A medical practice in the Essex area

5. Miss I complains about the care and treatment she received from 4 to 6 November 2019 from the Practice and the OOH service. She also says the Practice did not investigate the complaint appropriately.

The Practice

6. Miss I complains that on 5 November the Practice did not inform her of her blood results and text her in error to make a routine appointment. She says this should have been an urgent appointment or advice to attend A&E.

7. She says this error resulted in a hospital admission which could have been avoided.

The OOH service

8. Miss I complains that the service did not take any action despite her calling them numerous times with symptoms.

9. She complains that on 5 November it confirmed it could see the blood results which showed infection, and the OOH service advised her to contact her GP, instead of telling her to go to A&E.

10. Miss I says as a result of the infection not being picked up sooner, she was in hospital for six days. She says the delay meant she was in pain unnecessarily.

11. She says the final response to her complaint lacked empathy and this caused her upset.

12. Miss I would like service improvements.

13. On 1 November 2019, Miss I felt generally unwell and had a high temperature. She says she took paracetamol and went to bed.

14. On 2 and 3 November, she continued to take paracetamol as she still felt unwell.

15. On 4 November she visited her GP. Her symptoms included a high temperature, cold hands and feet, loss of sensation in the fingertips and pins and needles. The GP took a blood test and said they would inform her of the results.

16. On 4 November, Miss I still had a high temperature and called the 111 OOH service.

17. On 5 November, the Practice was closed for training and Miss I contacted the OOH service again and it informed her it could see the results of her blood test. It was also recorded on the system that her GP tried to call her at 12.15pm and she had missed the call. The nurse on the call advised her to contact her GP in the morning. She was informed her C-Reactive Protein (CRP) level was raised, at 252, with signs of an infection. However, the nurse on the call advised as the GP had already texted her to arrange a routine appointment, she should wait for the Practice to open.

18. On 6 November, Miss I phoned the Practice and was advised to go straight to A&E. She was admitted to hospital A the same day and received intravenous (IV) fluids and antibiotics. She was diagnosed with Pyrexia. She stayed in hospital for six days and was discharged with a seven-day course of antibiotics. A computerised tomography (CT) scan was scheduled for six weeks’ time.

Communication about blood results (the Practice)

22. Before we decide if we should investigate 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.

23. We have done this and found indications that both organisations failed to correctly respond to Miss I’s blood results and advise her appropriately. The advice we have received indicates she needed a hospital admission because of her symptoms, but the actions of both organisations delayed this by a day. We see this is likely to have caused Miss I worry and prolonged her pain.

24. We appreciate the time Miss I has spent in bringing her complaint to us and discussing her experience, and we are sorry to hear about what happened and how this affected her.

25. The General Medical Council (GMC), Good medical practice, point 5 tells doctors: ‘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’.

26. The medical records show Miss I’s blood results indicated a very high CRP level. This is a protein made by the liver, released in the blood stream in response to inflammation or infection. The raised CRP level indicated Miss I could have been significantly unwell, and the Practice did not appropriately communicate this with her or alert her to seek help.

27. In accordance with the above guidance, the Practice should have arranged an appointment that same day, but it did not.

28. The Practice said in its final response letter that Miss I’s blood test was taken on 4 November and the results were reviewed by a GP at the Practice on 5 November. The GP noted a slight rise in white cell count and a raised CRP level of 252. The GP called on 5 November to advise her of this but could not get through to her. The GP then filed the blood results and alerted the reception team to send a text.

29. The Practice has confirmed the text should have said ‘urgent’ instead of ‘routine’ and has apologised for this. The Practice has said because of this complaint it has made changes to its text messaging system and removed the word ‘routine’. The text messages sent should only say ‘make an appointment’.

30. The Practice did not make any further attempts to contact Miss I as it was closed on 5 November for training, and the GP returned to the Practice on 7 November.

31. Our adviser says based on the blood results, the GP should have made further attempts to contact Miss I or inform her to seek assistance from the OOH service as the Practice was closed.

32. If the GP had done this, Miss I would likely have gone to A&E a day sooner. We go on to consider the clinical impact of this failing.

Impact

33. We understand it was difficult for Miss I to cope with her symptoms, especially her constant high temperature and we are sorry for the distress she suffered.

34. Our adviser confirms the medical notes show Miss I had a kidney infection. This was first detected by a CT scan taken in hospital.

35. The medical notes show she had no urinary symptoms, therefore if she had been assessed by a GP, she would have been sent to hospital the same day for further investigations.

36. Our adviser explains a kidney infection can cause sepsis, but this was not the case for Miss I. If the Practice had sent the correct text on 5 November, it may have resulted in Miss I going to A&E on that day rather than 6 November. We cannot say her hospital admission could have been avoided entirely but we acknowledge it could have happened one day sooner. This would likely have meant her pain was addressed sooner and could have reduced the worry she experienced.

37. The final response letter acknowledges the error in the text message that was sent. We can see that the Practice’s poor communication and attempt to contact Miss I was distressing for her, at an already difficult time.

38. The Practice has apologised for this and made changes to their text message system to prevent this happening again. Miss I complained to us asking for service improvements. We are satisfied the Practice has already taken sufficient action to prevent recurrence of this incident and so we are not asking it to do anything further.

Care provided by the OOH service

39. Miss I is concerned the OOH service did not provide any care or treatment and did not advise her to go to A&E on 5 November despite seeing her blood results.

40. Our adviser says the medical notes show the nurse who reviewed Miss I over the phone had seen the blood results and the text sent by the Practice. The text suggests the GP had decided Miss I needed a routine appointment and that no further action was needed.

41. On seeing the blood results, the nurse should have arranged for Miss I to be assessed that evening through the OOH service. However, it is clear the text on the system influenced their actions.

42. Our adviser noted this may have been confusing for the nurse to see, and in these instances, nurses would generally follow the instruction of a more senior clinician.

43. Miss I did not have an opportunity to be assessed after her blood results, despite seeking assistance from the OOH service.

44. Therefore, this is an indication of a failing.

Impact

45. Having reviewed the notes and the advice we have received, we consider the error in the text message from the Practice, affected the care Miss I received from the OOH service.

46. The nurse should have arranged for Miss I to be assessed, and it seems likely their decision was clouded by the error made by the Practice. This has further prolonged Miss I’s distress and pain as she was denied the opportunity to be assessed for her clinical symptoms for the second time.

47. On 5 November the OOH service advised Miss I to contact her Practice for the routine appointment it referred to in its text. It was only when Miss I called the Practice that she was told she immediately needed to go to A&E.

48. The OOH service has acknowledged the care Miss I received fell short of its normal standards.

49. It is reassuring to see the OOH service has discussed this case with the clinician involved and carried out an audit of their work. It has confirmed this clinician has been monitored monthly to ensure this does not happen again.

50. The OOH service has also reiterated to its staff to carry out a full clinical assessment of all patients, regardless of any other assessment that may have been carried out by a senior clinician.

51. As with our consideration of the Practice’s actions, the delay in Miss I being treated at hospital did not have an effect on the treatment she received. This is because her symptoms would have meant she was sent to hospital and required an admission for several days.

52. We cannot say her hospital admission could have been avoided, however we acknowledge the OOH service’s actions meant she did not go to A&E until 6 November, which was one day after receiving her blood results.

53. While we acknowledge this may have been distressing for Miss I to learn, we can see evidence that the OOH service and the Practice have apologised and improved their service to prevent recurrence. Based on this, we would not ask it to do anything further.

Complaint handling (the Practice)

54. Miss I is also concerned the Practice did not investigate her complaint appropriately and that her concerns were not fully addressed.

55. The NHS complaints regulations state that when handling a complaint, a written response should be provided which summarises the nature and substance of the complaint and the conclusions reached.

56. The Ombudsman’s Principles of Good Complaint Handling say organisations should: ‘investigate complaints thoroughly and fairly, basing their decisions on the available evidence, and avoiding undue delay’.

57. We are sorry Miss I feels the Practice was not clear in how it investigated her complaint.

58. After careful consideration of the complaint response, we can see evidence the Practice has referred to the medical records when responding to the issues raised in the complaint, addressed the failing that took place and apologised for this.

59. We can also see a sufficient explanation of how the Practice updated its text messaging function to ensure prevention of future occurrences.

60. We cannot see any evidence the Practice has failed to address Miss I’s concerns and can see an explanation for the error in the text message has been provided. This indicates her complaint was investigated appropriately and is in line with the principles above.

61. To conclude, we have found no evidence of failings in the way the Practice has investigated Miss I’s complaint.

62. This is because while the Practice did not summarise her complaint, it did explain the events that led to the failing we identified and the action it took because of that.

63. We appreciate Miss I’s strength of feeling about her complaint and it is clear she feels deeply concerned about the service she received. We do not wish to diminish the impact she says these events have had for her.

64. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reason for it.

1. We have carefully considered Miss I’s complaint about a medical practice (the Practice) and an out of hours service (the OOH service), both in the Essex area. We are sorry to hear of the distress she has experienced because of these events.

2. In relation to her complaint about how the Practice and the OOH service responded to her blood results, we have decided neither of the organisations appropriately communicated these to her.

3. This resulted in her being admitted to hospital one day later than she should have. We have considered the actions the organisations have taken because of this and would not ask them to do anything further.

4. In relation to her concerns about how the Practice handled her complaint. We have not identified any failings in relation to this.