A medical practice in the Worcestershire area

4. Ms L complains about the care and treatment staff at the Practice gave to her father between September and November 2019. She says a practice nurse failed to arrange an appointment with a GP. She also says the nurse did not recognise how unwell her father was when he attended the Practice and did not take appropriate action. Ms L also complains that a GP did not take sufficient action following a telephone consultation with her father.

5. Ms L believes her father’s death might have been avoided if Practice staff had acted appropriately. She says the circumstances of her father’s death have been distressing for her and her family.

6. Ms L is also unhappy with how the Practice handled her complaint. She says its response was incomplete and inaccurate. She says poor complaint handling added to her distress at a time when she was grieving for her father.

7. Ms L wants the Practice to acknowledge its failings and apologise for the impact they had on her family. She also seeks a financial remedy, but this is not the main reason for her complaint.

8. Mr L had a history of chronic iron deficiency anaemia, due to rectal bleeding, since 2014. Doctors prescribed iron tablets, but Mr L chose not to take these because they caused stomach problems. Mr L also had diabetes, heart disease, asthma, chronic kidney disease, and high blood pressure. In 2018, GPs referred Mr L to colorectal surgeons for investigations. Mr L declined to have a colonoscopy (examination of part of the bowel using a scope).

9. On 5 October 2019, Mr L attended the Practice for a diabetes review. He saw practice nurse 1. They did not identify any concerns with his diabetes. Mr L complained that he was tired and had dizzy spells.

10. Mr L attended the Practice for an asthma review on 18 October 2019. He again saw practice nurse 1. They noted he left the appointment before they could complete the review.

11. On 24 October 2019, Mr L had a phone conversation with GP 1 (a GP at the Practice). Mr L’s haemoglobin levels had fallen. GP 1 recommended changing the iron tablets to a different type, and Mr L agreed to this. They also discussed a possible referral to colorectal surgeons. Mr L agreed and GP 1 sent a referral letter the same day. GP 1 also arranged a blood test for a month later, to monitor haemoglobin.

12. Sadly, Mr L had a heart attack and died in November 2019.

13. Ms L complained to the Practice in February 2020. The Practice replied to the complaint in March 2020. It did not consider there were any failings in care.

Nursing care

16. Ms L complains about two specific appointments her father attended, with practice nurse 1. She says practice nurse 1 failed to recognise how unwell her father was, and they should have arranged for him to see a GP.

17. The Nursing Adviser told us practice nurses review patients with chronic disease such as diabetes and heart disease. They are experienced in addressing deteriorating chronic disease control over time for example, high sugar levels in diabetes, high blood pressure, or high cholesterol levels. They do not see patients who are acutely unwell. Patients who are more unwell would normally see a nurse practitioner, an advanced nursing practitioner, or a GP.

18. The Nursing Adviser said practice nurses are expected to follow the NMC Code. This says they should accurately identify, observe, and assess signs of normal or worsening physical and mental health in the person receiving care. They should also make timely referrals to other practitioners when any action, care, or treatment is required.

19. The NMC Code also says nurses should act in partnership with those receiving care. This means they should provide advice and support to patients when managing chronic disease. They should also take immediate action of the patient has any life-threatening symptoms, for example chest pains or breathing difficulties. It also says nurses should respect, support, and document a person’s right to accept or refuse care and treatment.

5 October 2019

20. Ms L complains about a diabetes review appointment her father attended at the Practice on 5 October 2019. She says he was breathless, and the nurse agreed to arrange an appointment with a GP.

21. The Nursing Adviser told us practice nurses complete a template at these reviews, to capture the relevant information. This helps to ensure the patient’s diabetes is being properly managed, or to identify any areas of care relating to diabetes that need addressing.

22. Practice nurse 1 recorded Mr L’s height, weight, and blood pressure. They checked his feet for poor circulation or nerve damage. They noted his blood sugar levels had improved significantly, from being poorly controlled in 2018. Mr L’s cholesterol was also within expected limits and recent blood tests were not a concern. Practice nurse 1 also reviewed his medication.

23. During the assessment, practice nurse 1 noted Mr L complained of new symptoms. These were dizzy spells and lethargy. Practice nurse 1 considered this was because of his anaemia. His haemoglobin levels were very low. The Nursing Adviser said practice nurse 1 was correct in thinking this was the most likely cause of his symptoms.

24. Practice nurse 1 sought advice from a colleague while Mr L was with them. This was presumably a nurse practitioner, advanced nurse practitioner, or a GP. They suggested Mr L should try over the counter vitamins and minerals.

25. The records show no evidence that Mr L was acutely ill during the diabetic review. There was no requirement for practice nurse 1 to take any further action. They also obtained clarification from a senior colleague. There was no requirement for them to arrange an appointment with a GP, and there is nothing in the records to suggest practice nurse 1 agreed to arrange one.

26. We find practice nurse 1 followed the NMC Code. We do not uphold this part of Ms L’s complaint.

18 October 2019

27. On 18 October 2019, Mr L attended the Practice for his annual asthma review. Ms L says this was supposed to be an appointment with a GP. She says her father had blood in his urine and the nurse should have sent him to hospital.

28. The records show practice nurse 1 carried out the asthma review and reviewed Mr L’s blood test results. They advised him to continue taking multi-vitamins because his breathlessness was probably due to anaemia. Practice nurse 1 noted it was a difficult consultation. Mr L said he was ‘fed up with taking tablets’ and then put on his coat. Practice nurse 1 noted they advised him they needed to do a breath test, but Mr L left the room.

29. Practice nurse 1 could not complete the consultation because Mr L left. There were no signs of any acute or life-threatening symptoms that needed any immediate action. There is no record of any discussion about blood in Mr L’s urine.

30. Practice nurse 1 noted Mr L had an appointment with a GP scheduled for 24 October 2019. This was arranged before the asthma review. It is possible Mr L misunderstood the reason for his attendance on 18 October because of the appointment planned for the next week. The asthma review was incomplete because Mr L left the appointment early.

31. We find practice nurse 1 followed the NMC Code when they recognised, and documented, Mr L’s right to refuse care and treatment. We recognise Ms L has strong views about this issue. We have seen no independent evidence to suggest any failings by practice nurse 1.

32. We do not uphold Ms L’s complaint about the appointments her father attended with practice nurse 1.

Consultation on 24 October 2019

33. Ms L complains about the telephone consultation her father had with GP 1. She says GP 1 should have taken action to ensure her father received the treatment he needed. She believes GP 1 should have ensured her father went to hospital.

34. The GP Adviser told us GP 1 should have followed Good Medical Practice. This says doctors must provide a good standard of practice and care. They must adequately assess patients, taking account of their history. When necessary, they should examine the patient. They must also promptly provide or arrange suitable advice, investigations, or treatment where necessary. They should refer patients to another practitioner when this serves the patient’s needs.

35. GP 1 should have taken account of the Cancer Guideline. This says doctors should refer people for suspected colorectal cancer if they are aged over 60 with iron deficiency anaemia or changes in their bowel habit. This should be for an appointment within two weeks.

36. GP 1 should also have followed the Blood Transfusion Guideline. This says doctors should consider a red blood cell transfusion for patients whose haemoglobin levels are below specific thresholds. For Mr L this would have been below 70g/litre.

37. The clinical records show GP 1 discussed recent test results with Mr L. GP 1 advised him to start iron tablets. Mr L explained he had loose stools and had been to see a colorectal surgeon because of bleeding from haemorrhoids. GP 1 noted they offered to arrange a review and advised a colonoscopy (examination of part of the bowel using a scope). They noted Mr L did not want a colonoscopy.

38. GP 1 noted they told Mr L that, unless there was a review, he would need to have a blood transfusion because of his worsening haemoglobin levels. Mr L agreed for GP 1 to refer him to the colorectal team. There is no record Mr L described any symptoms related to his heart, such as chest pain.

39. The GP Adviser said the records show Mr L was already having appropriate treatment for vitamin deficiencies. The records from the consultation show GP 1 carried out an adequate assessment in this respect. They followed Good Medical Practice.

40. Mr L also explained how he had been experiencing loose stools and bleeding. These symptoms had been present for some time. GP 1 made a routine referral to the colorectal team. An urgent referral would only have been indicated if Mr L’s anaemia had been a recent development. But the anaemia had been ongoing for several years and had already been investigated by relevant specialists. GP 1 followed the Cancer Referral Guideline and Good Medical Practice.

41. The GP Adviser noted GP 1 also prescribed iron tablets, which is a suitable treatment for anaemia. Mr L’s haemoglobin level was 85g/litre. This was above the level at which a blood transfusion should have been considered according to the Blood Transfusion Guideline.

42. We found GP 1 followed the relevant standards and guidelines. There was no requirement for them to provide any other treatment, or for them to refer Mr L to hospital. We do not uphold this part of Ms L’s complaint.

Complaint handling

43. Ms L complains about the Practice’s response to her complaint of 18 March 2020. She says it was incomplete and inaccurate. She believes her father was more seriously unwell than the Practice has recognised.

44. Our Principles of Good Complaint Handling say public organisations should be ‘open and accountable.’ This includes providing evidence-based explanations and giving reasons for decisions. It says they should also act ‘fairly and proportionately.’ This includes ensuring complaints are investigated thoroughly and fairly to establish the facts of the case.

45. We have reviewed the complaint form Ms L completed in February 2020. In that form she raised several issues relating to the care and treatment staff at the Practice gave to her father. We can see the Practice replied to each of these points in its letter of 18 March 2020. We can also see that its response was based on the clinical records. There is no evidence the response was incomplete or inaccurate.

46. We find the Practice’s response showed it was ‘open and accountable’ and it acted ‘fairly and proportionately.’ The response was line with the Principles of Good Complaint Handling. We do not uphold this aspect of Ms L’s complaint.

Conclusion

47. We can see Mr L’s sudden death was devastating for Ms L and her family. We recognise Ms L has strong views that staff at the Practice failed her father and did not respond appropriately to her complaint. After carefully considering all the evidence we do not find any failings by the Practice. We do not uphold Ms L’s complaint.

1. Ms L complains about the actions of staff at the Practice during face-to-face and phone consultations with her father, shortly before his death in 2019. Ms L told us how the circumstances of her father’s death were heart-breaking for his family. We offer our sincere condolences to them for their loss.

2. We have carefully considered Ms L’s views and recollections. We find the GP and nurse she complained about followed the relevant standards. We also consider there were no failings relating to the Practice’s complaint handling.

3. We do not uphold Ms L’s complaint. We recognise this will be disappointing for her.