A medical practice in the Gosport area

3. Ms B complains about the Practice’s actions between July 2021 and 11 September 2021 in relation to her cousin, Mr V. She says it was difficult to get assistance and the Practice failed to act quickly on concerns about his health and rapid decline in cognitive ability.

4. Ms B says her cousin died in a terrible condition, and in acute pain and discomfort that the Practice should have addressed earlier. She says it caused her considerable distress seeing her cousin so unwell and the lack of action by the Practice added to this.

5. Ms B says it was extremely stressful trying to get medical assistance due to the Practice’s phone queuing system and overly complex online appointment system (Klinik). She is outraged by the difficulties that patients who are vulnerable, or have complex needs, would face while trying to access the Practice.

6. Ms B wants the Practice to improve its service including its phone queuing and online appointment systems. She also wants the Practice to apologise for the distress she experienced.

7. We include this brief background to put the complaint into context. A number of health professionals were involved in Mr V’s care, so we have referred to their involvement. We have not considered their actions as the complaint is only about the Practice.

8. Ms B’s concerns about the care Mr V received are partly linked to Klinik. This is the system the Practice uses to triage patients (assess their priority and decide what action to take). It is an online total triage and patient flow management software system and the Practice started using this during the COVID-19 pandemic.

9. The Practice asks all patients to complete a Klinik form. If necessary, it can complete the form on behalf of patients by telephone. The Practice then contacts patients to arrange an appointment or for an initial assessment.

10. We have considered the Klinik forms completed on 26 July, 3 August and 6 August 2021. The Practice contacted Ms B and Mr V on 27 July to discuss the first of these forms. It decided Mr V needed a routine home visit.

11. Mr V was under the care of dermatologists at a hospital. They had asked the Practice to review his leg oedema (swelling) and to continue his topical (applied to the skin) treatments. Mr V was being prescribed this medication for his leg swelling.

12. On 9 August, an occupational therapist visited Mr V. They were concerned he was falling multiple times a week and had swollen legs. The occupational therapist asked the Practice if it could review Mr V’s medication. The Practice tried to contact Mr V and noted he did not seem to be taking his medication.

13. The Practice referred Mr V to the community team on 11 August due to his poor mobility and increased falls. It also arranged a blood test. A GP (General Practitioner, a doctor) from the Practice attempted to visit Mr V on 16 August. This was unsuccessful.

14. The same GP visited Mr V on 18 August and reviewed him. Following this, they asked the neurological rehabilitation service to see Mr V urgently.

15. A nurse visited Mr V on 24 August and asked the Practice to review or visit him. After speaking to Ms B, the Practice arranged a hospital admission for Mr V on 25 August ‘due to extreme self neglect’. Sadly, Mr V died in hospital in September 2021.

19. 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.

Triage process

20. The GMC’s ethical guidance says: ‘Patients may prefer to access healthcare services face-to-face or through remote consultations via telephone, video-link or online, depending on their individual needs and circumstances. Where different options exist, and when it is within your power, you should agree with the patient which mode of consultation is most suitable for them’.

21. Ms B considers the Practice’s Klinik system and triaging an extreme form of gatekeeping. We appreciate her perspective. We also considered NHS England’s advice to Practices on how to establish a remote ‘total triage’ model. It expected Practices to implement this at the start of the COVID-19 pandemic.

22. NHS England’s guidance says:

'All practices should be using a total triage model to protect patients and staff from avoidable risks of infection.

• Patient requests should be triaged wherever possible to decide on what the most appropriate mode of care delivery is for that patient and to enable care to be provided by the right healthcare professional with the right level of urgency.

• Practices should continue to provide remote consultations (online, phone, video) alongside face to face care for those that need it. The approach should be tailored to the person, the circumstance and their needs’.

23. The NICE COVID-19 rapid guideline says, ‘in the community, consider the risks and benefits of face-to-face and remote care for each person’. It suggests how remote care can be optimised where the risks of face-to-face care outweigh the benefits. For example, offering telephone or video consultations and cutting non-essential face-to-face follow up.

24. The total triage model means every patient contacting the Practice first provides some information on the reasons for their contact and is triaged before making an appointment. The aim is to reduce avoidable footfall in Practices and protect patients and staff from the risks of infection.

25. The Practice used Klinik to provide a total triage model, as recommended by the NHS. Our adviser explained the way Klinik is used is no different to other total triage software in that it allows electronic access to GP services by directing patients (or relatives/ caregivers) to the appropriate healthcare professional.

26. This is why we cannot say the Practice’s use of Klinik is an indication of a failing in itself. We hope our explanation will reassure Ms B. We have gone on to consider the care the Practice provided.

July 2021

27. Point 15 of the GMC’s ‘Good medical practice’ guidance says doctors ‘must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:

a. 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 b. promptly provide or arrange suitable advice, investigations or treatment where necessary c. refer a patient to another practitioner when this serves the patient’s needs’.

28. Ms B submitted a Klinik form on 26 July which she says was ‘Seeking urgent help for [Mr V], for depression, self-neglect, underweight, psoriasis, oedema, loss of mobility, loss speech, inability to concentrate.’ A GP telephoned Ms B and Mr V on 27 July.

29. Ms B is concerned the GP did not consider it an urgent situation. She says the GP insisted the dermatologists had seen Mr V recently and had not raised any concerns. We understand Ms B feels the Practice should have taken action. When the GP spoke to Mr V, he was aware Ms B had contacted the Practice because she was shocked at his condition.

30. The GP established Mr V was more concerned about his frequent falls. Fortunately, Mr V had not experienced any significant injury but his mobility was worsening. He denied feeling depressed but ‘had nothing to look forward to’. The GP noted Mr V had no concerns about accessing help if he needed it.

31. We can see the Practice acted in line with the GMC’s ‘Good medical practice’ guidance by contacting Mr V and taking his views and history into account. The GP explained that there was no immediate concern. Mr V was due a blood test via the dermatology service and said he would await a GP assessment if needed. The GP advised him to contact adult services if he felt it was needed.

32. Based on the available information, the Practice appears to have acted in line with the relevant guidance. We have not identified any signs of a failing in relation to this.

August 2021

33. There are two Klinik forms from 3 August. The first was just a request for the Practice to provide supporting information for Mr V’s application for his benefits. In the second form, Ms B noted Mr V’s existing dermatology condition, his weight loss and worsening of his condition.

34. Mr V had red swelling on both legs, and he was feeling exhausted. He had lost confidence connected to his poor mobility and speech. Our adviser explained the request did not suggest Mr V’s condition had changed since the GP assessed him on 27 July.

35. Ms B submitted a further Klinik form on 6 August. This was for a referral to a private neurologist to get an up-to-date assessment of the impact of Mr V’s existing brain injury. This was forwarded to a GP to action. The GP sent a letter to the neurologist’s secretary.

36. Considering ‘Good medical practice’, this is in line with what we would have expected. We have seen no sign of a failing in relation to the action the Practice took. It referred Mr V to another practitioner, as requested.

37. On 9 August, an occupational therapist contacted the Practice and asked it to call them as they had visited Mr V. They reviewed him as he was reporting that he was falling multiple times a week and had very swollen legs, which were causing him to fall. They wanted to discuss whether his medication could be reviewed and adjusted to reduce his leg swelling and reduce his risk of falls.

38. The GP contacted the occupational therapist but was unable to speak with them. The GP looked through the records and asked the pharmacist to contact Mr V in relation to his medication. This was in line with the GMC guidance.

39. The GP eventually got through to the occupational therapist on 11 August. They told the GP that Mr V’s mobility had declined but he was well in himself. The occupational therapist was still seeing Mr V at home and would update the Practice as necessary.

40. In the meantime, the occupational therapist requested a blood test to see if there was any cause for his leg swelling. They also told the GP to refer Mr V to a physiotherapist and the community rehabilitation team, which the GP did. A blood form was emailed to the community phlebotomy team so it could carry out the blood test.

41. Mr V’s blood was taken on 17 August and tested. The results came through the next day and showed very low albumin (protein) and low vitamin D levels which were signs of his poor nutritional state.

42. The GP visited Mr V that day and noted his poor mobility and nutritional state. His psoriasis had flared up, covering his body. Mr V was also down and depressed. We recognise how difficult it must have been for him and Ms B at this time.

43. As a result of this consultation, the GP requested an urgent referral to the stroke consultant and a dietitian. The GP prescribed an antidepressant for his mood and treatment for his psoriasis. The GP prescribed protein shakes while awaiting input from dietitians and noted Ms B was arranging social services input.

44. Our adviser explained Mr V’s oedema was probably multifactorial (linked to multiple factors) with his immobility and low albumin caused by his liver problems. Dermatologists had referred Mr V to liver specialists so his leg swelling was unlikely to be simply addressed by reviewing his medication. This is because the medication alone would not help.

45. The GP quickly provided advice and treatment and referred to appropriate practitioners, in line with the GMC guidance. This is why we have not seen any signs of a failing in the care the Practice provided.

46. A healthcare worker visited Mr V on 24 August to take his observations. They asked the Practice to arrange a visit as Mr V’s psoriasis was not being managed and he was not looking after himself. The next day the GP spoke to Ms B. She says she demanded a safeguarding referral and feels this made the Practice consider arranging a hospital admission for Mr V.

47. We appreciate Ms B’s perspective. Mr V was not taking antidepressants and not using his psoriasis treatment, so the Practice arranged Mr V’s admission to hospital. It discussed this with Ms B and Mr V first. He was not taking his prescribed medication and admission was the only option after trying care in the community. In line with point 15c of the GMC guidance, it was appropriate to refer him to hospital at that point.

48. In conclusion, the care provided by the Practice appears to be in line with what we would have expected. As the Practice acted in line with the relevant guidance and standards, we have not identified any signs of a failing. We appreciate Ms B may not share our view but we hope our reasoning is clear and gives her some reassurance.

1. We have carefully considered Ms B’s complaint about a medical Practice in the Gosport area (the Practice). We recognise how concerned she is about the care her cousin, Mr V, received and we would like to offer our condolences for her loss. This was clearly a difficult experience for her.

2. We looked at the aspects of the Practice’s care which Ms B is concerned about. We have seen no signs that anything went seriously wrong. This is why we have decided not to consider the complaint further. We have set out our reasons for this in this decision statement.