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.
Middle of July to middle of September 2023
14. Mr C describes his mother became unwell in July 2023. Mr C complains the Practice did not manager his mother’s health conditions, and this led no improvement and a hospital admission in August 2023.
15. Medical records show the Practice undertook a medication review for Mrs C in March and May 2023. Mrs C asked for support as she lost her hearing aid and required a new appointment with a specialist service to remedy this.
16. Medical records show on 14 July 2023, Mr C contacted the Practice reporting his mother has been deteriorating over the last few days and she was complaining of abdominal pain.
17. The Practice was able to offer an appointment the same day. It is noted, in the medical records, during the consultation the physician provided a physical examination and noted the presenting symptoms as reported by Mrs C’s son. The physician prescribed two antibiotics to treatment both urinary tract infection (infection of the bladder) and chest infection. The Practice also recommended urine tests for an antibiotic review if necessary.
18. Medical records document Mrs C provided regular urine samples during this period. The Practice carried out medications reviews and prescribed new antibiotics when necessary.
19. Medical records show Mrs C had many consultations between July and September 2023 including many home visits with some lasting between 40 and 50 minutes. The records detail a thorough and detailed clinical review was done when needed.
20. NICE ‘Urinary tract infection (lower) – women’ provides clinicians with guidance on diagnosis, management and prescribing information on urinary tract infections.
21. NICE’s ‘Urinary tract infection (lower) – women’ details clinicians should consider a diagnosis of UTI in a woman aged over 65 years if they have a urinary catheter in situ or if there is isolated new-onset pain or discomfort when urinating. They should also consider a UTI diagnosis if there are two or more urinary or non-specific symptoms from the following list: • fever • new frequency or urgency • new urinary incontinence • new abdominal pain • new visible blood in the urine • new or worsening delirium • new or worsening general malaise • lethargy and reduced daily functioning.
22. NICE defines recurrent UTI as two or more episodes of UTI in six months or three or more episodes in one year. This can be due to a relapse (infection due to the same strain of organism or reinfection) or an infection due to a different strain or species of organism.
23. The above guidance also describes treatment options highlighting the importance of urine culture results, taken from urine samples.
24. Our adviser reviewed the medical records and agreed the Practice provided suitable diagnosis and treatment guided by the urine culture results.
25. Based on the presenting symptoms and medical review dated 14 July 2023, we are pleased to see the Practice considered the diagnosis of UTI and provided antibiotic treatment. Specifically, the Practice took into account the abdominal pain and the new confusion as indication of UTI as recommended in NICE’s ‘Urinary tract infection (lower) – women’.
26. Based on medical records, we can see this diagnosis was confirmed through urine testing.
27. Based on NICE guidance discussed above, we are pleased to see the Practice continued to review Mrs C’s antibiotic treatment and proposed treatment for recurrent UTI as Mrs C’s urine tests showed she was affected from reinfection (infection due to a different strain or species of organism) during this time.
28. Based on medical records, we can see the Practice reviewed Mrs C multiple times during this period and considered the efficacity of the UTI treatment. We Furthermore, we can see the Practice has escalated the antibiotic treatment in line with the NICE guidance ‘Urinary tract infection (lower) – women’ and guided by the urine culture results.
29. Considering Mrs Manner’s urine culture results, as recorded in the medical records, NICE’s ‘Urinary tract infection (lower) – women’ guidance and the views of our adviser we are of the view there are no indications of failings and as such, we will take no further action in respect to this aspect of the complaint.
15 August 2023
30. Mr C complains the Practice did not provide appropriate treatment or admit Mrs C to hospital during a consultation on 15 August 2023.
31. Medical records show on 14 August 2023, Mrs C received a home visit from the Practice. It is documented during this visit the doctor reviewed Mrs C and prescribed a stronger antibiotic.
32. On 15 August 2023, Mr C contacted the Practice again advising his mother was getting worse and not better. Medical records detail on 15 August 2023, Mr C asked the Practice if and admission to hospital would be appropriate for his mother.
33. The Practice arranged for a face-to-face appointment on the same day. During the consultation, the physician noted Mrs C had had five courses of antibiotics. She was experiencing abdominal pain, reduced appetite, but was not vomiting and she was sleeping more.
34. On examination, the physician noted Mrs C’s abdomen showed tenderness. The physician examined Mrs C’s chest and this examination did not raise any concerns. It is noted Mrs C’s blood pressure and pulse were within normal limits. The physician highlighted Mrs C’s abdominal pain was chronic (constant and reoccurring) and she could have multiple UTIs and diverticulitis (bowel infection).
35. Medical records document, during the consultation, Mrs C stated she ‘doesn’t want to go to hospital’.
36. Medical records document, the physician considered a hospital admission would not be beneficial or appropriate. The Physician noted Mrs C’s family were doing their best to look after her. It is noted the physician could not be guarantee a hospital admission would add any benefit to Mrs C, given the treatment she was already receiving and her wish to stay at home.
37. Medical records show Mrs C was admitted to hospital five days later with aspirated pneumonia.
38. GMC’s Good Medical Practice sets out the principles, values, and standards of professional behaviour expected of all doctors. It states when clinicians assess, diagnose, or treat patients, they must work in partnership with patients to assess their needs and priorities. The investigation or treatment clinicians propose, provide or arrange must be based on this assessment, and on their clinical judgement about the likely effectiveness of the treatment options.
39. GMC’s Good Medical Practice states when providing clinical care doctors must assess a patient’s condition, taking account of their history, including symptoms and the patient’s views. Doctors must carry out a physical examination where necessary and promptly provide (or arrange) suitable advice, investigation or treatment where necessary.
40. NICE ‘Pneumonia: diagnosis and management’ provides guidance on diagnosing, assessing, and treating community-acquired and hospital-acquired pneumonia, including bacterial pneumonia secondary to COVID-19, in babies over 1 month (corrected gestational age), children, young people and adults. It aims to optimise antibiotic use and reduce antibiotic resistance.
41. The above NICE guidance states clinicians should consider potential pneumonia if patient has a low blood pressure and raised respiratory rate.
42. NICE ‘Chest infections – adult’ provides clinicians with guidance on diagnosis, management and prescribing information on chest infections including pneumonia.
43. NICE ‘Chest infections – adult’ indicates clinicians should suspect pneumonia if course crepitations (crackles are abnormal lung sounds that indicate potential respiratory issues, often associated with fluid in the airways) are present on examination.
44. Our clinical adviser viewed the medical records and agreed is it difficult to ascertain whether a hospital admission would have been beneficial on 15 August 2023. Our adviser explained Mrs C was a frail patient with multiple health issues and did not present any symptoms that would have warrant and admission on that day.
45. Based on medical records, we are of the view the consultation dated 15 August 2023 was in line with GMC’s Good Medical Practice. Specifically, the physician took into account Mrs C’s presenting symptoms (abdominal pain, vomiting, reduced appetite), they considered Mrs C’s medical history (persistent abdominal pain, UTI and antibiotic history), provided a physical examination and provided advice based on the likely effectiveness of the treatment options (during this appointment the physician gave a consideration to the suitability of a hospital admission).
46. Based on medical records, Mrs C did not have any symptoms on 15 August 2023 that would have indicated a diagnosis of pneumonia. Specifically, Mrs C did not have a raised respiratory rate or low blood pressure which would have indicated a potential diagnosis of pneumonia as per NICE ‘Pneumonia: diagnosis and management’ guidelines. As such, we consider a hospital admission would not have been suitable without any indications of pneumonia.
47. We have also seen the physician carried out a physical examination of Mrs C and specifically listen for any abnormal sounds, noting no course crepitations (popping or crackling sounds) were observed. As such, based on the symptoms described in NICE ‘Chest infections – adult’, the Practice had no reason to suspect pneumonia on 15 August 2023.
48. We understand why Mr C enquired in August 2023 about the suitability of a hospital admission for Mrs C. We can see Mrs C had frequent appointments and the family were concerned about the lack of overall improvement in Mrs C’s health.
49. We are pleased to see the Practice was able to offer treatment and care during this difficult time.
50. Considering Mrs C’s symptoms, as recorded in the medical records, the GMC’s Good Medical Practice, NICE’s ‘Pneumonia: diagnosis and management’ and ‘Chest infections – adult’ guidelines and the views of our adviser, we are of the view there are no indications of failings. As such, we will take no further action in respect to this aspect of the complaint.
Diuretic
51. Mr C complains the Practice did not review his mother after it halved the dose of her furosemide medication. Furosemide is medicine used to treat fluid retention and high blood pressure by increasing urine production. It is also commonly referred to as a diuretic.
52. Medical records show Mrs C was prescribed diuretics to manage any fluid retention cause by heart failure.
53. Medical records detail the Practice halved Mrs C’s diuretic on 19 July 2023 due to having possible side effects to ‘run to the toilet all morning which affects daily life.’
54. Medical records document Mrs C had multiple consultations after 19 July 2023. We note Mrs C did not raise any concerns about side effects or concerns about fluid retention after 19 July 2023.
55. NICE ‘Heart failure – chronic’ provides guidance on managing chronic heart failure. It recommends clinicians review the diuretic dose to reduce the risk of dehydration, acute kidney injury, and electrolyte disturbances.
56. The above guidance focuses more on increasing diuretic doses and recommends clinicians organise blood tests soon after increasing a diuretic dose but not when decreasing.
57. Our adviser reviewed the medical records and agreed it was appropriate to review Mrs C’s diuretic medication on 19 July 2023, as she clearly described a side effect of the medication. Our adviser also noted Mrs C did not show any signs of fluid retention leading to leg swelling in the subsequent medical consultations.
58. Based on medical records we can see Mrs C had multiple consultations after 19 July 2023. As such, we are pleased to see she had the opportunity to discuss any symptoms which could have been related to the reduction in diuretic medication. Moreover, we are pleased to see the Practice organised blood tests on 31 July 2023 and these did not indicate Mrs C was impacted by the clinical decision made on 19 July 2023, to reduce her diuretic intake.
59. We can see Mr C cared deeply for his mother and is keen to understand how medical decisions might have impacted her wellbeing. We can see Mrs C had multiple appointments during this period and was not well. We recognise this had a significant impact on Mr C at the time.
60. Considering Mrs C’s consultations after 19 July 2023, NICE’s ‘Heart failure – chronic’ and the views of our adviser, we can see no indications of failings. As such, we will take no further action in respect to this aspect of the complaint.
Named GP
61. Mr C complains between July and September 2023 the Practice did not arrange appointments with Mrs C named GP. As such, Mr C feels the GP reviewing his mother did not have experience of her complex long-term conditions.
62. Medical records show Mrs C’s named clinicians did not consult her during this period.
63. The GMS contract in 2023/24 states every patient must be given an accountable GP. The name of the accountable GP must be shared with the patient. The accountable GP is also known as the named GP.
64. The GMS contract is an agreement Practices have with NHS England to deliver primary health care.
65. The GMS contract states;
‘The accountable GP must take lead responsibility for ensuring that any services which the Contractor is required to provide under the Contract are, to the extent that their provision is considered necessary to meet the needs of the patient, coordinated and delivered to the patient.’
66. To better understand the responsibilities of a name GP we looked at British Medical Association (BMA) ‘The named GPs' responsibilities’. Although this was updated in June 2024, we still feel the information is relevant to understand the role of a named GP. The BMA states: ‘The named GP is largely a role of oversight.’ It also details: • ‘patients do not need to see their named GP when they book an appointment with the Practice.
• the named GP will not take on 24 hour responsibility for the patient or have to change their working hours.’
67. It is understandable why Mr C would have liked her mother to receive continuity of care from the same clinician. We recognised he might have felt better supported.
68. Considering the above complaint sections and details included in the British Medical Association ‘The named GPs' responsibilities’, we are of the view there are no indications of failings. The Practice provided Mrs C treatment and care in line with relevant standards, as detailed in the above sections of this complaint. As such, we will take no further action in respect to this aspect of the complaint.
Breathlessness
69. Mr C is concerned that his mother did not have access to oxygen therapy despite her reduced capacity.
70. Mr C complaints the Practice did not consider is mother’s breathlessness could have been caused by kyphoscoliosis and did not take appropriate action. Mr C is of the view the Practice should have arranged further investigations, such as an arterial blood gas test to diagnose a potential build-up of carbon dioxide in the blood.
71. Medical records show Mr C voiced his concerns about the possible impact of the carbon dioxide build-up. The Practice made a referral to the oxygen service for a specialist respiratory assessment on 29 August 2023. The oxygen service declined the referral.
72. Medical records also show Mrs C was admitted to hospital during this period. We note the hospital discharge summary does not mention arterial blood gases or carbon dioxide retention. Furthermore, there is no mention on the discharge letter that the Trust felt Mrs C shortness of breath was due to kyphosis.
73. We accept we have not considered the treatment and care as an inpatient, as this is not in the scope of this complaint.
74. Our adviser reviewed the medical records and advised there was no suggestion Mrs C shortness of breath may be due to her kyphosis. Our adviser confirmed GPs are unable to take arterial blood gases as the blood needs to be analysed as soon as the blood has been taken from a patient. GP Practices do not have onside blood tests laboratories and so it would not have been able to analyse Mrs C’s blood even it had taken a sample.
75. GMC’s Good Medical Practice states when providing clinical care doctors must refer a patient to another suitably qualified practitioner when this serves their needs.
76. Considering GMC’s Good Medical Practice and the views of our adviser, we can see no indications of failings, as the Practice made the necessary referral when requested. As such, we will take no further action in respect to this aspect of the complaint.
77. It is important to acknowledge that where we have not identified any indications that something went wrong, it does not detract from Mr C and his family’s experience, nor the impact this has had on them.
78. Complaints give us valuable insight into the organisations we investigate, and we recognise this has been an emotionally challenging process for Mr C. We would like to thank Mr C for sharing her experience with us.