The Practice 19. Leading up to the events complained about, Mr K called the Practice on 9 May 2022. He reported his wife was not eating, her hands were shaking and she had slurred speech. The Practice advised she needed to go to hospital, but Mr K reported a concern that if she went, she would die. The Practice called back several times to try and provide the number of the Community Treatment Team (CTT), with no answer. CTT is a service that attempts to avoid preventable hospital admissions where it may be possible to treat in the community.
20. The next contact with the Practice was on 12 May 2022. Mr K called again due to his wife suffering from severe constipation, which her visiting district nurses had been trying to help with. Mrs K had received two enemas but was not opening her bowels. She was alert and drinking normally, and had no acute abdominal pain, but had nausea and bloating. Mr K informed the Practice his wife did not want to visit hospital.
21. The Practice advised Mrs K should take 2-3 Movicol laxative sachets a day and agreed a follow up would be done in 24 hours. The notes also document that Mr K was advised that, if his wife was still poorly then, she would need to be reviewed by the CTT. The notes state the district nurses and Practice had tried to manage Mrs K getting her insulin, but she was not taking all of her medications.
Unsuitable medication 22. Mr K complains that prescribing Movicol was unsuitable treatment for the cause of his wife’s illness as she died a few days later of sepsis.
23. GMP Good Medical Practice guidance on assessing patients, states:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: • adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs’
24. Our GP adviser said that, as there were no other concerns mentioned in the call to the Practice on 12 May 2022, the prescription of Movicol medication was in line with GMC guidance on assessing patients. Movicol is an appropriate medication to treat constipation and our GP adviser noted that Mr K reported to the district nurses on 14 May that his wife had subsequently opened her bowls and her symptoms eased. Therefore, the treatment was also effective in treating the condition Mr K had sought help for.
25. We note there was no information provided on 12 May that would raise suspicion of Mrs K having an infection or sepsis which may call into question the GP treating constipation as the primary problem to be addressed at that time. We found no evidence that prescribing Movicol was unsuitable. It was the medication we would expect to be given for the condition reported and this is what happened.
Not receiving a call following agreement for one on 12 May 26. Mr K complains that the Practice agreed to call on 13 May 2022 as a follow up following his call on 12 May, but the call never happened. The Practice has accepted this is what it agreed, and that the GP did not call. It has apologised for this and explained that the GP was going to arrange a call but forgot to inform the admin team to schedule one for the next day. The Practice also took steps to put additional training and procedures in place to prevent future errors of this kind.
27. We can see there was a failing here and this was due to an individual error. The Practice has provided some remedy for this error, but Mr K does not feel this recognises the effect this had on his wife’s outcome. We considered if these actions were enough by considering what impact, if any, this failing had.
28. In order to consider the impact of this we asked our GP adviser. They noted, the only medical condition raised on 12 May was constipation and there was nothing mentioned that could have allowed the GP to anticipate Mrs K would suffer sepsis later due to a urinary tract infection. As explained in the previous complaint point, Mrs K’s constipation eased following her opening her bowels two days after the initial call to seek help for this. They said there was no significant impact from the missed call, as the assessment and treatment of the reported condition was effective and in line with GMC Good Medical Practice.
29. Nonetheless we can see a follow up call would have been reassuring so it is right that the Practice acknowledged the error. We have not identified any evidence of Mrs K’s constipation changing, other than to improve over this time period. There is no indication Mr K felt the need to seek medical help for his wife on 13 May 2022 in the absence of that call. If he had, due to her becoming more unwell, on balance of probability the advice would have been similar to that already offered. This would again be to advise her to attend hospital.
30. The Ombudsman's Principles for Remedy - Putting things right sets out that there are no set remedies for injustice resulting from poor service, and ‘An appropriate range of remedies will include...an apology, explanation, and acknowledgement of responsibility...revising procedures to prevent the same thing happening again; training or supervising staff; or any combination of these.’
31. We found that the actions taken were appropriate and in line with our Principles for Remedy. There is a minor customer service failing in the Practice not making an agreed call, but we have seen no clinical failing or impact from this oversight. We found the apology provided was sufficient to put right the worry this caused Mr K.
Not getting a home visit 32. Following the missed follow up call, the Practice received a call from Mrs K’s district nurse on 16 May 2022, who was attending her home for a dressing change and was calling due to concerns raised by Mr K. We note this is four days after the last contact from him.
33. The district nurse reported that Mr K had questions about his wife’s diabetes, her poor oral intake, and bloating. The nurse noted no vomiting and asked for Mrs K to be reviewed. The Practice agreed to arrange a home visit the next morning as her GP was not in that day.
34. Before arriving on 17 May 2022, Mrs K’s GP made a telephone call to Mr K to confirm the visit. The GP’s notes of that call document that Mr K informed the GP that his wife was more unwell, was not eating, and had only recently been discharged from hospital. The GP advised that if Mrs K had continued to become more unwell despite her constipation easing, she needed to be admitted to hospital. They advised Mr K to call an ambulance, and they would cancel the home visit, but to call if he had further concerns.
35. In the Practice’s response to Mr K’s complaint, Mrs K’s GP said, ‘We are limited to what care we can provide in primary care and in this case for sepsis the best place would be a hospital and often the outcome can be the same.’ Mrs K understandably is concerned that his wife’s death may have been avoidable if the GP had visited on that day or agreed to a home visit earlier. We asked our GP adviser if the correct actions were taken in relation to this. They provided the following advice.
36. They said there is no specific guidance covering when a GP should do a face-to-face consultation. As such we cannot say one was mandated by any rule, and it would be a matter of clinical judgement. According to our adviser’s interpretation of the GMC Good Medical Practice cited earlier, if it is not possible for a GP to gather enough information to complete satisfactory assessment on phone, a home visit would be needed.
37. Based on the information available to the GP, they appear to have been satisfied that a phone consultation was adequate on each occasion. Therefore, our GP adviser said it was clinically appropriate to not resort to a home visit. This is further supported by the treatment provided being effective in resolving Mrs K’s symptoms, following the earlier call on 12 May 2022.
38. Our GP adviser noted there were several issues discussed during the consultation on 16 May 2022. Mr K was also presumably happy with the plan to follow up with a home visit the next day. From the information available, the GP who called knew Mrs K and had a familiarity with her health difficulties.
39. Our GP adviser said the information provided during the pre-visit call was sufficient to establish Mrs K needed to be seen in hospital. They said it was the correct decision to cancel the home visit in light of her deterioration, as this would have contributed to delays in her accessing hospital care. They said, to have attended first would have led to a delay in seeking an ambulance. Subsequent events establish Mrs K was in need of hospital, not GP services, so a GP could not have prevented this need with a visit, or been in a position to provide the treatment she needed in her home.
40. They also explained that GPs will generally fit home visits in a short window between morning and afternoon surgeries, so it would not have been practical for a GP to attend Mrs K while she waited for an ambulance. Our GP adviser said the GP showed reasonable clinical judgement to identify Mrs K's immediate need at the earliest opportunity and provide advice to get her to hospital.
41. Taking this advice into consideration, we also noted no warning signs of her suffering a urinary tract infection, or that this would later progress to sepsis, in any of the communications with the Practice leading up to Mrs K’s hospitalisation. Also, the visiting district nurses did not identify any concerns about this either.
42. There appears to have been no missed opportunity to anticipate what happened later. If either condition had been indicated earlier, it is unlikely this could have been managed at home. Mrs K would have been advised she needed to go to hospital if any clear sign of an infection or sepsis had arisen.
43. We concluded the Practice made every reasonable effort to support Mrs K in the days leading up to her death. She was consistently advised she needed to attend hospital if she remained unwell, as the Practice and district nurses had reached the limit of what they could do to help in the community.
44. As the Practice acted in line with professional standards, and its GPs showed reasonable clinical judgement in relation to the information available, we do not consider the lack of a home visit a failing.
The Trust 45. Upon advice from his wife’s GP on 17 May 2022, Mr K called 999 for an ambulance at 2.44pm. Mrs K’s need was graded as a Category 3. She was referred to the 111 service for further assessment due to a Clinical Safety Plan (CSP) being in place to manage high service pressures. At 3.39pm, following Mr K's 111 discussions, a request for a Category 3 ambulance was submitted to the ambulance service.
46. Unfortunately, due to service pressures, an ambulance was not immediately available to send. At 4.40pm Mr K's son made a call to 999 and Mrs K’s priority was upgraded to a Category 2. At 5.47pm an ambulance arrived, and the crew then requested a bariatric ambulance (a special ambulance equipped to manage patients who exceed the weight and size limits of standard ambulances can manage).
47. At 7.50pm the bariatric ambulance arrived and transported Mrs K to hospital with suspected sepsis. The handover to hospital was completed at 9.47pm. This was 7 hours after the initial call to request an ambulance.
Incorrectly categorising calls for an ambulance 48. Mr K complains that his initial calls to seek an ambulance for his wife were wrongly categorised and that this led to avoidable delays in her getting to hospital.
49. Our paramedic adviser said that, based the written call logs, the categorisations applied at each stage were appropriate for the information provided to the service. They explained that, at the time of this incident, London Ambulance Service used the Medical Priority Dispatch System (MPDS). MPDS is a structured emergency medical dispatch system which follows scripted pathways to determine patient priority according to the answers given by the caller. The categorisation would reflect what is reported during the call in answer to the questions, not what may later be clinically diagnosed.
50. For Mr K's first call (to 999 at 2.44pm) the call log records that Mrs K was vomiting green liquid, not eating, in pain, bedbound with bedsores, and aged 68. While these features are concerning in hindsight, the records do not indicate Mr K reported immediately life-threatening features (such as collapse, abnormal or absent breathing, seizure activity, or ongoing unconsciousness) which would increase the priority to a higher category.
51. Under MPDS, a Category 3 (urgent) is consistent with the information provided on Mrs K's condition at the time of that call. Therefore, the initial call was handled in line with the relevant guidance, and the correct category was applied.
52. The Trust records show that at the time of the first call the service was operating under its CSP Red policy. Under CSP, Category 3 calls should be referred to NHS 111 for further clinical assessment, and an ambulance can be sent if needed. There are some limited criteria where this would not be the approach taken.
53. The available evidence indicates that, the initial call was correctly categorised as Category 3. It did not meet any of the criteria for not referring to 111, so the handling was in line with the guidance.
54. We recognise that Mr K felt this added to delays, but it also provided the opportunity to gather more information from him through the 111 service. This would not have been possible to collect during a 999 call at the level of demand the service was under at that time. It also provided the information required for the service to justify dispatch of an ambulance to her.
55. During the second call with 111, under MPDS, the presence of a ‘high-risk condition’ (age over 65) without an immediately life-threatening airway, breathing or circulatory problem would be a category 3. There is no evidence in the call log of Mr K reporting unconsciousness, abnormal breathing, collapse, severe chest pain, active seizure or profuse haemorrhage. These signs would have resulted in a higher category but were absent.
56. On that basis, requesting a category 3 ambulance was in line the MPDS and the Trust's local CSP policy. Although Mrs K was clearly very unwell (with the knowledge we have now), the information provided at that time did not meet the MPDS thresholds for a Category 1 or 2 ambulance at that moment, so keeping the priority at category 3 was appropriate based on the information available to the service at that time.
57. We see the situation had changed by the time of the third call made by Mr K's son at 4:40pm. Mrs K’s son now described her as ‘in and out of consciousness’. Under MPDS reduced alertness is a red flag for escalation. This appropriately triggered an upgrade to category 2. It is understandable that Mr K may feel his wife should have been a higher priority earlier and this would have resulted in getting an ambulance sooner. Based on the information available to the service, this was only possible under its operating procedures once this new sign was reported. The Trust appropriately escalated matters in line with the relevant guidance immediately.
58. Considering the above, we found no evidence of a failing, as the Trust acted appropriately in handling these calls and request for an ambulance. The delay in an ambulance arriving appear to be due to pressures on the service and demand for ambulances outside the Trust’s control. Appropriate demand management measures were in place so, rather than any missed opportunity to identify Mrs K’s need sooner, the categorising was correct based on her condition, as related over the phone.
Incorrectly requesting a specialist ambulance 59. Mr K complains that it was not necessary to order a specialist ambulance to transport his wife to hospital and this added further avoidable delays in her getting to hospital.
60. Upon arrival at Mrs K’s home the initial ambulance crew identified she would need a bariatric ambulance and requested one within 10 minutes. The crew documents that Mrs K weighed in excess of 26-30 stone, had one leg, was bed-bound, and also less responsive and so presumably able to offer little assistance in moving to an ambulance.
61. Our paramedic adviser referenced South East Coast Ambulance Service (SECAMB) East of England Ambulance Service NHS Trust (EEAST) and Yorkshire Ambulance Service (YAS) policies on this, which would also apply to the Trust's services in London.
62. Bariatric ambulances are specially designed vehicles equipped to transport patients who are classified as bariatric, typically those weighing over 25 stone. They are manned with extra crew members (4 rather than the usual 2) with specialised training to ensure the safety and dignity of larger patients during transport. The ambulances include specialised equipment such as hoists and wider ramps, and more space to accommodate patients who need more room.
63. Decisions on whether a patient needs a bariatric ambulance depend on: • patient dimensions and body shape • ability to assist with movement • environmental constraints (bedroom layout, door widths, stairs) • staffing levels and equipment available • the safe system of work for staff and patient
64. Based on the factors that needed to be considered, we can see that Mrs K would have met the requirements of a bariatric ambulance under multiple criteria in this list. It was not her weight alone, but also her lack of mobility, inability to assist the crew, and the logistics of moving her with these challenges to manage, that placed her at increased risk of harm without appropriate measures in place.
65. UK ambulance trust bariatric and moving and handling policies consistently emphasise that these factors cannot be reliably determined by telephone triage and require on scene dynamic risk assessment by attending clinicians. We see that due to this it would not be possible to have decided on ordering a bariatric ambulance sooner, as it required some on site assessment by a trained ambulance crew.
66. SECAMB’s Bariatric Policy requires initial responders to undertake a dynamic risk assessment using the TILEO framework (Task, Individual, Load, Environment, Organisational factors). TILEO states that where safe movement by a standard double-crewed ambulance cannot be achieved, no attempt should be made due to unacceptable risk.
67. EEAST and YAS policies similarly require dynamic risk assessment for all manual-handling activity, describing it as an ongoing process that evolves as circumstances change.
68. This approach aligns with Health and Safety Executive (HSE) guidance on moving and handling, which requires risk assessment and competent decision-making to prevent injury. We can see how an accident or injury during transportation could have resulted in Mrs K not surviving the journey in her condition. It was important to ensure she got to hospital safely to have a chance of successfully treating her.
69. We can understand Mr K’s unhappiness with how long it took to get his wife to hospital on 17 May, especially considering that she later died from sepsis. We found no failing in the decision to wait for a bariatric ambulance to be available to transport her as the ambulance crew acted in line with all the relevant safety guidelines in making that decision. We consider this was the right decision to make at that time, in order to ensure Mrs K got to hospital safely and without harm.
70. We understand why Mr K thinks there were failings leading to his wife’s death. We are sorry for the distress this caused him, and for the ongoing thoughts he has that the outcome could have been different. We hope this report explains the reasons why we have not found failings in the Trust’s care, and that Mr K is reassured that where we did see a minor failing in communication, we consider the Practice has taken sufficient action regarding that.