A practice in the Braintree area

3. Mrs L complains about aspects of the care the Practice provided her husband, Mr L, prior to his death in July 2024.

4. Mrs L says the Practice: • did not implement a care plan for her husband • was not aware of just how unwell her husband was, despite receiving correspondence about his condition from secondary care • did not test her husband for type 2 diabetes.

5. Mrs L says as a result, the Practice did not offer her husband any potential advice, support, treatment, or medication he may have needed. Mrs L says her husband felt like he had nowhere to turn to when he was depressed, not sleeping or eating, and unable to walk very far at the end of his life. Mrs L said this caused her and her husband a great deal of distress.

6. As an outcome, Mrs L wants the Practice to acknowledge and apologise for what went wrong, and implement service improvements to reduce the risk of this happening with other patients.

7. Mr L was born in 1945, and had a history of cardiomyopathy (general term for diseases of the heart muscle), biventricular failure (when both sides of the heart are failing to pump blood effectively), left ventricular systolic dysfunction (when the heart's main pumping chamber can't squeeze effectively to pump out enough blood), left bundle branch block (where electrical signals to the left side of the heart are delayed or blocked, causing the ventricles to contract out of sync), and ischaemic heart disease (when narrowed heart arteries reduce blood flow and oxygen to the heart muscle).

8. Mr L had an internal cardiac defibrillator (a small device implanted in the chest to monitor heart rhythms and deliver electrical impulses or shocks to correct dangerously fast or unsteady heartbeats) fitted.

9. Mr L also had stage 3 (moderate) chronic kidney disease.

10. Mr L was under the care of secondary care cardiologists and nephrologists at a trust.

14. When we consider whether there is an indication of a failing in the care and treatment complained about, we first determine what should have happened in line with relevant policies, guidelines, standards and good clinical practice. We then use all available evidence to determine if we can say what should have happened, did happen. If it did not, we then consider if what did happen fell so far short of what should have happened that it amounts to an indication of a failing.

15. Only if we identify an indication of a failing in the care and treatment provided do we then consider the impact of this failing.

Care plan

16. Mrs L complains the Practice did not implement a care plan for her husband.

17. The Practice said there is no requirement for primary care to have a care plan in place for someone with a long-term condition, which is why it did not have one.

18. NG106 says, ‘The specialist heart failure MDT should write a summary for each person with heart failure… [and] Use the summary as the basis of the person's care plan’. Our adviser told us the MDT responsible for this would have been the cardiology team in secondary care. We are not considering the trust’s actions as part of this complaint.

19. Our adviser told us they are not aware of any guidance which say a person with chronic heart failure needs to have a separate or different care plan in place in primary care. Mr L’s condition was complex, and secondary care were monitoring him closely. It would have been for the Practice to follow directions from secondary care where required, and undertake regular blood tests and medication reviews, which it was doing.

20. Mrs L highlighted the NHS website which says, ‘If you have heart failure, you and everyone involved in your care will be given a care plan… The care plan should be reviewed at least every 6 months by your GP.’

21. Our adviser told us the NHS website is information for patients, and not a guideline primary care clinicians must follow. However, even if the Practice were to have reviewed Mr L’s care plan as it says, it would not have been its place to amend or override it.

22. Mrs L also highlighted the personalised care operating model. While this talks about personalised care and support planning, there is nothing which specifically says primary care should have a care plan in place. Our adviser also told us it is not a specific guideline primary care clinicians must follow.

23. We were sorry to learn Mr L felt unsupported by the Practice at the end of his life. We have seen there was no requirement for the Practice to have its own care plan in place for Mr L. We will therefore not consider this aspect of the complaint any further.

Condition

24. Mrs L complains the Practice was not aware of just how unwell her husband was, despite receiving correspondence about his condition from secondary care.

25. The Practice said it reviewed, and acted upon where necessary, any letters it received from the hospital. The Practice explained its actions were dependent on the instructions from the specialists.

26. Mr L’s records detail the regular blood tests and medication reviews the Practice carried out, as well as the heart failure reviews with the community cardiac team. The records also contain various letters to the Practice from secondary care.

27. Our adviser told us there is no evidence the Practice failed to follow up on any requests from secondary care. We have not seen anything to suggest the Practice was not aware of how unwell Mr L was. We will therefore not consider this aspect of the complaint any further.

Diabetes

28. Mrs L complains the Practice did not test her husband for type 2 diabetes.

29. The Practice said her husband did have tests for diabetes and the results of these were normal.

30. Mr L’s records contain results from blood tests the Practice carried out on 21 November 2022, and 25 September 2023. These results include Mr L’s HbA1c levels, which clinicians can use to diagnose diabetes.

31. Our adviser told us they are not aware of any guidelines which say when a person with chronic heart failure should be tested for diabetes. In general, a diabetes test would be done annually at a patient’s health check.

32. The Diabetes UK website says, ‘You have diabetes if your HbA1c level is 48mmol/mol or above. You are at risk of developing type 2 diabetes (often known as prediabetes) if your HbA1c is between 42 and 47mmol/mol.’

33. The Practice recorded Mr L’s HbA1c levels as 36mmol/mol in 2022, and 39mmol/mol in 2023, which are within the normal levels. As Mr L’s last test was in September 2023, he would not have been due another until September 2024. However, Mr L sadly died in July 2024.

34. We recognise Mr L did develop diabetes, and this was listed on his death certificate, which must have been concerning for Mrs L. We have seen the Practice did regularly test Mr L for diabetes as it should have, and the results of these tests were normal. We will therefore not consider this aspect of the complaint any further.

35. This concludes our consideration of Mrs L’s complaint. We thank Mrs L for bringing us her concerns.

1. We have carefully considered Mrs L’s complaint about a Practice in the Braintree area (the Practice). We were very sorry to learn of the death or Mrs L’s husband, Mr L. We recognise that having concerns about a person’s care and treatment in the run up to their death can make an already difficult time even more upsetting.

2. We have decided not to consider Mrs L’s complaint any further. This is because we have seen the Practice did not make any mistakes in its care of Mr L.