A practice in the Tunbridge Wells area

3. Mr R complains a practice in the Tunbridge Wells area (the Practice) did not offer his wife, Mrs R, a face-to-face consultation and did not take into account her history and vulnerability when she contacted about having COVID-19 between 16 and 22 December 2021.

4. Mr R says that the failure to see Mrs R face-to-face resulted in a delay in her receiving hospital treatment for pneumonia which she developed as a complication from COVID-19. Mr R feels that if Mrs R had received treatment sooner, she may not have died. He also says the events have caused him a severe amount of distress and upset.

5. Mr R wants the Practice to apologise, make improvements regarding telephone consultations and pay financial compensation.

6. On 18 September 2017, Mrs R was diagnosed with stage four lymphoma. Mrs R was referred to hospital and underwent chemotherapy which was successful, and she went into remission in March 2018.

7. The lymphoma returned in November 2020 so Mrs R had more chemotherapy and a stem cell transplant between 8 July and 6 August 2021. This was successful but had a significant impact on her immune system.

8. On 6 December 2021, Mrs R tested positive for COVID-19.

9. She rapidly deteriorated on 16 December, called the Practice on 17 December and was given a telephone appointment.

10. Mrs R continued to deteriorate and contacted the Practice again who conducted a further telephone appointment on 20 December.

11. Mr R contacted the Practice on 22 December as his wife continued to get worse. The Practice told Mr R to contact a paramedic if he was concerned.

12. Mrs R was admitted to hospital later that afternoon where she was diagnosed with acute pneumonia caused by COVID-19.

13. Mrs R sadly died on 3 January 2022.

Face-to-face appointment 17. It is recorded in Mrs R’s records that she was high risk for developing complications from COVID-19. Mr R says the Practice should have taken this into account when she reported she had tested positive for COVID-19 and was unwell.

18. He says she should have been seen by a doctor face-to-face.

19. The Practice said any patient that requests an appointment or home visit, that they consider is urgent for that day, is contacted by a doctor by telephone to make an initial assessment, and if deemed necessary is invited for a face-to-face assessment at the Practice or as a home visit.

20. The Practice said it followed the recommended guidance which was in place at the time and directed by NHS England. However, the guidance on the triaging of patients through the use of screening phone calls had been in place for several years before the COVID-19 outbreak. It said the GPs decision-making about making home visits have always been based upon the information obtained from conversations held with the patients themselves.

21. The records show when Mrs R’s family first contacted the Practice, on 17 December, it was 12 days after testing positive for COVID-19. The notes document Mrs R had no fever but had a sore throat, cough, lost her sense of taste and smell, nausea and was coughing up phlegm. She did not report any breathing difficulties but ‘was not doing much’. This was put down to be ‘fairly par for course of COVID’ and the Practice gave safety-netting advice.

22. This was on the background of the patient being immunosuppressed with her recently having undergone a stem cell transplant and chemotherapy for lymphoma. This went into remission in 2017 and she was taken off the palliative care register at this point.

23. NICE guidance for managing COVID-19 says:

‘Use the following signs and symptoms to help identify people with COVID‑19 with the most severe illness:

• severe shortness of breath at rest or difficulty breathing • reduced oxygen saturation levels measured by pulse oximetry (see recommendation 2.1.2 on pulse oximetry levels that indicate serious illness) • coughing up blood • blue lips or face • feeling cold and clammy with pale or mottled skin • collapse or fainting (syncope) • new confusion • becoming difficult to rouse • reduced urine output.’

24. The NICE guidance lists the symptoms of severe COVID. Mrs R was not deemed to have these although many would require a face-to-face examination to confirm fully.

25. Our adviser says there would be differences on how GPs would have handled this scenario with some opting for a face-to-face examination and others happy to assess the patient remotely. Some may feel an immunosuppressed patient presenting on day 12 of COVID-19 would need a review whereas other may feel she was not presenting as very unwell and could closely monitor with safety-netting.

26. We recognise there were different ways in which the GP could have responded. We believe it is positive that the GP gave worsening advice but at this stage, we do not think a face-to-face appointment was absolutely required.

27. The family contacted the Practice again on 20 December (three days later) as per the safety-netting advice. They reported Mrs R was spending most of the time in bed but was not sleeping, she continued to have a cough, loss of taste and smell and nausea. She was also breathless when coughing. On this day, the GP made note about Mrs R’s stem cell transplant that had occurred in July showing an awareness of the patient’s vulnerability.

28. Our adviser says complications of COVID-19 are normally higher at this time of the disease especially in a vulnerable patient. Their breathing can also look relatively normal even if the oxygen saturations are dropping which can only be assessed face-to-face.

29. Therefore, our adviser says it was not appropriate for the GP to conclude the symptoms were that of an acute COVID-19 infection. There was also a history of sepsis on two previous occasions on Mrs R’s history list.

30. GMC guidance says:

‘In providing clinical care you must:

• adequately assess a patient’s condition(s), taking account of their history, including • symptoms • relevant psychological, spiritual, social, economic, and cultural factors • the patient’s views, needs, and values

• carry out a physical examination where necessary

• promptly provide (or arrange) suitable advice, investigation or treatment where necessary.’

31. The family contacted the Practice on 22 December, two days later, Mrs R had a severe cough and was getting worse. At this point when her symptoms were worsening, the family called the paramedics and Mrs R was taken to hospital.

32. Based on all of the evidence available, we find that the Practice should have arranged a face-to-face visit on 22 December for Mrs R. This is due to her still being very unwell in the later stages of COVID-19 infection along with her being immunosuppressed. Some of the key symptoms of a severe COVID-19 infection could only be confirmed via a face-to-face visit.

33. Our adviser said the face-to-face review could have showed clear signs the patient was unwell and needed to go to hospital. This could have meant an earlier admission to hospital.

34. However, our adviser said Mrs R may not have had these symptoms at the face-to-face appointment so we do not know whether she would have warranted a hospital admission at that stage. It is impossible to know what would have happened if she had been assessed face-to-face.

35. We find the Practice should have arranged the face-to-face appointment for Mrs R. However, we will never know whether she would have been admitted to hospital sooner or whether the outcome could have been different. This is because we do not know whether her symptoms would have warranted a hospital admission on 22 December or whether an earlier admission would have changed the treatment or her response to it in hospital.

36. We recognise that not knowing whether Mrs R’s death could have been avoided has been incredibly distressing for Mr R and this has exacerbated his grief.

37. This has been experienced over a significant period of time since Mrs R died in January 2022 and is likely to be experienced long into the future.

1. We find the Practice should have arranged for Mrs R to have a face-to-face appointment due to her symptoms and being immunosuppressed. We have not been able to determine what the outcome of this appointment would have been. However, we have found that Mr R’s grief was likely exacerbated by knowing his wife was not seen as she should have been. Therefore, we partly uphold the complaint.

2. We recommend the Practice apologises to Mr R, puts together an action plan for service improvements and pays Mr R £750.