28. Before we decide if we should investigate a complaint in more detail we look at whether there are signs an organisation concerned has got something wrong. We do this by comparing what should have happened with what did happen. If what happened fell far short of what should have happened, we call this a failing.
29. When we see indications of a failing, we next look at whether that failing had a negative impact on the person in question. If we think it did, we will go on to consider what, if anything, the organisation has done to try and put things right.
The Practice
30. Miss E complains about the care and treatment the Practice provided to her mother at the appointment on 7 August 2024.
Assessment and investigation
31. Miss E says the GP did not assess or investigate her mother at the appointment. Miss E said her mother was presenting symptoms of lethargy, confusion and breathlessness. Miss E believes the GP did not take this into account and as a result, her mother did not receive appropriate assessment or investigations. As such, Miss E believes the Practice failed to recognise her mother could have been suffering from a potentially serious infection or sepsis.
32. Ms E’s patient records demonstrate Ms E attended an appointment for an electrocardiogram (ECG), with a nurse. An ECG is a test which looks at your heart’s rate, rhythm and electrical activity. Ms E complained of feeling unwell and was referred to her GP. No specific symptoms were documented apart from the nurse’s notes which mentioned a fainting episode that day.
33. The records indicate Ms E’s hands were cold, but otherwise her examination was normal, including her blood pressure, pulse, oxygen saturations, temperature and blood glucose. Ms E also had her lungs, heart, abdomen and neurological system examined twice by both the nurse and the GP. The ECG came back as normal, and bloods were taken.
34. We refer to NICE guidance on sepsis which highlights the symptoms and signs of sepsis. The guidance says these include:
‘a new altered mental state, raised respiratory rate, systolic blood pressure, raised heart rate, not passing urine in the previous 18 hours, skin changes such as mottled or ashen appearance or cyanosis of skin, lips or tongue.’
35. We also refer to the following GMC guidance which states:
standards 6 and 7, providing good clinical care:
‘you must provide a good standard or practice and care.’ The guidance outlines what must be done when providing clinical care, and this includes to ‘adequately assess and a patient’s condition, carry out a physical examination where necessary and promptly provide (or arrange) suitable advice, investigation or treatment where necessary’.
36. Based on the evidence provided, and the aforementioned guidance, there were no indications from this appointment Ms E was presenting with symptoms of sepsis or that Ms E needed to attend hospital urgently. Furthermore, Ms E was given a thorough assessment with two sets of observations, and she had a comprehensive assessment done by a GP. She also had an ECG and blood tests. Our adviser confirmed our view.
37. We hope to reassure Miss E we have seen no evidence to indicate her mother’s care was not in line with expected standards, therefore we will not be looking into this part of her complaint further.
Calling an ambulance
38. Miss E says based on her mother’s presentation and symptoms, the GP should have called an ambulance for her mother. She said she was given two options, which were to either take her mother to the hospital, or take her mother home and monitor her symptoms. She said she was told by the GP that the hospital would be busy, and hospital staff would most likely come to the same conclusion as the GP. Miss E said she trusted the GP’s advice and decided to take her mother home instead of making her sit in the hospital’s emergency department for hours.
39. The medical notes from the consultation state Ms E was offered an ambulance but this was refused.
40. As Ms E did not present or have any symptoms of sepsis as per the NICE sepsis guidance, there is no evidence an ambulance should have been called at the time of her appointment. Our adviser also confirms this view.
41. We hope to reassure Miss E that we have found no indications the Practice did not act in line with relevant guidance and standards by not calling an ambulance for her mother at the time of her appointment. We will not be taking any further action on this part of the complaint.
Incorrect consultation notes
42. Miss E says the consultation notes are incorrect and do not reflect what happened at the appointment. Miss E said she was told by the GP she could take her mother home and monitor her or take her to the emergency department and wait there. She said the nurse told her if her mother’s presentation was not as usual, she should take her mother to the hospital. Miss E said this conflicting information confused her; however, she trusted the GP’s advice and took her mother home.
43. The consultation notes say Ms E was offered an ambulance and this was refused by Miss E.
44. It is important to explain our role is to make independent final decisions about NHS complaints in England. We make decisions by weighing up and considering all the available evidence. We then consider the likelihood that something has gone wrong with the service provided. As we are impartial, we must make robust decisions based on facts and evidence.
45. We do not doubt Miss E’s account or recollection of the GP appointment. When considering this point, we paid particular attention to what Miss E told us and looked to see if there was any evidence in the medical records which we could use to support her account. We have been unable to identify any records or any other supporting information which would allow us to challenge or criticise the information provided by the Practice.
46. Unfortunately, Miss E believes she did not refuse an ambulance, and we are not able to prove or disprove this. Regrettably, without further evidence we are not able to reach a view on whether something likely went wrong. We appreciate this would have been distressing and confusing for Miss E, who was understandably worried about her unwell mother.
47. We hope to reassure Miss E we have seen evidence to suggest the GP acted inappropriately in the consultation with her mother. We have seen no evidence they ignored her symptoms and failed to recognise symptoms of sepsis. On this basis, we saw no indication her care fell below the expected standard. We are very sorry to hear of how unwell Ms E became and we recognise and do not wish to dismiss how shocking and distressing this must have been for Ms E and her family.
The Trust
48. Miss E also complains about the care and treatment her mother received from the Trust between 8 August 2024 and 26 September 2024.
Do Not Resuscitate decision
49. Miss E says the Trust made a Do Not Resuscitate decision (DNR) for her mother without properly discussing it with the family or explaining why it was needed. She said this caused the family distress and anxiety at an already difficult time, and they felt they were not being listened to.
50. The Trust records show there is a completed DNR in place, with a documented discussion with Miss E when making the decision.
51. The resuscitation statement and GMC guidance should be followed when making resuscitation decisions. This includes ensuring ‘every decision about CPR must be made on the basis of a careful assessment of each individual’s decision.’ It also confirms ‘it is not necessary to obtain the consent of a patient or of those close to the patient to a decision not to attempt CPR that has no realistic prospect of success. The patient and those close to the patient do not have a right to demand treatment that is clinically inappropriate and healthcare professionals have no obligation to offer or deliver such treatment.’
52. The records show the documented discussion was held with Miss E at the time of making the DNR order. We understand these types of decisions can be traumatic for family members and loved ones, and our adviser confirmed as per the resuscitation guidelines, CPR decisions should always be considered when any patient is at risk of cardiorespiratory arrest. Any CPR decision should also be reviewed in the setting of acute illness and should be discussed with a person close to them if the patient lacks capacity.
53. From the evidence available, we can see Ms E was at risk of cardiorespiratory arrest, which is the sudden loss of breathing and heart function. We can also see the decision was discussed with Miss E as Ms E lacked capacity at the time, and the DNR decision was subsequently rescinded when Ms E’s clinical condition improved, which is line with the resuscitation guidelines referenced above.
54. From the evidence provided, we can see the decision to make the DNR was in line with the aforementioned guidance.
55. We understand this must have been a distressing time for Miss E and her family, and we hope to reassure her we have found no indications the Trust acted against expected standards and practice. The Trust has also apologised for the upset caused to Miss E. As such, we will not be looking into this part of the complaint further.
Discussions about life support and communication
56. Miss E said discussions were had between the family and clinical staff about turning off her mother’s life support, and these discussions were insensitive and distressing. She said staff did not listen to the family’s position, and communication was poor.
57. The records show documented discussion was had with Ms E’s daughter about the DNR decision and life support.
58. The resuscitation guidelines state CPR decisions should always be considered when any patient is at risk of cardiorespiratory arrest, should be reviewed in the setting of acute illness and should be discussed with a person close to them if the patient lacks capacity.
59. We can see from the medical records that Ms E was at risk of cardiac arrest which is why the decision to put the DNR in place was made. The order was subsequently removed once Ms E’s clinical condition improved, and discussions were had with Ms E’s family about this.
60. GMC guidance requires communication to be ‘considerate and compassionate to those close to a patient and be sensitive and responsive in giving them support and information’.
61. The Trust also provided a copy of its local policy which is in line with the guidelines referenced above. Our adviser confirms this view.
62. Our adviser says there is no formal guidance on the frequency and content of family interactions, other than the GMC guidance referenced above. Our adviser says the records show the critical care team documented several discussions on almost a daily basis which sound comprehensive. Our adviser confirms there is nothing to suggest the general approach was inappropriate.
63. There are numerous discussions documented in the medical records, which show comprehensive discussions were being had with Ms E’s family regarding her care. On 8 August, there was a conversation with Ms E’s daughter and the consultant, which shows empathy and understanding while also providing them with the relevant information regarding Ms E’s condition. The records also show on 9 August, the consultant has documented ‘multiple conversations with the family.’ Further, on 31 August, the records document a ‘long discussion with family at bedside’ and on 2 September, the consultant had a face-to-face meeting with Miss E following her complaint to PALS.
64. There is also evidence of post discharge communication, which was out of hours, which show staff were making efforts to keep up communication with the family. The records show a detailed discussion with Miss E regarding her concerns about her mother’s discharge from the ICU was had on 29 August, and the Trust has apologised for the distress caused to Miss E.
65. We can see no indication there was anything inappropriate in these discussions therefore we will not be looking at this part of the complaint further.
Concerns about care and mental health
66. Miss E said she raised numerous concerns about her mother’s care and the effect of her mother’s mental health on her care. She said the staff failed to take into consideration how her mother’s paranoid schizophrenia would affect her recovery and the care provided to her mother was not adequate.
67. The records show upon her admission, Ms E received levels of organ support including intubation, insertion of invasive lines and blood pressure support. She was also given renal filtration, and she had further investigations such as an echocardiogram of the heart and a CT scan of the abdomen. The records further show metformin was identified as a contributing factor to Ms E’s symptoms and it was stopped.
68. The sepsis guidelines say the signs and symptoms of sepsis are nonspecific and often mimic multiple other diseases. Our adviser also says metabolic acidosis has a broad range of possible causes and all potential causes should be considered and addressed.
69. Upon review of the records and noting the treatment which was provided to Ms E upon her admission, our adviser says Ms E received timely and appropriate levels of organ support and says the renal filtration was in place to help address the acidosis. The Trust considered sepsis as a possible factor, and our adviser confirms the further investigations were appropriate to help determine the cause of the acidosis.
70. We can see the Trust acted in a timely and appropriate manner, and the actions were consistent with the aforementioned guidance. We can understand this must have been a very difficult time for Miss E and the family, as their mother was very unwell.
71. We hope to reassure Miss E we have seen no indications the Trust acted against the expected guidance and standards while caring for Ms E during her admission. As such, we will not be looking into this part of the complaint further.
Mental health
72. Ms E has paranoid schizophrenia and has a regular Paliperidone depot injection to manage her mental health. The records show Ms E’s depot dose was due on the day of her appointment at the GP practice in August 2024, and this was missed due to Ms E’s subsequent hospital admission. The Trust were aware of Ms E’s mental health history from admission.
73. The records also note medical concerns raised about the risk of bleeding given Ms E’s low platelets and raised ureal levels. There was evidence of liver dysfunction on admission, which our adviser says can be a caution for many drugs.
74. When caring for a critically unwell patient who has a known mental health condition, the intensive care mental capacity guidance states it is important to recognise emergency treatment, and clinical care should always be the first priority. Our adviser states the Mental Capacity Act should always be followed when caring for patients without capacity. Our adviser also stated while paranoid schizophrenia does not necessarily make someone lack capacity, being critically ill as Ms E was upon admission, usually does.
75. Further, the delirium guidance broadly states considering starting baseline psychiatric treatments as soon as is appropriate. The clinicians would have taken this into consideration when Ms E presented to the emergency department.
76. The records show the family raised the issue of the missed dose with the Trust on 19 August. This was then discussed with the critical care pharmacist and administered to Ms E the following day.
77. Our adviser says Ms E had a very high baseline risk of critical care delirium due to the profound nature of her critical illness as well as her age and baseline psychiatric condition.
78. It is difficult to say if the depot injection was given earlier, this would have reduced the risk of critical care delirium. The delirium guidance states the incidence of delirium in critically ill ventilated patients is as high as 74%.
79. We understand critical care delirium is not only extremely distressing for patients and their families, but as indicated by the guidance mentioned above, it carries an increased risk of morbidity and mortality.
80. We find the baseline risk of critical care delirium for Ms E was already very high at the time of her admission, and we cannot say on the balance of probabilities that if her depot medication was administered earlier, it would have prevented this. As confirmed by our adviser and the aforementioned guidance, the focus of treatment in a critically ill patient should be clinical care. Ms E was also provided with her depot injection as soon as it was medically appropriate and with discussions with the critical care pharmacist.
81. The Trust apologised for the delay and the distress caused before Ms E’s mental health medication was given, and confirmed the delay was due to concerns about potential bleeding issues and high urea levels while Ms E was on the renal filter.
82. We therefore find there are no indications the Trust did not act in line with guidance regarding Ms E’s mental health and we will not be looking into this part of the complaint further.
Ward transfers
83. Miss E complains staff moved her mother from the Intensive Care Unit (ICU) to the Acute Medical Unit (AMU) and then to a ward without a proper handover and it was poorly managed.
84. The records show there was a completed nursing discharge summary but a review by a medical registrar on the ward following step down states there was no written or verbal handover. The medical registrar contacted the intensive care team and received a 25-minute verbal handover, and he asked for a written handover to be completed.
85. We refer to the GPICS guidelines which state: ‘when a patient is ‘stepped down’ from an intensive care unit, there should be a standardised handover procedure which should include:
• a summary of the critical care stay, including diagnosis, treatment, and changes to chronic therapies • a monitoring and investigation plan • a plan for ongoing treatment • rehabilitation assessment and prescription, incorporating physical, emotional, psychological and communication needs • follow up arrangements • any treatment limitations in place • plans if readmission to critical care becomes necessary, including DNAR (Do not attempt resuscitation) /treatment escalation plan and • communication with GP and patient (where appropriate).’
86. Our adviser explained the receiving ward team responsible for the ongoing care needs to be directly involved in this process and there should be a verbal as well as written handover.
87. The rehabilitation guidance says before a patient is discharged from critical care, staff must ensure the transfer of patients and the formal structured of their care is in line with the acutely ill adults’ guidance and should include the formal handover of the individualised, structured rehabilitation programme.
88. The acutely ill adults’ guidance says the critical care area transferring tram and the receiving ward team should take shared responsibility for the care of the patient being transferred, and they should jointly ensure there is continuity of care through a formal structured handover of care from the critical care area staff to ward staff, supported by a written plan.
89. We can see from the records the handover was not consistent with GPICS practice or the aforementioned guidance, as the there was no verbal or written medical handover until requested by the on-call register. This is potentially a failing.
90. Miss E says as a result of the poorly managed handover, her mother was unnecessarily moved between wards which caused her distress and inconvenience. She says the lack of handover notes caused confusion and she was concerned her mother would not been properly looked after.
91. We understand this must have been a distressing time for Miss E, who was concerned her mother’s recovery could be affected due to the additional stress of being placed on the AMU instead of the ward, and the concern of the lack of handover notes which meant staff were not aware of the care her mum needed.
92. The records demonstrate on there was a prompt review by the critical care team on 29 August to assist with Ms E’s continuity of care, and there is also evidence of the critical care team speaking to Miss E that same evening to provide support and reassurance. This can be seen in the stepdown review in the records, which detail a discussion had with Ms E’s daughter and niece.
93. We can see all care delivered for Ms E was timely, appropriate and consistent with the available guidance, apart from the stepdown process. This was rapidly remedied, and we cannot see this resulted in any apparent harm. Our adviser reviewed Ms E’s patient records and confirmed our view.
94. We consider the approach taken by the Trust is in line with the Ombudsman’s Principles of Good Complaint Handling and the Ombudsman’s Principles for Remedy. These Principles explain that providing fair and proportionate remedies is an integral part of good complaint handling, and a public body has failed to get things right and this has led to an injustice, it should take steps to put things right.
95. Appropriate remedies can include apologies, remedial action, and financial remedies, and in addition to this, public bodies should ensure that all feedback and lessons learnt from complaints contribute to service improvement.
96. The Trust has apologised to Miss E and confirmed it would be making service improvements following the investigation into Miss E’s complaint. This is in line with our complaint standards, and we can see once Ms E was transferred to the ward, her care was of a good standard, and her medications were given in a timely way.
97. We consider this is a fair and proportionate remedy in line with the Ombudsman’s Principles of Good Complaint Handling and for Remedy.
Conclusion
98. We thank Miss E for taking the time to bring her complaint to our attention. We hope our explanation brings some reassurance about the care and treatment her mother received from the Practice and the Trust.