18. When we consider 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. If we see signs of a mistake, we look at the likely impact caused and what the organisation has done to put things right.
The Practice – Attendance
19. Mrs A says Practice staff should have attended Mr R’s care home to provide him with a face-to-face consultation. We considered this issue with the help of our GP adviser. Mr R’s clinical records show that as of 13 August 2024, Mr R was a new patient who had recently moved to the care home. The records show Mr R had a number of pre-existing medical problems, including a documented history of issues with his catheter. We can see the clinical records include a full assessment of Mr R’s needs regarding his catheter prior to the events of 13 August 2024.
20. Following a consultation, the Trust’s Neighbourhood Triage Team advised staff at the Care Home to contact Mr R’s GP. Mr R’s medical records show the care home contacted the Practice on the afternoon of 13 August and their request was triaged to identify whether Mr R required contact from a GP. A GP spoke with the team leader at Mr R’s care home via telephone approximately 30 minutes later. According to the records, Mr R was reported as being well, with his catheter draining clear urine, but he was experiencing discomfort within the area of the catheter.
21. In response to the reported symptoms, the GP issued a remote prescription for a cream to be applied at the catheter site, provided advice on what to do should Mr R’s symptoms worsen, and a follow-up plan was put in place for Mr R to be reviewed during the care home’s ward round three days later (on 16 August). However, Mr R was admitted to hospital on 15 August, so it was not possible to complete the follow-up care as planned.
22. The GMC provides guidance on the use of remote consultations, including telephone consultations, including its ‘remote consultations flowchart’ to help clinical staff decide whether a remote consultation is appropriate in the circumstances. The guidance indicates that remote consultations are generally suitable when the patient’s clinical needs or treatment requests are straightforward, when the practitioner has full access to their medical records, and when the practitioner is able to give the patient or their carer all the information they need about treatment options. They are also considered appropriate when the patient has the capacity to make decisions about their care and when there is a safe system in place for prescribing.
23. We understand from our GP adviser that, apart from the criteria relating to Mr R’s capacity, these criteria appear to have been met in this case. This means a telephone consultation was suitable in the circumstances and the Practice acted in line with applicable guidelines and standards in deciding a face-to-face visit was not needed at that time.
24. The GMC guidance also provides advice regarding when remote consultations may not be appropriate. These include situations where the patient has complex clinical needs, where the practitioner is not the patient’s usual doctor, or where the practitioner does not have access to the patient’s medical records. A remote consultation may also be unsuitable if a physical examination is required, if it is difficult to confirm that the patient has got and understood all necessary information about treatment options, if there are concerns about the patient’s capacity, or if the practitioner is prescribing injectable cosmetic products. When considering this guidance, our GP adviser explained that, although Mr R had complex needs, the symptom of soreness surrounding the catheter site was a relatively simple issue, and a plan was put in place to examine the patient on the ward round at the care home three days later. Therefore, the Practice’s actions were appropriate and supported by the guidance available.
25. The Practice told us it was following a ‘Total Triage’ system, in line with NHSE guidance (‘Modern general practice model’) for improving access to primary care at the time of Mr R’s consultation on 13 August. Our GP adviser explained that NHSE does not give formal guidance with regards to remote consultations but does give a comprehensive list of benefits and pitfalls relating to such consultations. Listed benefits include accessibility for patients and carers, and reductions in wait times. We understand from our GP adviser that the Practice’s actions demonstrate awareness of the contents of the NHS practice model and there is no indication it failed to take that guidance into account in reaching its decisions.
26. The GMC also provides guidance on proposing or prescribing remotely for patients in care homes, nursing homes or hospices (point 69 of ‘Good practice in proposing, prescribing, providing and managing medicines and devices content’). The guidance says ‘if you are proposing or prescribing medicines or treatment remotely for a patient in a care or nursing home or hospice, you should communicate with the patient, or if that’s not practicable, the person caring for them, to make your assessment and to provide the necessary information or advice. You should make sure any instructions, such as how to administer the drug or monitor the patient’s condition, are understood. And you should send written confirmation to them as soon as possible’.
27. We understand from our GP adviser it is appropriate and in no way unusual for a Practice to triage a care home request in the way Mr R’s case was handled, and the prescribing was also appropriate when considering the GMC guidance on remote prescribing. When considering the GMC and NHSE guidance, alongside Mr R’s medical records, we can see the Practice’s decision to assess Mr R and prescribe medication remotely was suitable in this instance and in line with applicable standards.
The Practice – Diagnosis
28. Following a review of Mr R’s medical records, we can see that during a telephone consultation with Mr R’s GP, the team leader at the care home reported that his catheter was draining well, with clear urine. The team leader reported the end of Mr R’s penis was sore where the catheter had been rubbing, but there was no bleeding and Mr R was otherwise well. In response to the reported symptoms, the GP prescribed Mr R a hydrocortisone cream to be applied twice daily and arranged for him to be seen during the care home’s ward round three days later, on 16 August. The GP also advised the team leader to contact the Practice again if there were any concerns or changes in the meantime.
29. NICE provides guidance relating to the management of catheter-associated UTIs (‘Urinary tract infection (catheter-associated): antimicrobial prescribing’). This says a patient with a catheter-associated UTI will likely show symptoms of either a bladder or kidney infection. Bacteria will likely be present the longer the catheter is in place, and after one month most people will have bacteria in their urine. NICE does not recommend routine antibiotics for asymptomatic bacteriuria in patients with a catheter. Asymptomatic bacteriuria means patients have bacteria but are not showing any signs of associated illness. This means GPs should not provide antibiotics unless certain symptoms are present.
30. Our GP adviser confirmed these symptoms would not include soreness at the end of the penis in the absence of other symptoms such as a fever, abdominal pain, general illness, or cloudy urine. Given the symptoms reported by the care home, in line with the NICE guidance and advice from our GP adviser, we cannot see any indications of failings in the way the Practice reached its diagnosis on 13 August 2024.
31. We hope the explanations we have provided above are reassuring to Mrs A and that we have clearly explained how we considered her concerns here.
The Trust - Attendance
32. Mr R’s care home had requested a community nurse visit due to pain from his catheter site, and Mrs A complains this was not provided. She says this omission meant Mr R remained in pain and discomfort. We understand the Trust’s administrator, who took the initial telephone call, instructed the care home to contact Mr R’s GP. We discussed this with our nursing adviser who explained in these circumstances a nurse would usually phone the patient to triage the call and assess the priority level, for example the level and area of pain, whether the catheter is draining, whether there is any blood in the catheter, whether the patient is feeling well. This is so staff can ensure they are acting in line with the NMC’s Code, section 13.1, which says staff should ‘accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care’.
33. Our nursing adviser told us once the patient had been triaged by a nurse, the decision of whether to visit the patient would be made. As the telephone call was not passed on to the Triage Nurse, which the Trust confirmed was its usual practice at the time of these events, we can see indications of a failing here. This administrative error meant the Trust did not act in line with our Principles of Good Administration, which say organisations should ‘follow their own policy and procedural guidance, whether published or internal’.
34. In our view, this caused some avoidable distress to Ms A, although we have not seen anything to indicate this error led to any direct clinical impact to Mr R. We can see the Trust recognised this error in its response and identified the cause of the error in Mr R’s case.
35. Following discussions with Mrs A, we understand that as an outcome to this complaint she would like an acknowledgment of failings and service improvements to prevent errors like this happening again. When reviewing the complaint responses from the Trust, we can see the Trust acknowledged the error and implemented a new process to prevent similar situations occurring in the future. We discussed this with Mrs A to better understand why she remained unhappy.
36. We requested a copy of the action plan from the Trust, completed in response to Mrs A’s complaint, so we could explore whether the actions it had taken were suitable to resolve the issue we identified. We reviewed the Trust’s action plan and discussed it with our nursing adviser to explore whether those actions were appropriate.
37. The service improvement the Trust implemented as a result was a new Standard Operating Procedure (SOP) staff must follow. The new procedure was successfully trialled before it was implemented, and all administrative staff have received training. The Trust is also completing ongoing auditing to ensure the procedure is fully and successfully implemented longer term.
38. We understand from our nursing adviser that the service improvement is appropriate as the evidence shows the Trust identified the root cause of the failing, identified a specific and appropriate improvement it could make, trialled it to ensure it would be effective, provided training to its staff to make sure the changes were put in place as they should be, and arranged for ongoing auditing to ensure the new SOP is fully implemented longer term.
39. We can see from our nursing adviser this is in line with NHS guidance (‘The Handbook of Quality and Service Improvement Tools’) which advises beginning with a thorough root analysis to identify the cause of the issue. Once the causes are understood, more detailed objectives can be created to address the issues effectively. After the first steps are taken, it is important to test them to ensure they work as intended. The guidance also highlights the need to provide training and mentoring where appropriate to support successful implementation. Lastly, once the change is fully in place, ongoing monitoring is necessary to ensure the original objectives continue to be achieved and the new ways of working are sustained. All these steps are present in this case.
40. Given the actions taken by the Trust in response to Mrs A’s complaint, we can see the Trust has followed the above NHS guidance when recognising and apologising for its mistakes, implementing service improvements, and has taken reasonable steps to prevent similar circumstances occurring in future. These steps are also in line with our NHS Complaint Standards, which say organisations should ‘explain why things went wrong and identify suitable ways to put things right for people’ and ‘take action to make sure any learning is identified and used to improve services’. It is evident some things did not happen as they should have with Mr R’s care, and we can see the Trust has taken appropriate steps to put right the distress caused to Ms A and learn from the complaint. With this in mind, we will take no further action.
41. We are sorry to hear of the distress the Trust’s actions caused Mrs A, and the rest of Mr R’s family, at what was certainly a sad and difficult time. We hope our review of the Trust’s actions gives Mrs A some reassurance that we have thoroughly and independently considered her complaint.