A GP practice in the Wiltshire area

3. Ms O complains about the Practice’s care and treatment from May to September 2021.

4. Ms O complains the Practice: • gave her father the COVID-19 vaccine without her consent as power of attorney • failed to diagnose Mr R with bronchopneumonia (a type of pneumonia).

5. Ms O says the COVID-19 vaccination caused Mr R’s pneumonia.

6. Ms O says the Practice’s failure to diagnose and treat her father’s pneumonia meant there was a lost opportunity for a better clinical outcome.

7. Ms O would like the Practice to take responsibility for what happened and to apologise.

8. Mr R had dementia and other conditions and lived in a nursing home.

9. In the six weeks before Mr R’s death, the Practice reviewed him by phone and in person as his health was getting worse.

10. Ms O requested her father’s medical records and saw there was an entry saying he was given the COVID-19 vaccination despite her sending the Practice clear instructions the day before saying she did not want her father to have it.

11. In August 2021, Mr R went to hospital for an X-ray as he had fallen and injured his hip. Blood tests showed he had leukaemia (a cancer affecting the production and function of blood cells).

12. Mr R’s health continued to get worse and he sadly died in September 2021 from bronchopneumonia.

COVID-19 vaccine

16. Before we decide if we should do 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 seen any signs that something has gone wrong.

17. Ms O emailed the Practice manager in May 2021 to discuss whether or not her father should have the COVID-19 vaccine as he had an intolerance to drugs.

18. On 26 May 2021, Ms O emailed the Practice and said as power of attorney, she did not want her father to have the vaccine planned for the next day and would like it postponed until 21 June when more vaccine types would be available.

19. The Practice replied the next day to say it would make sure it did not send someone out to give the vaccine.

20. In August, Ms O asked for a copy of her father’s medical records and found he had been given the vaccine on 27 May.

21. Ms O asked the Practice about this and a doctor confirmed her father had been given the vaccine. Ms O complained to the Practice.

22. Ms O said the vaccine vial number was logged to her father’s medical records and he described a pain in his upper left arm after having the vaccine.

23. The Practice investigated to find out how this happened.

24. The Practice explained that after getting Ms O’s email a member of staff crossed Mr R’s name off the list of patients to get the vaccine. But the Practice said it had printed off the list the night before and Mr R’s name was on it at the time.

25. A paramedic had been due to give Mr R the vaccine. The Practice asked them if they had vaccinated Mr R and they said they had not.

26. The Practice’s investigation found the vaccination record had been put on Mr R’s records by accident.

27. The Practice explained the paramedic gave in 15 forms after returning from vaccinating patients. 14 forms had been completed but the 15th form (Mr R’s) was blank. The form was unsigned and the consent form did not include the injection site or the batch number.

28. The Practice thought the form had not been completed in error and used the information from the other vaccination forms (like the vaccine batch number) to put information on Mr R’s records.

29. The Practice took a statement from the staff member who added the information and they said they assumed Mr R had been given the vaccine because the form had been handed back, although incomplete.

30. The Practice gave us a copy of the paper vaccination form and the consent form which were both blank. The Practice also gave us a copy of the patient list that shows Mr R’s name crossed off with a handwritten note saying ‘cancelled at daughters request 27/5/21’.

31. The Practice also got a written statement from the paramedic that says:

‘I have reviewed the paperwork from the 27th May 2021 covid vaccines. Your father was on a list of patients to be vaccinated that day; however, his name was crossed out to show he was not to receive a vaccine. I did not complete a written vaccination form for your father, which was completed for every patient who received a vaccine that day.’

32. The Practice’s complaint response also says the Practice manager checked with all staff involved to make sure Mr R had not been given the vaccine.

33. We understand it would have been worrying when Ms O read her father’s records and saw the entry.

34. We looked at all the available evidence to make a decision on what happened. We have not seen anything in Mr R’s records to suggest he had pain in his arm after having a vaccine.

35. Overall, the evidence suggests Mr R did not have the vaccine. There is written evidence from the paramedic confirming he did not give Mr R the vaccine. The staff member confirmed Mr R’s vaccine and consent forms were blank and they admitted they assumed information had not been completed by mistake. Based on this, we do not think the Practice failed to follow Ms O’s request not to give her father the vaccine.

Pneumonia diagnosis

36. Mrs O complains the Practice failed to diagnose her father with pneumonia. Mr R’s cause of death is recorded as bronchopneumonia.

37. Between July and September, Mr R had appointments at the Practice. These included phone appointments with Ms O or a member of the care home or a home visit to see Mr R. Mr R had episodes of vomiting and general unwellness.

38. We have not listed every appointment because Ms O has a copy of her father’s medical records. We have highlighted the ones we think are important.

39. On 4 August 2021, a GP visited Mr R at home because his stools were paler and he also looked pale. The Practice arranged for Mr R to have blood tests.

40. The Practice visited Mr R at home on 9 August as he had fallen three days before. The Practice reported Mr R had bruising on this left hip and he was in pain. The Practice agreed with the care home that Mr R should go to A&E for an X-ray. The hospital X-rayed Mr R’s left hip but did not find a fracture. Mr R also had blood tests that showed no clear sign of infection.

41. The pharmacist recorded on 10 August that Mr R had issues with heartburn and feeling sick. After the blood tests, Mr R was diagnosed with possible leukaemia.

42. The Practice spoke with the nursing home and on 13 September the Practice noted that Mr R had deteriorated rapidly the day before. There were signs of muscle twitching. Mr R was described as being pale with slurred speech. He had not eaten or drunk anything and was sleepy.

43. The GP had called Ms O who thought her father may have candida (yeastlike fungus that can cause thrush) as he seemed in discomfort when he ate a banana at the weekend. The GP said Mr R may have discomfort from his reflux and recent dose of ibuprofen. The Practice prescribed Mr R nystatin to treat oral candida.

44. The Practice visited Mr R at home on 22 September. Ms O asked the GP to check Mr R’s throat. The records note Mr R’s swallowing was deteriorating but this was in keeping with his general health getting worse.

45. Our adviser says GMC guidance states that when treating patients, you need to assess the patient’s conditions, taking account of their history including symptoms, examine the patient and quickly provide or arrange suitable advice.

46. Our adviser also said the NHS website lists the main symptoms of a chest infection as: • a chesty cough – you may cough up green or yellow mucus • wheezing and shortness of breath • chest pain or discomfort • a high temperature • a headache • aching muscles • tiredness.

These symptoms can be unpleasant, but they usually get better on their own in about seven to ten days. The cough and mucus can last up to three weeks. Our adviser explained the Practice did not miss an opportunity to diagnose Mr R with a chest infection because, from reviewing Mr R’s records, there is no sign of Mr R having any symptoms of a chest infection as listed on the NHS website. The records do not note a cough, wheezing or shortness of breath or anything to suggest Mr R had chest pain.

47. The records show Ms O told the Practice how her father looked in discomfort while eating a banana which led to her thinking he had oral thrush.

48. Another home visit in September says the GP reviewed Mr R’s throat and noted his swallowing was deteriorating which was in keeping with his general decline. These symptoms alone would not be reason to suspect a chest infection.

49. There was also no sign that Mr R had an infection when he went to A&E in August. It was recorded that he had a very abnormal white cell blood count but ‘no clear infectious source/evidence of infection’.

50. From reviewing the records, our adviser explained the Practice’s actions were in line with GMC guidance. The GP reviewed Mr R’s symptoms and, where appropriate, prescribed him medication to help. Mr R’s raised white cell count was discussed with a consultant haematologist, and it was decided that further investigation was not in his best interests because of his other health problems. This was explained to Ms O who agreed. The haematologist said that chronic leukaemia was a possibility.

51. It should be noted that Mr R then deteriorated rapidly. There is an entry in Mr R’s records on 3 September where it was recognised that he had pain in his hip and back and he may be terminal. There was a long discussion with Ms O about whether Mr R should be admitted to hospital and it was decided he should remain at the care home. This means he was sadly expected to die and would have treatment to relieve symptoms and make him more comfortable.

52. Our adviser explained it is not abnormal for a patient who is at the end of life and on palliative care to die from pneumonia. They explained this is because a patient will often struggle to cough and clear their throat because of drowsiness. Mr R was given medication to help with this but not being able to cough puts pressure on the lungs and can cause pneumonia. Our adviser explained treating pneumonia in this situation with antibiotics would either not work or just prolong the dying process.

53. Based on the evidence available, there are no signs of failings. The Practice acted in line with GMC guidance by reviewing Mr R’s symptoms and, where appropriate, prescribing Mr R’s medication to help relieve his symptoms. Our adviser also explained Mr R was not showing any signs of a chest infection that needed further investigation.

54. We hope our consideration of Ms O’s concerns has given her reassurance that the Practice provided care and treatment in line with the national guidance and it did not miss opportunities to do more.

1. We have carefully considered Ms O’s complaint about the care and treatment her father, Mr R, had from a GP practice in the Wiltshire area (the Practice). We are very sorry to hear about Mr R’s death and appreciate what a difficult time it has been for Ms O.

2. We have seen no sign that the Practice gave Mr R the COVID-19 vaccination or that anything went seriously wrong with its care.