A medical practice in the Chesterfield area

3. Ms L complains about the care provided by the Practice to her husband, Mr I, between 30 September 2020 and 5 October 2020. She says the Practice were insensitive in a telephone consultation and did not make call backs when requested.

4. Ms L says this contributed to Mr I’s untimely death, which has devastated her and her family.

5. She says she wants the Practice to acknowledge wrongdoing.

6. Ms L says her husband, Mr I, had been feeling anxious about returning to work after being on furlough. Ms L says it was out of character for her husband to feel this way, so she suggested he call his GP.

7. Ms L says Mr I was highly distressed following a telephone consultation with the GP on 30 September 2020. She says he indicated the GP had been insensitive.

8. Ms L says she called the Practice on 1 October 2020, 2 October 2020, and 5 October 2020 requesting call backs from a different GP. She says she provided a contact number each time for the Practice to call back, but it did not return any calls.

9. The Practice says it made attempts to call Mr I on 1 October 2020, 2 October 2020, and 5 October 2020 but could not get through. It later found the call handling staff had recorded the contact number incorrectly.

10. Mr I sadly died on 5 October 2020 from a sudden cardiac arrest.

11. Ms L complained to the Practice on 3 January 2021. She says the telephone consultation on 30 September 2020 contributed to Mr I’s death. She says the doctor was insensitive and this increased Mr I’s stress and anxiety.

12. In their response, the Practice says the doctor tried to be helpful in the consultation and explained the matters discussed. It says the clinical findings do not support her feeling that its neglect caused Mr I’s death.

13. Ms L complained to us in March 2021. She says she does not believe the doctor’s account of the telephone consultation.

Telephone consultation

17. 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. We have done this and while we recognise the sad circumstances of the complaint, we have not found any indications that something has gone wrong.

18. Ms L says her husband was highly distressed after the telephone consultation on 30 September. She says Mr I indicated the GP had not taken his concerns seriously or handled them sensitively. We are sorry to hear of the upset Mr I felt, and how this memory lives on with Ms L.

19. We are not able to independently check the phone call between Mr I and his GP on 30 September 2020. This is because the only record that exists of the conversation is made by the GP in the clinical records.

20. We discussed this with our adviser. They told us there is no specific guidance about managing patients who are feeling anxious about returning to work after being on furlough for several months.

21. The relevant guidance is: General Medical Council’s (GMC) good medical practice, specifically, Domain 3: Communication partnership and teamwork. This says the GP must listen to patients and give patients information they want or need to know in a way they can understand.

22. The records show Mr I said he was having trouble sleeping and had palpitations when he thought about returning to work. Mr I asked for medication to help with the lack of sleep and anxiety.

23. The records show the GP prescribed diazepam. Our adviser explained that, in line with the NICE British National Formulary (BNF), this was an appropriate medication for the presenting symptoms. The notes also show the GP arranged a follow-up appointment for a week later.

24. GMC’s good medical practice guidance says GPs must promptly provide or arrange suitable advice, investigations, or treatment where necessary. It also says GPs must provide effective treatments based on the best available evidence. We can see the steps taken by the GP indicate they acted in line with this.

25. Our adviser added that Mr I’s history of high blood pressure meant he had increased risk of heart problems. There is no indication in the record of the conversation that there were any other markers, such as chest pain, that would have led the GP to foresee Mr I’s sad death.

26. Ms L said the Practice should have offered Mr I a face-to-face consultation, rather than telephone. We recognise the distress Ms L feels when she said that if Mr I had the opportunity to speak to someone in person, he would likely still be here today.

27. The NHS guidance and standard operating procedures (COVID-19 and general practice, March 2020) says GPs must assess patients remotely where possible to minimise risks to patients and staff. It says all patients should be remotely triaged to assess whether a face-to-face appointment is clinically necessary or whether follow up care and advice can be given using remote consultation.

28. Our adviser explained, as the records do not indicate Mr I requested a face-to-face consultation, there was no clinical need for it and a remote appointment was appropriate in this case.

29. Ms L has told us her husband’s death has left her and her family distraught. She says it is still very painful for her to think of how upset her husband was after the telephone consultation. We are sorry to hear about the grief Ms L feels.

30. We are not able to say what was said on the call or the manner it was said.

31. We can determine the GP took steps to assist Mr I in prescribing medication to help him sleep and relieve his anxiety. We can also determine there were no indications the GP should have taken extra precautions, which could have prevented Mr I’s death.

32. We are sorry to hear of the sad and sudden death of Mr I. For the reasons above, we see no indication of a failing and will not be taking further action on this part of the complaint.

Lack of call backs

33. Ms L says after she saw her husband’s upset, following the telephone consultation 30 September 2020, she called the Practice on 1 October 2020, 2 October 2020, and 5 October 2020 requesting call backs from a different GP. She says she provided her contact number each time, but they never received any call backs.

34. We discussed this with our clinical adviser and asked what should happen when call backs continuously fail. They said there is no specific guidance on what to do in this instance, but they would expect staff to have double checked the medical records, especially as the number on there was correct.

35. When assessing whether an organisation has made a failing, we consider what should have happened compared to what did happen and the size of the gap between them. There is no specific guidance on what should have happened in this specific scenario.

36. Our Principles of Good Administration say public bodies should create and maintain reliable and usable records as evidence of their activities.

37. As the Practice did have a correct record of the contact number in the medical records, we can see the Trust did act in line with Our Principles.

38. We can also see the Practice tried to make the requested call backs as the attempts are recorded on the call logs. It is not recorded what number the Practice dialled and how this differs to the phone number provided by Ms L, or the number given in the records.

39. We appreciate the frustration Ms L, and Mr I, must have felt when they made repeated requests for call backs with no clear response. We also accept the Practice could have done more to ensure the contact number it was trying was correct.

40. We do not consider the Practice’s shortcoming fell so far short to become an indication of a failing. This is because the Practice did attempt and had the intention of making call backs. It is unfortunate they did not check the medical record for the correct number.

41. Although we have not found a failing by the Practice, we are pleased to note the Practice has apologised and explained how this error occurred.

42. The Practice has also implemented a failed encounter protocol to try and ensure a similar scenario does not come up again. This is in line with Our Principles of Good Complaint Handling.

43. Our Principles of Good Complaint Handling says to put things right organisations should provide an apology, explanation, and an acknowledgement of responsibility, as well as remedial action. This may include reviewing or changing a decision on the service given to an individual complainant, revising published material, revising documentation to prevent the same thing happening again, training or supervising staff, or any combination of these.

44. Ms L says she felt if her husband had spoken with a different GP they may have listened more to his concerns and ultimately avoided his untimely death.

45. It is understandable the lack of call backs remains a concern to Ms L, particularly given the distress she saw from Mr I following his telephone consultation on 30 September 2020.

46. We consider as the Practice attempted to make call backs, the gap between what should have happened and what did happen is not great enough to call it a failing. For these reasons we will not be taking any further action.

1. We have carefully considered Ms L’s complaint about a medical practice in the Chesterfield area (the Practice). We recognise these events cause ongoing grief and we are sorry to hear of Ms L’s distress.

2. We have seen no indication that anything went seriously wrong in the telephone consultation between her husband and the GP. We also did not find a failing in the lack of successful call back from the GP.