The telephone consultation
20. Mrs A told us that the telephone consultation in early February was inadequate. She said her father, Mr I, had been to see her mother on the afternoon in question, and he was unhappy that she could not walk.
21. He spoke to the care home that evening and asked if the GP had been to examine Mrs I. Care staff told him the ACP prescribed paracetamol overnight and arranged a face-to-face appointment the next day.
22. Mrs A explained that the family raised their concerns about this plan with a family friend (who was also a GP) and spoke to the care home again. She told staff her concerns that her mother needed to be seen ‘urgently’. Care staff passed on that the ACP ‘did not feel she needs to be seen urgently’ and the ACP ‘did not think it necessary to come today’.
23. She said that although her mother could still weight bear, the day before she was able to get up from a chair and walk around unassisted. She did not understand how a medical professional then reached the view that her mother did not need to be urgently seen.
24. We considered with the input of our GP adviser, the actions of the Practice on the day in question and the morning after.
25. NICE CKS explains that patients with (community acquired) pneumonia have a history of symptoms including ‘shortness of breath, sputum (mucus mixed with saliva), sharp, chest pain, sweating, fever, shivers, aches and pains’.
26. It explains patients would be moderately to severely ill. They would have a high temperature (38 degrees and over), decreased and/or harsh breath sounds, wheezes, and you would be able to feel vibrations on the patient’s chest.
27. Our adviser explained that there was no indication from the telephone call that Mrs I was very unwell. Care staff reported Mrs I’s leg pain started that morning, she was able to weight bear with assistance, and she normally walked independently. Care staff examined her leg and found no obvious injury which would account for the pain Mrs I was in.
28. Care staff did not report that Mrs I was experiencing any respiratory symptoms at that time which would indicate that she was poorly with pneumonia. The only concern raised in the call was Mrs I’s leg pain.
29. GMC’s Good Medical Practice domain 1: knowledge, skills and development: providing good clinical care explains at point 6 that clinicians should ‘provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must work in partnership with them to assess their needs and priorities. The investigations or treatment you proposed, provide or arrange must be based on this assessment and on clinical judgement about the likely effectiveness of the treatment options’.
30. Point 7 explains that ‘in providing clinical care you must:
• Adequately assess a patient’s condition(s) taking account of their history including i. symptoms, ii. Relevant psychological, spiritual, social, economic, and cultural factors.
• Carry out a physical examination where necessary.
• Promptly provide (or arrange) suitable advice, investigation or treatment where necessary.
• 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.
• Propose, provide of prescribe effective treatment based on the best available evidence.’
31. Based on the telephone consultation with the ACP and Mrs I’s reported symptoms that day, the plan was to administer paracetamol to help with the leg pain and to review Mrs I the next day at 8am. This was reasonable considering the reported symptoms, which did not include signs of pneumonia. The evidence indicates this decision was in line with the GMC and NICE guidance.
32. Our adviser considered the events of the next day when the second ACP saw Mrs I face-to-face. Mrs I’s observations taken earlier than morning by the care staff were noted to be ‘unremarkable’, meaning there was nothing concerning in the time between the telephone call with the Practice and the ACP’s attendance the day after.
33. Mrs I’s GP records show that the ACP was concerned about her condition when she attended the care home. Mrs I’s observations were abnormal, and the ACP asked paramedics to attend the care home and take over Mrs I’s care. The paramedics took Mrs I to hospital, and she sadly died the next day.
34. From Mrs A’s explanation of the events leading to Mrs I’s unexpected death, we appreciate the trauma that this caused her, her father and wider family. From our work and the advice we have received, the evidence does not indicate the Practice failed to diagnose Mrs I with pneumonia.
35. The evidence in Mrs I’s medical records indicate the Practice assessed Mrs I based on the care home’s reported symptom of leg pain and put a plan in place to manage this with a follow up appointment the next day.
The complaint handling
36. Mrs A said that the Trust handled her complaint poorly. She said it failed to respond to deadlines, and she had to chase responses. This made its long-winded, drawn-out process more stressful at an already stressful time for her and her family.
37. She said the Trust was vastly unprepared for its LRM. The Trust did not share the meeting agenda beforehand, and this meant it did not adequately answer her questions, and she was left with more. She said this made her feel that the complaint was not a priority for the Trust.
38. The Trust’s complaint policy says that is has a key performance indicator (KPI) of 30 working days to respond to complaints in 95% of cases and 60 working days to respond to complex complaints. This is also the timeframe set out in the NHS Complaints Regulations.
39. The Trust initially set a timeframe of 30 working days for a response meaning its response was due on 15 April 2024. This was extended to 19 April 2024 due to staff availability which delayed responses to the complaints team. The Trust sent its first written response on 26 April 2024, 7 working days outside of the timeframe it set.
40. From the complaint file, we can see the Trust’s written response was drafted by 10 April 2024 and sent for quality assurance sign off the same day. The delay was due to its three-part quality approval process. We can see from the complaint file that the complaints team actively pursued sign off and made the staff involved in the approval process, aware of the necessary target date. Despite this, the response was not approved until 26 April 2024.
41. While the response was sent outside of the timeframe set by the complaints team, we do not feel that the additional time it took to approve the letter was so far outside of the timeframe that it constitutes a failing in the Trust’s actions. The evidence indicates the complaints team did everything in its power to enable the response to be sent to Mrs A as quickly as possible and in line with its processes. We have determined that the complaints team could have updated Mrs A in the interim and we highlight a shortcoming in terms of the Trust’s communication around this short delay.
42. On 2 May 2024, after Mrs A received the Trust’s first response letter, she requested an LRM. The Trust’s complaint policy says meetings must be arranged within 20 working days of receipt of the request and the meeting must take place no more than 30 working days from the meeting request.
43. The meeting took the Trust some time to arrange. From reviewing the complaint file, there were several factors for the Trust to consider when making its arrangements which led to the meeting being arranged outside of its 30-working day timeframe.
44. The Trust considered whether it was appropriate to facilitate a joint meeting which would include the care company alongside the Trust’s clinical staff. The Trust asked Mrs A to provide her concerns in writing to help it with its considerations. Mrs I provided her concerns on 13 May 2020.
45. The Trust needed to coordinate availability for all the clinical staff who needed to attend and there was a period that a member of staff was away on leave. Similarly, Mrs A and her father had limited availability within Mrs A’s working week and they were unavailable for a week in early July.
46. The date of the LRM was confirmed with all those involved on 2 July 2024 and took place on 24 July 2024. Although outside of its 30-working day timeframe, given all interested parties’ availability, we are satisfied that the Trust acted as quickly as it reasonably could have done in arranging a meeting that suited everyone’s availability.
47. Mrs A said that she provided an agenda of (20) questions which she wanted to discuss with the Trust. The staff members involved in the meeting did not receive a copy of these questions beforehand. The Trust confirmed with Mrs A in the meeting that it could not explain why these had not been shared.
48. We listened to a recording of the LRM. We can see that some of the questions Mrs A raised needed to be answered by the care company and some questions needed to be answered by the staff member from the emergency department (ED) who looked after Mrs I on the day she died. Unfortunately, the ED staff member was unable to attend the meeting. Instead, the Trust gave a general response to the ED questions in the meeting.
49. The Trust provided the explanations as far as it could based on Mrs I’s medical records to answer Mrs A’s remaining questions. While in the meeting, it listened to the ACP’s telephone call with the care home the day before Mrs I died. This telephone consultation confirmed that the only concern raised about Mrs A was the pain in her leg. The Trust explained to Mrs A why in its view this telephone consultation and plan was appropriate again, based on the clinical presentation presented by the care home staff to the ACP.
50. It also explained (again, in its view) why the ACP who attended the care home the next day was very concerned about Mrs I and why she rang for an ambulance to attend. It acknowledged that although the care home had noted that Mrs I’s observations were ‘unremarkable’, there was no record of these observations, and the ACP noted that Mrs I’s observations were ‘deranged’ on their arrival to the care home. This indicated that Mrs I was very poorly that morning and the ACP’s actions were appropriate (in its view) given Mrs I’s presentation.
51. When closing the meeting, Mrs A and her father asked how long it would take to get a response to their concerns. The Trust did not give a set timeframe for its final response and the complaints team said, ‘it would take as long as it takes to get a satisfactory response’.
52. The Trust sent its final written response to Mrs A on 15 August 2024. This letter addressed why staff had not had sight of Mrs A’s questions before the meeting. On our review of the letter, it appears that this was due to an oversight and human error. This letter also provided additional clarity to some of Mrs A’s questions as it became apparent more information was needed after the meeting.
53. Our complaint standards explain we expect an organisation to be thorough and fair during an investigation. They should give fair and accountable responses, giving a clear and balanced account of what happened based on established facts.
54. The NHS complaint regulations outline how a response must be sent in six months of a complaint being received. From our review of the full complaint file, we can see that the Trust did provide a full and final response to Mrs A’s concerns within the six-month timeframe.
55. We appreciate that Mrs A raised her complaint, and the Trust’s written responses and its LRM all happened in the months following her mother’s sad death. We appreciate that this was a very stressful and deeply upsetting time for Mrs A and her family.
56. From our review of the complaints process we cannot say that the Trust handled Mrs A’s complaint poorly. We can see that the complaints team acted as quickly as it was able to and through its written responses and meeting, it answered Mrs A’s concerns to the best of its ability. Overall, we consider it handled Mrs A’s complaint in line with our complaint standards and the NHS complaint regulations.
57. While we have not found a failing in its actions, we have found a shortcoming in its communication with Mrs A and we will raise this with the Trust to allow it to consider how it may communicate more effectively with its service users in the future.
58. We understand how important this complaint is to Mrs A and we thank her for sharing her concerns to us and allowing us the time to consider these. We hope that she will be reassured that we have not found anything to make us think that we need to ask the Practice and the Trust to take further action in relation to the issues considered.