14. 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. We have done this and have not found any indications that something has gone wrong.
15. Mrs D says her mother’s symptoms indicated she had a problem with her heart. She says a GP at the Practice did not fully investigate this and did not provide her with the treatment they should have.
16. We are sorry to hear that Mrs W got worse following this appointment and died two days later. We are also sorry to hear about the emotional impact this had on Mrs D and her father.
17. In their response to Mrs D’s complaint, dated September 2024, the GP said Mrs W had not presented with features related to a heart issue. They said the symptoms, including pain, indicated a muscular or skeletal issue.
18. In December 2024, the local Integrated care board (ICB) also responded to Mrs D’s complaint. It said the clinical care the Practice provided was appropriate.
19. GMC’s Good medical practice says doctors must:
‘a. adequately assess a patient’s condition(s), taking account of their history, including symptoms, relevant psychological, spiritual, social, economic, and cultural factors, the patient’s views, needs, and values.
b. carry out a physical examination where necessary
c. promptly provide (or arrange) suitable advice, investigation or treatment where necessary
d. propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs
e. propose, provide or prescribe effective treatment based on the best available evidence’
20. At the appointment with the GP at the beginning of April 2024, Mrs W presented with pain in her upper back (known as the thoracic spine) for the last three days. She said it was aching and radiated round the front of her ribs. She complained of pain when lying on her back.
21. NICE guidelines say what clinicians should consider when investigating potential injuries to the spine. It says they should consider the person’s age and if they have pain in the thoracic spine. It goes on to say they should consider if the person has had any recent falls or any history of osteoporosis.
22. As Mrs W’s pain radiated around to the front of her ribs, NICE CKS guidance on chest pain is also relevant. This says that says chest pain can be classified by cause – either cardiac (heart related) or non-cardiac. Non-cardiac causes include lung related issues, gastroenterological issues (the digestive system), musculoskeletal causes (muscles, bones, joints, tendons or ligaments) and cancer.
23. This guidance says to determine the cause of chest pain, clinicians should take a medical history and an examination, with further investigations organised as appropriate, based on the suspected cause.
24. It says an acute (sudden) onset, with central or band-like chest pain which radiates to the person's jaw, arms, or back, is suggestive of cardiac chest pain. It also says a patient with cardiac related chest pain can have breathlessness.
25. It goes on to say a heart attack should be considered if the chest pain lasts longer than 15 minutes, is central, dull and/or crushing. It also says a patient may have nausea/vomiting, sweating or breathlessness or a combination of these.
26. Similarly, NHS online advice for heart attacks says symptoms of a heart attack can include:
• chest pain – a feeling of pressure, heaviness, tightness or squeezing across your chest • pain in other parts of the body – it can feel as if the pain is spreading from your chest to your arms (usually the left arm, but it can affect both arms), jaw, neck, back and tummy • feeling lightheaded or dizzy • sweating • shortness of breath • nausea or vomiting • an overwhelming feeling of anxiety (similar to a panic attack) • coughing or wheezing.
27. This online advice says that some people may have other symptoms such as shortness of breath, feeling or being sick and back or jaw pain without any chest pain.
28. In the appointment notes, the GP recorded that Mrs W had no recent falls, had no weakness in her limbs, no shortness of breath and was not in distress. They recorded that she had no tenderness of the spine, there was no evidence of spinal deformity and no history of osteoporosis in the family. Our adviser said the doctor took a good history of Mrs W’s presentation, and considered the potential cause in line with GMC and NICE guidance.
29. The records indicate Mrs W’s pain was aching, started in her back and went round the front of the ribs. As indicated in NICE CKS and NHS guidelines, our adviser said a typical cardiac related chest pain, would start in the chest and radiate elsewhere, for example around the back or jaw or left arm/hand. They said if the back pain had been cardiac related, this would usually cause the other symptoms outlined in the guidance and advice, particularly shortness of breath, clamminess and feeling extremely unwell. This was not the case with Mrs W.
30. Mrs W did not display any of the other symptoms associated with a heart attack. She was not in distress, short of breath, light headed, sweating and did not complain of feeling or being sick. Mrs W described the pain in her back and ribs as aching and not crushing, pressure, heaviness, tightness or squeezing across her chest, as described in NICE and NHS guidelines. There is no indication that the aching pain came on suddenly and Mrs W reported she had this for three days.
31. Our adviser said, as Mrs W did not display any other symptoms which would indicate a cardiac cause, the GP was right to suspect this was a musculoskeletal issue. They said cardiac chest pain is very unlikely to present the way Mrs W did. They said her pain was worse on movement, when Mrs W lay down and it improved with painkillers. Our adviser said this suggested a musculoskeletal cause, as it would be unlikely painkillers would help significantly with a cardiac issue.
32. Our adviser also said that as Mrs W did not have any shortness of breath and no pain on breathing, there was no indication for the GP to listen to her chest. Our adviser said it is important to note that the GP did ask questions about this and record it in the notes.
33. In summary, our adviser said they consider the GP took a good history by speaking to Mrs W, examined her back, explored the potential causes and assessed this was likely to be a musculoskeletal issue. Our adviser said the GP’s actions at the appointment were in line with accepted good practice for GPs.
34. NICE guidance says patients with a suspected spinal injury should have an X-ray as a first line investigation. The GP referred Mrs W for an X-ray of her upper back and she had this at hospital on the same day. Our adviser said this was a suitable investigation based on Mrs W presentation.
35. For these reasons, we consider the GP acted in line with GMC, NICE, NHS guidance and accepted good practice and we will not be investigating this further.
36. We would like to thank Mrs D for giving us the opportunity to consider her complaint and we hope she is reassured by what we have seen. We are again very sorry to hear of her mother’s death and how this has affected her and her family.