A practice in the West Sussex area

4. Mrs A complains the Practice did not recognise her husband might have a brain tumour despite the symptoms he reported on 29 December 2020, 19 and 29 January 2021 and 1 February. She complains his history of bowel cancer and lung nodules and the way his symptoms became more serious meant the Practice should have recognised his illness may have been related to cancer.

5. She complains the Practice missed a final chance to recognise this when a GP decided not to see him in person during Mr A’s visit to the Practice on 1 February 2021.

6. Mrs A also complains the Practice showed no empathy or care for her or Mr A when it made no contact between his brain tumour being diagnosed and his death.

7. Mrs A complains the Practice’s failures meant Mr A suffered an undignified and difficult end to his life. She said he was experiencing symptoms such as falls that were serious and very challenging. This added to her own stress and anxiety at that time, and the lack of help left her feeling abandoned and not taken seriously by the doctors at the Practice.

8. Mrs A wants the Practice to accept where it got things wrong, apologise for the impact this had on her and Mr A at the end of his life and show it has learned from this.

9. Mr A had a history of bowel cancer and was being treated by the colorectal clinic and renal clinic at his local hospital. He also saw an oncologist.

10. Mr A took medication to keep his blood pressure down. This was prescribed by his renal consultant, who changed his prescription in December 2020. Mr A was asked to monitor his blood pressure and watch out for an uncontrolled increase, and to have blood tests at his GP practice at the end of the month.

11. Mr A began to feel dizzy during December 2020. He had a blood test at the Practice on 29 December. Mrs A told us he was not able to speak to his renal consultant when he made calls in January 2021.

12. He talked to the Practice about his increasing difficulties on 19 January 2021. The Practice told him to speak with his renal consultant.

13. He called the Practice again on 29 January. His symptoms, including falls, were becoming more intense. The Practice advised him to take betahistine, a medication for vertigo.

14. Mr A called the Practice again on 1 February. Mrs A said she and her husband were distressed by his worsening symptoms and he wanted to see a doctor. They attended the Practice and a paramedic assessed Mr A. The paramedic discussed Mr A’s presentation with a GP and an urgent referral for him to be seen in the stroke clinic was sent the following day.

15. Mr A’s symptoms got worse from this point on. After consulting NHS 111, on 6 February they called an ambulance and Mr A was taken to hospital. Scans at the hospital showed two tumours in his cerebellum (a part of your brain at the back of your head). These could not be treated surgically or with chemotherapy, but treatment to help control his symptoms did begin.

16. Mr A returned home on 15 February. By this time his symptoms were so severe he needed daily visits form carers and palliative care to help cope with the pain his illness was causing.

17. Mr A sadly died in March.

21. Mrs A told us she felt Mr A’s history as a cancer patient and how poorly he was becoming should have led the GPs at the Practice to investigate whether he had a new cancer. She pointed to the Practice having misdiagnosed him on three occasions by saying his symptoms were caused by blood pressure, vertigo or stroke.

22. When the Practice responded to the complaint, it said it had considered his history when it assessed him but felt the decisions were appropriate, and it had not had reason to think his symptoms meant his cancer had spread. Mrs A felt this was unreasonable and the Practice had failed to assess her husband in line with the guidance.

23. We reviewed Mr A’s history, including the communication from the specialists he was seeing. Mrs A explained his first action when he began to feel dizzy was to try to contact his renal consultant. This is what he was asked to do when his renal consultant changed his medication on 3 December 2020.

24. He attended the Practice on 29 December 2020, where he had blood tests. There is no record he discussed symptoms such as dizziness or headaches that he talked about later on, and there is nothing to suggest Mr and Mrs A felt he needed to see a GP at that point. They were warned at the start of the month that he needed to carefully monitor his blood pressure.

25. This appointment was for a planned blood test that Mr A’s renal consultant had asked for. We have not seen any record the Practice received a request to have a full GP consultation. As such, it acted in line with the GMC guidance by fulfilling the purpose of the appointment, in line with the section 15 commitment to ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’. It seems Mr A thought the change in his medication was the probable cause of his symptoms at this stage and those symptoms became more severe over time.

26. Mr and Mrs A began to be more worried by his dizziness in January 2021. Mr A spoke with a GP on 19 January and told them he felt his dizziness could be caused by another, undiagnosed problem.

27. Looking at the clinical evidence and what we know from Mrs A about the assessment on that date, we can see dizziness was beginning to have a significant effect on Mr A. He reported hurting himself due to a fall the previous day and said he could not walk as far as he would usually be able to because loss of balance was making him unsteady.

28. GPs should consider how a patient is presenting, consider anything relevant in their history and quickly provide appropriate advice, investigations or treatment, in line with section 15 of the GMC guidance. Having considered the records and our independent clinical advice, we can see the telephone assessment at this point was appropriate. The GP could see Mr A had difficulty controlling his blood pressure and this would still reflect the likely cause, even if it was more than six weeks since he had changed his medication.

29. We recognise Mr A was alarmed by his symptoms at this point, and his call gives the impression he no longer felt his blood pressure medication was what was causing him to feel unwell. The GP advised him to contact the renal unit to discuss his blood pressure and medication review and to wait for the results of his blood tests.

30. We do not think the evidence shows this dizziness alone required further investigation, having considered the relevant guidelines and our independent advice. Mr A had suffered a fall but was not reporting other symptoms at this point. The plan that he seek advice about his blood pressure appears evidence-based, as high blood pressure is a recognised cause of dizziness or poor balance.

31. We understand the GP provided an appropriate assessment under section 15 of the GMC guidance, asking appropriate questions for the symptoms described and providing suitable advice. There are numerous causes of dizziness, and knowing both Mr A’s medical history and that he was having difficulty controlling his blood pressure, it was an evidence-based working diagnosis that his dizziness was related to his blood pressure treatment.

32. Mr A called the Practice again on Friday 29 January, and the discussion led the GP to suspect he had an ear infection. The GP prescribed medication for this and asked him to get back in touch if things changed.

33. Having discussed the records with our adviser, we understand there were no signs that would mean Mr A needed to be referred to hospital at that point, or any signs there was a clinical need for the GPs to make a different intervention. The GP advised Mr A he might have vestibular neuronitis, an infection of the vestibular nerve in the inner ear. It causes the vestibular nerve to become inflamed, disrupting the patient’s sense of balance. The GP advised Mr A this was likely affecting his balance mechanism and his raised blood pressure was a cause of this. He prescribed betahistine, a medication used to calm the balance mechanism, and provided advice to contact the Practice should his symptoms worsen.

34. The evidence available shows the GP adequately assessed Mr A under section 15 of the GMC guidance. We understand from our clinical advice Mr A’s symptoms had changed with the spinning (vertigo) he had developed, which is indicative of a problem with the inner ear balance mechanism, and betahistine is suitable for treating this.

35. We also think it was reasonable for the GP to assess Mr A over the phone given the way he was presenting and what he reported at that time. We understand having consultations face to face is generally preferable to having them over the telephone, and clearly it does allow healthcare professionals to find out more about a patient.

36. Despite this, it can still be most appropriate for both patients and doctors to have telephone consultations where that can be done safely. Importantly, the account Mr A gave over the telephone seems to have been detailed enough that the Practice could reach a view.

37. In Mr A’s case, considering Covid-19 was still a significant risk at the time of these events, it was also in line with subsection 6.1.1 of the NICE COVID-19 rapid guideline to have telephone consultations where possible. These guidelines tell clinicians: ‘In the community, consider the risks and benefits of face-to-face and remote care for each person. Where the risks of face-to-face care outweigh the benefits, remote care can be optimised by offering telephone or video consultations’. We can see no signs there was a failing in conducting the consultations over the phone until the evidence suggested Mr A needed an in-person review.

38. Mr A was asked to seek further medical advice if he did not improve, and he did this on 1 February. He appears to have called the Practice after having a worrying weekend, and Mrs A said he was desperate to see a doctor at this point. He spoke with a GP, who noted he ‘feels dreadful’ and was struggling to walk because of his vertigo. Mr A was asked to go to the surgery for an assessment, as the GP wanted to exclude a cerebrovascular accident (commonly known as a stroke) as the cause of his symptoms.

39. When he went to the Practice, a paramedic practitioner saw Mr A. Based on this assessment, the GP decided to refer him to the stroke team at his local hospital.

40. The GP did not see Mr A personally. Mrs A complained a GP needed to see her husband face to face at this stage and not doing so meant the assessment was poor and his condition was not understood. We appreciate this would also add to her feeling the Practice did not show care or empathy for her husband.

41. A paramedic practitioner is trained with the skills to assess and treat patients, and we understand someone in this role is appropriately qualified to assess someone in Mr A’s situation. The paramedic practitioner consulted a GP and, based on the finding Mr A did not have obvious signs of stroke but did have some clinical signs that needed further exploration, they decided to make an urgent referral to the stroke clinic at the local hospital. When the Practice responded to Mrs A’s complaint, it said one of the things it considered at that time was that hospital admissions were to be avoided where possible due to the status of the Covid-19 pandemic at that time.

42. We can see from the records that the assessment carried out by the paramedic practitioner was thorough and in line with the NMC Code. The Code advises that staff must:

13. Recognise and work within the limits of your competence

To achieve this, you must, as appropriate:

13.1 accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care

13.2 make a timely referral to another practitioner when any action, care or treatment is required

13.3 ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence.

43. The paramedic practitioner appears to have acted in line with all parts of the Code as set out above, including providing an appropriate assessment and agreeing a plan for treatment with a GP. Stroke can cause a range of symptoms, but the NICE Headache clinical knowledge summary explains patients will not require emergency treatment unless they display red-flag symptoms. We can see Mr A was not displaying any red flags at that time.

44. Having carefully considered the sequence of events and what we know about Mr A’s clinical picture, we have not seen that the Practice’s decision-making in January and February 2021 was flawed or that it failed to treat Mr A in line with relevant guidelines and standards of care.

45. Mr A received the devastating diagnosis of having incurable brain tumours after going to hospital on 6 February. He was discharged with medication and home care that reflected how seriously ill he was becoming.

46. Mrs A felt the Practice should have provided more support for her and her husband after he was discharged from hospital.

47. The medical records show detailed information about how district nurses and then hospice staff relayed Mr A’s his care and treatment to the Practice. This information also reflected how shocked and distressed Mr A and has family were by the sudden advance of his illness and by his terminal diagnosis.

48. The Practice did call Mr A on 17 March, as the district nurses felt he needed a medical assessment. His son helped him with this consultation - help Mr A needed because it was now very difficult for him to communicate. A nurse practitioner visited on 22 March to assess a rash on his back and advise how this could be managed.

49. Mr A died a few days later. Despite it being clear in the patient records that Mr A was deceased, a member of staff at the Practice made a call to Mrs A around 14 April to ask to speak to him. Mrs A felt that was extremely insensitive.

50. Having reviewed with our adviser the evidence of Mr A’s clinical needs after discharge from hospital, we cannot see there were further points where we would expect the Practice to have been involved after Mr A was returned home. None of the issues he experienced once he returned home indicated he needed further GP support, and our adviser identified that any further physical contact could have been a risk to Mr A, given the ongoing risk of Covid-19 and the fact he was so clinically vulnerable. As such, we can see it was in line with the GMC guidance and the NICE Covid-19 rapid guideline to have allowed hospice and community support staff to treat Mr A rather than providing GP intervention.

51. From what Mrs A has told us, we understand she felt the terrible and unexpected news Mr A had received in hospital meant the Practice needed to show empathy for him. The Practice appears to have been involved with clinical matters, but his regular care needs were being met by district nursing and hospice staff.

52. The Practice apologised that it made an unnecessary call asking to speak to Mr A after he died and said this should not have happened. Our Principles of Good Administration say: ‘Public bodies should treat people with sensitivity, bearing in mind their individual needs, and respond flexibly to the circumstances of the case’.

53. We appreciate this unnecessary and inappropriate call was for Mrs A. Having thought very carefully about this, we do not think the Practice’s mistake on this matter is so significant as to indicate a failing happened. However, we are glad to see the Practice has acknowledged and apologised for the distress caused by its error, which is appropriate in the circumstances.

54. Having carefully considered Mrs A’s complaint to us, we have decided to take no further action for the reasons set out above. We hope the explanations we have provided and the independent advice we sought are helpful to her and reassure her we have not seen anything to suggest her husband was denied the care he needed.

1. The Parliamentary and Health Service Ombudsman has carefully considered Mrs A’s complaint that poor care and missed opportunities made the end of her husband’s life more difficult and upsetting. Mr A became extremely unwell and needed a high level of care when he developed symptoms due to a brain tumour. We understand from our correspondence with Mrs A that she remains worried and distressed by the poor care she believes her husband received from a practice in the West Sussex area (the Practice).

2. The Practice discussed Mr A’s symptoms with him on three occasions and the evidence we have seen shows it provided clinically appropriate care. Although its communication might have been better, we have not seen any signs of mistakes significant enough to suggest a failing has taken place, and we can see the Practice has responded appropriately to Mrs A’s concerns.

3. With this in mind, we have decided to take no further action. We explain our decision further below.