End of life care
13. 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.
14. Mrs F complains the Practice did not offer her father, Mr F the choice of receiving end of life care in March 2025.
15. Mr F had a history of heart failure and was receiving treatment under a community heart failure team. Mr F’s clinical records show he had a New York Heart Association (NYHA) classification score of three. This is a scale used to classify the severity of symptoms in heart failure. The score tells us Mr F’s heart failure was moderate and defines symptoms as:
• Class III: Marked limitation of physical activity; comfortable only at rest, less than ordinary activity causes fatigue or shortness of breath.
16. Mr F attended the Practice on 5 March as he had been feeling unwell and coughing up blood. The Practice examined Mr F and suspected a chest infection based on his symptoms.
17. NICE chest infection guidance on diagnosis and assessment says consider investigations, including: a chest X-ray if the person has suspected community-acquired pneumonia and they are at risk of underlying lung pathology (for example lung cancer) or the cause is uncertain — chest X-ray may be helpful to rule out pneumonia, but is not normally initially necessary for most people with suspected community-acquired pneumonia who are managed in primary care.
18. We have reviewed the consultations and care provided with our clinical adviser. Our adviser explained Mr F’s observations taken during this appointment did not indicate end of life care was required. Based on his symptoms, we consider the Practice acted in line with the above guidance by arranging an X-ray and prescribing antibiotics.
19. Mr F had neither improved or deteriorated by 17 March and continued to be short of breath. The Practice requested blood tests and an electrocardiogram (ECG), a test that records the electrical signals of the heart.
20. Mr F attended the Practice to receive the results on 20 March and was seen by a different GP. During the appointment, the GP examined Mr F and took observations. He reviewed and discussed Mr F’s test results, which showed a clear chest X-ray with an increased heart size, and blood pressure noted to be slightly raised. The GP increased the prescription of spironolactone and requested an echocardiogram, an ultrasound scan used to look at the heart and nearby blood vessels.
21. Our adviser reviewed Mr F’s test results and does not consider they raised any red flags that would require hospital treatment or indicate Mr F was near end of life. They explained based on his symptoms, the results appear to be related to Mr F’s heart failure. This is in line with the Practice’s consultation notes.
22. We consider the Practice acted in line with NICE heart failure guidance by increasing the spironolactone. The guidance says treatment should offer four types of medication together to people with reduced ejection infraction, including a Mineralocorticoid receptor antagonist (MRA) such as spironolactone.
23. MRAs make you pass more urine and help lower blood pressure and reduce fluid around the heart. Ejection fraction is the percentage of blood the left ventricle pumps out with each heartbeat, and a reduced ejection fraction means it is 40% or less.
24. Mr F returned to the Practice on 26 March. It prescribed antibiotics, further increased his spironolactone prescription, and arranged a follow-up appointment for 28 March.
25. Based on the clinical records of this consultation, our adviser explained Mr F’s observations were reasonable, showing his breathing rate at 20, oxygen level at 98% and pulse at 82 beats per minute. They do not consider there was anything here to indicate Mr F was acutely unwell or required end of life care.
26. NICE heart failure guidance section 1.12 says if the symptoms of a person with heart failure are worsening despite optimal specialist treatment, discuss their palliative care needs with the specialist heart failure multidisciplinary team (MDT) and think about a needs assessment for palliative care.
27. Mr F’s first appointment at the Practice was on 5 March. His final appointment was three weeks later, on 26 March. Our adviser told us as it had been a relatively short period of time since his first appointment, they do not consider optimal treatment had been achieved in line with the above guidance, and not enough time had been given for it to take effect at any of his visits to the Practice.
28. In its response to Mrs F’s complaint, we can see the Practice agreed with Mrs F’s perspective that Mr F’s decline should have been recognised during the appointment on 20 March and the idea of supportive/palliative care should have been broached. We recognise the Practice has discussed these matters and agreed to offer patients the choice of hospital admission or broach the subject of palliative care if hospital admission was declined going forward.
29. Based on the evidence provided and with the help of our clinical adviser, we can see things progressed quickly, and do not think it was necessarily appropriate to raise the option of palliative care given Mr F had only first attended the practice three weeks earlier. Treatment was ongoing, and there were no clinical indications or results that suggested Mr Howarth was near the end of life. We therefore consider the Practice acted in line with appropriate standards and guidance in its care and treatment of Mr F. As such, we will take no further action.
30. We recognise how devastating the events surrounding Mr F’s death have been for Mrs F and her family and we are sorry for their loss. We hope this statement has clearly explained the reasons for our decision and provides reassurance about the care provided by the Practice.