A medical practice in the Leicestershire area

6. Mrs L complains about the care and treatment provided to her late sister, Ms P, by the Practice on 30 September. Mrs L says the Practice made a home visit to her sister but did not thoroughly examine or assess her, and did not provide treatment or arrange her admission to hospital.

7. Mrs L says that as a result, her sister’s pulmonary embolism was not identified and treated. Sadly, Ms P died the next day.

8. Mrs L says she was shocked and extremely distressed at her sister’s death, as they were very close. She says Ms P’s sudden death has caused considerable distress. She says she was unable to work due to her grief and organising her sister’s affairs.

9. In bringing the complaint to us, Mrs L seeks an apology, service improvements, compensation for loss of earnings and a financial payment for the significant emotional distress at the sudden death of her sister.

10. Ms P was in her early seventies. She had a history of type 2 diabetes and macular oedema. Type 2 diabetes is a common condition that causes the level of sugar (glucose) in the blood to become too high. It can increase the risk of getting serious problems with the eyes, heart, and nerves. Macular oedema is where swelling or fluid accumulates under a specific area of the retina, known as the macula.

11. Ms P telephoned the Practice on 24 July, as she had been experiencing loose stools for approximately eight days. She spoke with a nurse who gave her advice around keeping hydrated and a GP review was arranged.

12. Ms P saw a GP at the Practice the next day. The GP examined her and requested a stool sample. The results of this were received on 29 July and were normal.

13. Ms P telephoned the Practice about loose stools again on 2 August. A GP gave her advice about managing this with her type 2 diabetes and arranged a blood test and a Faecal Immunochemical Test (FIT). A FIT is a stool test designed to identify possible signs of bowel cancer. The results of these were again normal.

14. A GP saw Ms P at the Practice on 22 August again with continuing loose stools. They prescribed antibiotics and loperamide (a medicine to help reduce loose stools), requested further blood tests, and made an urgent referral for a gastroenterology review.

15. Ms P was seen at a local hospital and had a sigmoidoscopy (a procedure where a doctor or nurse looks into the rectum and sigmoid colon, using an instrument called a sigmoidoscope) on 24 September. This diagnosed diverticulitis which is a digestive condition that affect the large intestine (bowel). Diverticula are small bulges or pockets that can develop in the lining of the intestine.

16. The next contact with the Practice was on 30 September. A GP visited Ms P at home as she was still experiencing bowel problems and was now feeling faint and nauseous. The GP prescribed codeine (pain relief) and planned to arrange a further blood test.

17. Ms P’s friend found her collapsed on her bedroom floor the following morning. Sadly, she died shortly afterwards. A post-mortem took place and found the cause of death was a pulmonary embolism.

21. A GP home visit was arranged on 30 September as Ms P was experiencing a continuation of her bowel symptoms, as well as new symptoms of feeling lightheaded, fainting, and nausea.

22. The records show the GP examined Ms P’s abdomen, which was noted to be soft, and took a history of her symptoms. She was noted to still be experiencing loose bowels, and that Imodium (over-the-counter medication) was not helping. She was now experiencing fainting during the night when she got up to open her bowels and was feeling lightheaded on standing. Ms P was also noted to be feeling nauseous, which was affecting her appetite.

23. The GP made note of the recent tests, prescribed codeine, and arranged for a further blood test.

24. We have considered whether this appointment was in line with the GMC guidance ‘Good Medical Practice’ and the NICE guidance ‘Transient loss of consciousness (‘blackouts’) in over 16s’.

25. The GMC guidance for doctors says:

‘You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must:

1. 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

2. promptly provide or arrange suitable advice, investigations, or treatment where necessary

3. refer a patient to another practitioner when this serves the patient’s needs.’

26. In addition to this, the NICE guidance for transient loss of consciousness (TLoC) says clinicians should:

‘1.1.2.1 Assess and record:

· details of any previous TLoC, including number and frequency

· the person’s medical history and any family history of cardiac disease (for example, personal history of heart disease and family history of sudden cardiac death)

· current medication that may have contributed to TLoC (for example, diuretics)

· vital signs (for example, pulse rate, respiratory rate, and temperature) – repeat if clinically indicated

· lying and standing blood pressure if clinically appropriate

· other cardiovascular and neurological signs.’

27. In line with the above guidance, we consider the GP did not complete a thorough assessment or examination based on Ms P’s symptoms. As she had been experiencing fainting (loss of consciousness), the GP should have examined her and noted her vital signs (pulse, blood pressure, oxygen saturation level, respiratory rate, and temperature), blood pressure, and arranged an ECG (a test that can be used to check the heart’s rhythm and electrical activity), though we recognise this would not be completed at the home visit.

28. We also note Ms P was taking medication to reduce her blood pressure, which was not recorded but should have been as it was relevant medical history. Mrs L also notes there was a family history of sudden heart failure, which should have been considered.

29. We can see Ms P had been experiencing her bowel symptoms for some time and had various tests for this. However, she had previously been attending the Practice for appointments, but this time had requested a home visit. We consider this was a sign she was potentially more unwell. This adds to our view that an examination and recording of her vital signs should have taken place.

30. Overall, we consider there was a failing in the assessment and examination of Ms P, as the vital signs were not taken in line with the GMC and NICE guidance. We have considered the impact of this further below.

Impact

31. We have considered if the GP should have suspected pulmonary embolism during the home visit, based on the evidence we do have about the appointment. This evidence includes the GP’s records, Mrs L’s account and the post-mortem.

32. Our adviser has first carefully considered the GP’s record of the appointment. They explain the symptoms noted are not suggestive of pulmonary embolism. However, we recognise there is limited information within the records.

33. We have next considered Mrs L’s account of Ms P’s symptoms. She explains a friend of her sister called the Practice as Ms P ‘looked like she was going to die’. She says her sister had swelling in her leg, which moved up her groin. She is therefore concerned the GP missed symptoms of pulmonary embolism or a blood clot.

34. The NHS website for patients advises people to see a GP if they feel pain in the chest or upper back, have difficulty breathing, or are coughing up blood, as this can indicate pulmonary embolism. It also advises patients see a GP if they have pain, redness or swelling in one of the legs, as these are symptoms of a blood clot in the vein, also called deep vein thrombosis (DVT).

35. We have also reviewed the post-mortem report. The report says there were no signs of oedema (swelling) and does not mention DVT in the legs. Our adviser explains this would be noted if one was present during the post-mortem examination. We therefore consider it is unlikely the swelling noted by Ms P’s friend would have contributed to her death.

36. The post-mortem examination: ‘showed pulmonary thromboembolism in pulmonary arteries. This would have led to sudden rapid death due to hypoxia [a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level] with a right sided decrease in cardiac output and lack of left ventricular filling leading to right and left heart failure.’

37. Our adviser says that if such significant pulmonary embolism had been present when the GP saw Ms P, they would expect her to have had significant difficulty breathing, possibly to the extent that she was struggling to speak, and this should have been obvious to a doctor.

38. Our adviser said it is therefore more likely the ongoing diarrhoea, associated dehydration, and the blood pressure medication were causing Ms P to have the episodes of light-headedness and loss of consciousness. Therefore, we consider it is unlikely the GP would have missed signs of pulmonary embolism at this time, had an assessment and examination taken place.

39. We recognise Mrs L will wonder if her sister’s outcome could have been different had she been in hospital when the pulmonary embolism occurred, even if her admission was for her bowel symptoms, as she would have had nursing and medical staff around her. This is a difficult aspect to address, as we are unable to say if Ms P should have been admitted to hospital due to the lack of recorded vital signs.

40. Our adviser explains Ms P had a ‘massive’ pulmonary embolism, and sadly this has a high mortality rate. The article ‘How is massive pulmonary embolism (PE) defined and what is the associated mortality rate?’ explains ‘the mortality for patients with massive pulmonary embolism is between 30% and 60%, depending on the study cited. Autopsy studies of patients who died unexpectedly in a hospital setting have shown approximately 80% of these patients died from massive pulmonary embolism.’ Therefore, there is large chance that Ms P would still have sadly died, even if she had been admitted to hospital.

41. Overall, we are unlikely to be able to link the failing we have seen in not taking the vital signs to Ms P’s death. We do however recognise that our finding that there was failure to check the vital signs will cause Mrs L distress, as she will be concerned her sister did not receive appropriate care. We consider this distress to be an injustice to Mrs L.

42. We have not seen that the Practice has recognised the failing in the assessment and examination and therefore has not considered the impact of this in its complaint handling. We have made recommendations to address this.

1. We have carefully considered Mrs L’s complaint about care and treatment a medical practice in the Leicestershire area (the Practice) provided to her late sister, Ms P. We recognise this is a very distressing complaint and do not underestimate the effect her sister’s sudden death has had on her and her family.

2. We have seen evidence of failings in the care the Practice provided to Ms P during a home visit on 30 September. We consider the GP did not carry out an appropriate assessment and examination, in line with the relevant guidance. Ms P sadly died from a pulmonary embolism (a blocked blood vessel in the lungs) the following day.

3. We cannot link the failing of not taking Ms P’s vital signs to her death. This is due to the significant nature of the pulmonary embolism Ms P experienced. We explain this further in our report.

4. We recognise our finding that there was a failure in the assessment and examination will cause Mrs L distress as she will be concerned her sister did not receive appropriate care. We consider this distress to be an injustice to Mrs L.

5. It is for these reasons that we partly uphold this complaint. We have made recommendations at the end of this report.