations, diagnosis and management all fit with the clinical picture of influenza. As this is the case it was correct for the doctor to follow the above guidelines, which they have done.
30. We know Ms E is concerned that due to her high temperature the doctor should have prescribed antibiotics. The guidelines do list a fever as a symptom of influenza, so we can see the doctor took her temperature and considered it as part of the diagnosis. This did not change the clinical picture or indicate to the doctor that they should prescribe antibiotics.
31. The available evidence indicates that the doctor followed the correct guidelines and made a reasonable diagnosis considering the symptoms Ms E presented with at the appointment. We have seen no indications of maladministration in how the doctor conducted the appointment on 7 January 2025. As this is the case we will take no further action.
Second GP appointment on 10 January 2025
32. Ms E told us that although the Surgery had said this appointment was not as thorough as it could have been, she was prescribed antibiotics on this occasion. She also told us that the fact the Surgery admitted she could have had a more complete assessment shows it could have done more. Ms E said that following this appointment later the same day she had to attend Accident and Emergency (A&E), due to her worsening condition.
33. In its complaint reply the surgery told Ms E: ‘On review of the consultation on the 10 January 2025, we feel could have been a more complete assessment including a Blood Pressure check and respiratory rate. This information is used to score against the possibility of infections such as pneumonia or other bacterial infections. The clinician you saw on this date has taken this on board as part of his learning development’.
34. To consider if the appointment on 10 January 2025 had been completed in line with the relevant standards and guidance, we have considered the guidance contained in the NICE guidance ‘Chest infections – adult’. A physician associate conducted this appointment at the Surgery.
35. From the medical records we can see that the clinician correctly diagnosed a community acquired pneumonia. As this was the diagnosis the clinician also correctly prescribed antibiotics, specifically amoxicillin. This is in line with the NICE guidance that says for people with community-acquired pneumonia you should offer antibiotics.
36. Although we can see the diagnosis was correct, we can also see the physician did not carry out all the required observations on this appointment. The relevant guidance sets out that if an adult has symptoms suggestive of pneumonia, you should assess the severity of the illness using clinical judgement and the CRB-65 score for mortality risk.
37. The CRB-65 score is a clinical prediction rule used by healthcare professionals, to assess the severity of community-acquired pneumonia and determine the patient's risk of death within 30 days. The guidance says to calculate the risk you should give one point for each of the following: • Confusion (new disorientation in person, place, or time; or abbreviated mental test score 8 or less).
• Raised respiratory rate (30 breaths per minute or more).
• Low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg).
• Age 65 years or more.
38. If followed the guidance produces a score of between zero and four. A score of zero would indicate low risk with treatment at home. A score of one or two would indicate intermediate risk and consideration should be given to a referral to hospital. A score of three or four would indicate high risk and urgent hospital admission.
39. We know Ms E would not have scored three or four as she was not over 65 and was not suffering from confusion. However, as the clinician did not complete a blood pressure check or record the respiratory rate we do not know if Ms E might have scored one or two on the scale. If she had scored one or two hospital admission may have been appropriate.
40. As there are indications the clinician did not follow the relevant guidance, we have considered the impact on Ms E and what the Surgery have already done to address this.
41. In relation to the impact as we do not have the relevant observations we cannot say if the clinician completed these correctly it would have indicated a hospital admission was appropriate. We can also see to mitigate the risk to Ms E the clinician provided advice during the appointment.
42. From the medical records we can see the clinician advised Ms E that if her symptoms worsened, she should seek an urgent medical review. That was appropriate ‘safety netting’ advice. We know that later the same day Ms E followed this advice and attended her local A&E department.
43. Even if Ms E had scored one or two on the relevant scale she may not have been admitted to hospital any sooner, as that is only something to be ‘considered’ If she had been sent to hospital sooner, that would have been around four hours earlier. As any treatment she then received would have been the same, we have seen nothing to indicate there was any significant, clinical impact on her. We do understand Ms E’s frustration, at what happened and the fact that she will not know whether she might have been admitted to hospital earlier that day.
44. We have considered the impact on Ms E in line with our Principles for Remedy. As we can only say any impact on Ms E is in relation to frustration this would be at level one on our scale. A case will generally be level one if we consider the person affected has experienced a low impact injustice such as annoyance, frustration, worry or inconvenience. In cases such as this we will usually consider an apology to be an appropriate remedy for these cases.
45. We can see from the complaint replies that the Surgery has apologised to Ms E. The surgery has also taken steps to make sure the same mistake does not happen in the future. The Surgery provided a copy of the minutes from its meeting on 4 March 2025 in which Ms E’s complaint was discussed with the team and learning agreed. The clinician responsible has also taken learning from Ms E’s complaint.
46. We can see the Surgery have apologised to Ms E and taken appropriate steps to make sure the mistakes in the second appointment have been addressed. As the Surgery has already done enough to put right the impact on Ms E, we will take no further action.
47. We understand Ms E remains very concerned that because of failings at the Surgery her health deteriorated much more than it otherwise would. We hope the clear explanations of what we found can go some way to helping her understand why the Surgery did not do more on the first appointment. We are very sorry to hear that she did become extremely unwell and wish her the very best on her recovery.