A practice in the Islington area

3. Mrs E complains about the care and treatment Miss E had from the Practice in November and December 2022 and about its complaint handling. She says the Practice did not do anything about her daughter’s worsening symptoms and it did not show empathy when handling her complaint.

4. Mrs E says her daughter felt ignored and distressed due to her worsening symptoms and died four weeks later. Mrs E and her family are left wondering if more could have been done. Mrs E wants the Practice to make service improvements.

5. Miss E attended the Practice on 22 November 2022. She said she had an ongoing cough, tightness in her chest and she had a cold the week before. Miss E had asthma. The Practice prescribed a preventative inhaler and advised her to have an asthma review with its pharmacy. She had the asthma review on 30 November and said her chest tightness and cough had improved after she used the inhaler.

6. On 7 December, Miss E contacted the Practice using eConsult (an online NHS consultation service patients can use) because she had a rash. She had a phone consultation with the Practice on 12 December and was prescribed an antihistamine (to help allergy symptoms). Miss E had a faceto-face appointment on 14 December and showed the Practice photos of her rash. It advised her to take antihistamines and prescribed antibiotics for her cough and cold symptoms. It advised her to come back if she still had her rash after taking antihistamines.

7. Miss E was admitted to hospital later that month and moved to intensive care the next day where she sadly died from a severe infection that caused a rare form of asthma that attacked her organs. Miss E’s cause of death was recorded as multiorgan failure (when organs stop working), eosinophilic myocarditis (inflammation of the heart muscle), pneumonia, asthma and eosinophilia (raised white blood cells).

10. 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. If we are unable to see signs to suggest anything has gone wrong, we do not consider a complaint further.

Worsening symptoms

11. Mrs E says the Practice did not take the right action for her daughter’s symptoms in November and December 2022. We have looked at when Miss E contacted or attended the Practice to see if it acted in line with the relevant guidelines.

12. It is first helpful to explain that GMC guidance on Good medical practice says a doctor must provide ‘a good standard of practice and care’ when assessing a patient’s conditions. It says they must consider the patient’s history (symptoms and psychological, spiritual, social and cultural factors), their views and values and where necessary they should examine the patient. The guidance says doctors should refer a patient to another practitioner when needed.

13. In line with this, the Practice had a duty of care to assess Miss E’s symptoms each time she contacted or attended the Practice in November and December 2022.

14. Miss E attended the Practice on 22 November and the records show her symptoms were an ongoing cough and tightness in her chest as well as having a cold the week before. The Practice examined her and looked at her history of asthma. It prescribed her with a preventative inhaler and advised an asthma review would be helpful.

15. NICE asthma guidance says clinicians should discuss with the individual whether to continue their treatment and take into account the degree of the patient’s response to the current treatment.

16. The records show that on 30 November Miss E had an asthma review and she said her chest tightness and cough had improved after using her preventative inhaler.

17. Our adviser explained the symptom of chest tightening is a typical asthmatic symptom so the Practice advising Miss E to have an asthma review and to prescribe a preventative inhaler were in line with the GMC and NICE guidelines. It assessed her, considered her history, recognised her need for a preventive inhaler to loosen her tightened chest and recognised her asthma treatment may need reviewing.

18. The symptoms of rash which Miss E thought was an allergic reaction were sent by eConsult on 7 December. She also said she had a cold for a month with a blocked nose, nasal congestion and headaches.

19. The Practice contacted Miss E on 12 December and asked her if she had any swelling of her face, lips, tongue, fever or difficulty breathing. Miss E said she did not have any of these. Our adviser explained the Practice asked these questions to rule out an anaphylactic (lifethreatening) allergic reaction which would need emergency treatment. The Practice prescribed antihistamines and arranged a face-to-face appointment to investigate these symptoms further.

20. The actions of the Practice at this time seem to be in line with the GMC guidelines because the Practice assessed her needs to decide on a diagnosis or the need for further investigations.

21. Miss E attended the Practice on 14 December. The records show she discussed two cases of possible hives (raised itchy bumps or patches on the skin) that she had on and off over the last couple of f weeks. She showed the Practice photos of the rash on her body. reviewed these and saw she did not have a rash on her body at this time. The Practice advised Miss E to continue taking her antihistamines and to contact it again if the rash came back.

22. NICE rash guidance says investigations are not usually required for the diagnosis of hives, but clinicians can use clinical knowledge to consider if it seems necessary. It seems the Practice acted in line with this guidance by physically assessing Miss E and considering all of the information she gave about her symptoms. As she did not have a rash at the time, it gave her safety net advice to contact it if this happened again as the treatment given seemed to help.

23. The records show Miss E also had a cough, sore throat and green sputum (mucus that is coughed up) for a month. The Practice examined her chest and mouth and found that her chest was clear but her mouth was red. It prescribed antibiotics.

24. NICE cough guidance says people with acute coughs may be at a higher risk of complications if they have a pre-existing condition and immediate antibiotics should be prescribed for those who are identified as higher risk of complications.

25. In line with this, the Practice identified Miss E’s pre-existing asthma condition and prescribed antibiotics immediately. Our adviser explained the Practice acted quickly in response to Miss E’s cough and cold symptoms between November and December.

26. We understand why Mrs E thought something was missed by the Practice, because her daughter went on to be admitted to hospital soon after the Practice saw her and she sadly died the next day.

27. The records show Miss E’s cause of death was multiorgan failure, inflammation of the heart muscle and pneumonia, asthma and raised white blood cells. Our adviser explained Miss E’s cause of death was very rare and not something GPs usually see.

28. Our adviser explained that in their clinical experience Miss E’s hospital admission and her death could not have been predicted by the Practice. They said based on Miss E’s symptoms, there was nothing more the Practice could have done to prevent her death.

29. We were pleased to see that after Miss E’s unexpected death, the Practice did a significant event analysis on 30 August 2023, which detailed her attendances in November and December, her cause of death and what it could learn from her symptoms and cause of death.

30. We understand why Mrs E wanted to bring her complaint to us. The Practice did not miss anything in November and December and it could not have prevented her sad death. We hope this reassures Mrs E and settles her uncertainty and worry about this.

Complaint handling

31. Mrs E says the Practice did not handle her complaint with empathy. We looked at the complaint correspondence between Mrs E and the Practice to see if it acted correctly.

32. Our Principles say organisations should be customer focused. This means they should use language that is easy to understand and communicate with the complainant in a way that is appropriate to them and their circumstances.

33. Our Principles also say organisations should be open and accountable. This means they should be open and honest when accounting for their decision and actions and should give clear, evidence-based explanations and reasons for their decisions about what happened.

34. The Practice gave Mrs E detailed information in response to the complaints she made. In the complaint response dated 27 February 2023, the Practice said how sorry it was to learn of Miss E’s death and it explained how knowing this came as a shock. It expressed sympathy to Mrs E and her family.

35. Mrs E said she wanted the Practice to give her more empathy because of how sensitive her complaint was. From what we have seen the Practice was sympathetic to her daughter’s death and answered all of her concerns thoroughly. The Practice did not do anything wrong and we think it treated Mrs E with empathy. We will not take any further action on this complaint.

36. We want to thank Mrs E for bringing her complaints to us so we could make sure the Practice did not miss any opportunity that might have helped her daughter. We are so sorry to hear about what happened and the impact this had on Mrs E and her family. We hope our investigation can put her at ease knowing we have examined the evidence, seen the Practice followed relevant guidelines and did not get anything wrong.

1. We have carefully considered Mrs E’s complaint about the care and treatment her daughter, Miss E, had from a GP practice in the Islington area (the Practice) in November and December 2022. We are sorry to hear that Mrs E feels the Practice did not give her daughter a good standard of care. We understand from speaking to her what a worrying time it was and how she now wonders if her daughter’s death could have been avoided. We do not underestimate how difficult and distressing this was for her and the family.

2. We have not seen signs that anything went wrong with the Practice’s in the care and treatment. We will not investigate the complaint further but hope our explanation below gives Mrs E some reassurance.