A practice in the Hackney area

3. Mr M complains about aspects of the care and treatment provided to him in February 2024. He complains:

• during appointments on 2 and 5 February, the GP misdiagnosed him with a stomach bug, despite his family explaining the symptoms he was suffering with • the Practice ignored complaint emails and calls for 6 months, and the response letter dated 29 February was not sent until August 2024.

4. Mr M was diagnosed with Pneumonia on 7 February by a private GP. He then had to be rushed to the critical care unit in hospital and the pneumonia progressed further into Sepsis. Mr M was extremely ill for 3 months and almost died due to the misdiagnosis and delay in treatment caused by the Practice. He had to be looked after by family and was unable to work. The way the Practice handled the complaint caused great distress for Mr M and his family as they felt ignored and this has compounded the loss of trust they feel for the GP.

5. As a result of bringing this complaint to us, M is seeking service improvements and an explanation of why the GP’s complaint response was so delayed.

6. During the last week of January 2024, Mr M began suffering with flu-like symptoms.

7. Mr M attended 2 emergency appointments with the Practice on 2 February and 5 February. He was diagnosed with a stomach bug during these appointments.

8. As his symptoms were not improving, Mr M went for an appointment with a private GP on 7 February. He was diagnosed with pneumonia and advised to go to hospital for treatment.

9. Mr M was admitted to hospital on 7 February 2024 and moved to critical care on 8 February as he had developed sepsis.

10. Mr M remained in hospital for treatment and was discharged from hospital and returned home on 13 February 2024.

11. Mr M took 3 months off work to recover and was cared for by his family at home.

12. Miss H complained to the Practice on 16 February 2024 on behalf of her father, Mr M. The Practice sent its complaint response on 9 August 2024. Miss H brought the complaint to us on 13 August 2024.

GP appointments 2 and 5 February 2024

16. 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.

17. Miss H says at her father’s GP appointments on 2 and 5 February, the GP misdiagnosed him with a stomach bug, despite the family explaining the symptoms he was suffering with. She says he had been suffering with flu-like symptoms for about a week before he contacted the Practice for an appointment on 2 February. She says following a second appointment on 5 February his symptoms worsened so he went to a private GP on 7 February where he was diagnosed with pneumonia and suspected sepsis. Miss H says although he has now made a full recovery, he was very poorly and had to take 3 months off work. She says he had to learn how to walk again, have physiotherapy and it took a long time to get back to normal.

18. Miss H says her father was falling over, couldn't walk properly and was vomiting so it was clear something was very wrong. She says when he and his family described his worrying symptoms to the GP they were just ignored. She says as English is not his first language, her brother attended the first appointment with her father and her mother. Miss H’s mother attended the second appointment with him and they described the symptoms to the GP. She says her father expressed to them he was worried he had some sort of infection and needed antibiotics, but this was dismissed. She says the GP never checked his chest or his breathing at either appointment which she thinks they should have done.

19. The records show Mr M spoke to the triage doctor on 2 February and was booked to see the GP the same day. The records show he reported 2 days of abdominal pain and vomiting, which he said started after he had eaten something. Mr M denied having a cough or runny nose when the GP triaged him, and it is documented that there was no cough or respiratory symptoms during the assessment with the GP. The records say he had observations taken and a targeted abdominal examination. His temperature was recorded as 39.6, his heart rate was 105, his respiratory rate was 18 and his oxygen saturation was 98%. Mr M was diagnosed with gastroenteritis and advised to take plenty of fluid and come back if his symptoms worsened.

20. Mr M contacted the Practice again on 5 February as he was experiencing ongoing vomiting every time he ate and had a fever. On this occasion he saw a different GP. Mr M explained he was able to manage small sips of fluid but had no appetite. He reported no diarrhoea or blood in his vomit or stools and he did not report a cough or any other symptoms. Mr M had a recorded temperature of 38.2 and a pulse of 115. His blood pressure was in the normal range at 115/89. The GP diagnosed him with an ongoing stomach bug and advised him to take anti-emetics and fluids and to come back if he was not feeling better.

21. The record of when Mr M was seen by the out of hours private GP on 7 February note he had developed a cough since he was seen on the 5 February and had continued to vomit and had intermittent diarrhoea. Mr M denied having any chest symptoms. His temperature was recorded as 40 degrees, his respiratory rate was 35, his pulse 116 and oxygen saturation was 94%. His NEWS2 score was 8 which put him in the high-risk bracket. He was given a diagnosis of pneumonia and suspected sepsis and advised to go to A&E for urgent assessment.

22. In its complaint response, the Practice thanked Miss H for raising her concerns and apologised for any emotional distress caused. It says on reflection it thinks it can be very challenging sometimes when a patient does not have the typical symptoms of a chest infection. It says Mr M had a normal respiratory rate an oxygen saturation, possibly reassuring the clinician the focus should have been on his abdomen.

23. The Practice says Mr M’s raised heart rate and temperature were a concern but that it believed these would settle with the replacement of fluids. It says whilst it is pleased Mr M was able to access same day appointments and followed safety netting advice, it wants to learn from his presentation. The Practice says it will bring his case to its clinical meeting and it will be treated as a significant event with learning disseminated across the clinical team. It says it will also undertake annual training on various topics, including sepsis and spotting sick patients. The Practice thanked Miss H for bringing the complaint to its attention and says her feedback is invaluable in helping improve its service.

24. We asked our advisor what guidelines are relevant to this complaint and should have been followed during Mr M’s appointments.

25. The GMC advises doctors that, ‘you must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:

• Adequately assess the patient’s condition, taking into account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • Promptly provide or arrange suitable advice, in investigations or treatment where necessary • Refer a patient to another practitioner when this serves the patient’s needs.’

26. As per the above GMC guidelines, Mr M was assessed and examined at each of his appointments and advised to return if symptoms worsened.

27. NICE guidance on sepsis says for clinicians to consider sepsis if a person presents with symptoms or signs that indicate possible infection. They should assess people with any suspected infection to identify:

• Possible source of infection • Factors that increase risk of sepsis • Any indications of clinical concern, such as new-onset abnormalities of behaviour, circulation, or respiration.

It says on initial assessment and examination;

‘Assess temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation in people aged 12 or over with suspected sepsis. Examine people with suspected sepsis for: • Mottled or ashen appearance • Cyanosis of the skin, lips or tongue • Non blanching petechial or purpuric rash • Any breach of skin integrity (for example, cuts, burns or skin infections) • Other rash indicating potential infection.

28. The National Early Warning Score (NEWS) is a widely used system within the NHS used to standardise the assessment and response to acute illness. It is a tool used to detect and respond to the clinical deterioration in adult patients. It is based on a simple combined scoring system in which a score is allocated to physiological measurements. Six physiological parameters form the basis of the scoring system; respiration rate, oxygen saturation, blood pressure, heart rate, level of consciousness and temperature.

Physiological observations and normal parameters:

Respiratory rate – (12 to 20 rpm) Oxygen saturation – (88 to 92%) Systolic blood pressure – (111 to 219) Heart rate – (51 to 90 bpm) Level of consciousness - (alert) Temperature – (36.1 to 38°C)

A score of 0,1,2 or 3 is allocated to each parameter. A higher score means the parameter is further from the levels of the normal range. Appropriate clinical responses are given for the threshold (trigger) levels, with a recommendation to review and agree these locally:

• Low risk (combined score 1 to 4) – prompt assessment to decide on change to frequency of monitoring or escalation of clinical care • Medium risk (combined score 5 to 6) – urgent review to decide on change to frequency of monitoring or escalation to critical care team • High risk (combined score of 7 or over) – emergency assessment by critical care team, usually leading to patient transfer to higher dependency care area.

29. Our adviser says the GP adequately assessed and examined Mr M’s condition at both his appointments on 2 and 5 February, taking into account his history as per GMC guidelines above. After examining Mr M the GP came to a reasonable working diagnosis of an ongoing stomach bug. When seen on the 2 and 5 February, Mr M’s symptoms were ‘gastric’ and when questioned, he reported no respiratory symptoms, so the GP did targeted investigations on his abdominal symptoms.

30. We can see from the records when Mr M was assessed and examined at both of his appointments on 2 and 5 February, he reported none of the above symptoms associated with sepsis.

31. Our advisor says we can see on 2 and 5 February Mr M would have had a NEWS2 score of 3. He was low risk and did not require hospital admission.

32. Our clinical advisor says in general practice, doctors see a huge number of patients with symptoms which may or may not be a presentation of a serious underlying condition. Patients present at different stages of their illness and will have different thresholds for seeking medical advice. Safety netting is important where a patient may have risk factors for a specific disease, or where specific complications are recognised as part of the illness or the treatment.

33. Safety netting involves ensuring that systems are in place to provide safe monitoring and follow-up, as well as the specific advice given to individual patients by the clinician.

34. Our advisor says Mr M was given the appropriate safety netting advice. The Practice told him what to do if his symptoms continued or worsened.

35. Mr M chose to go to a private GP on 7 February. During this appointment Mr M first showed a possible symptom of pneumonia in the form of his cough. The private GP escalated Mr M’s care accordingly.

36. The Practice acted in line with NICE and GMC guidelines in the way it assessed Mr M’s symptoms and the advice it gave to him to return if his symptoms worsened. We cannot see any indications of failings in the treatment he received and will take no further action on this part of the complaint.

Complaint handling

37. Miss H says the Practice ignored her complaint emails and calls for 6 months, and the response letter dated 29 February was not sent to her until 9 August 2024. She says the way the Practice handled the complaint caused Mr M and the family great distress as they felt ignored and this compounded the loss of trust they felt in the Practice.

38. From the records we can see Miss H first complained to the Practice on 16 February 2024. She sent her complaint letter via email to the practice manager, and they acknowledged the complaint on the same day via email reply. The email response dated 16 February from the practice manager says they will investigate the complaint and respond within 20 working days. They say if they need more time, they will let Miss H know when to expect the response.

39. We can see Miss H emailed the Practice again on 13 April 2024 as at this point she had been waiting 40 days. In her email she asked the practice when she could expect to receive a response. There is nothing within the record to show this email was responded to by the Practice. Miss H emailed the Practice again on 9 May 2024 to say it had been 60 days and she was still waiting for a response. Again, there is nothing within the records which shows this email was responded to. Miss M emailed a final time on 30 July 2024 and explained if she did not receive a response by 9 August 2024 she would escalate the complaint to the Ombudsman. The practice sent its response on 9 August 2024 as a direct reply to the original complaint email Miss M sent on 16 February. The email from the Practice manager to Miss H on 9 August says;

‘I apologise for the time it has taken to reply. I have attached a letter for your attention which was written and presumed sent in February 2024’.

40. We contacted the Practice to ask the reason for the delay in responding to Miss H’s complaint and follow up emails. The Practice manager explained they received the complaint on 16 February 2024 and on the same day spoke to the GP partner about the complaint and sent them the complaint details. It said that they had completed the full complaint response by 29 February and provided evidence of this. The Practice manager explained they had just returned from leave and that sending the response ‘slipped their mind’ and they made a mistake. The practice manager explained when they realised the response that had been prepared on 29 February had not been sent, they immediately forwarded it to Miss H and apologised. This was after Miss H had contact the Practice three times to follow up on her complaint.

41. The Ombudsman’s standard for good complaint handling and being open and accountable says public bodies should deal with complaints promptly, avoiding unnecessary delay, and in line with published service standards where appropriate. Resolving problems and complaints as soon as possible is best for both complainants and public bodies.

42. The Practice’s own complaint handling policy says it will seek to investigate the complaint and respond fully withing 20 working days of receipt of the complaint. It says if for any reason it is unable to investigate and respond in that time frame it will notify the patient and give an explanation of the delay and inform them of when they can expect a complete response.

43. Miss H feels Practice did not keep to its policy of providing an explanation for the delayed response, and we can see that, although the complaint response was written in February, due to an oversight by the Practice manager it was not sent until August. We appreciate Miss H’s frustration at not receiving a response after contacting to the Practice and how this would have exacerbated her and her father’s distress.

44. Whilst we accept that there were no updates sent to Miss H in response to her emails to chase up the complaint response, we consider the apology and explanation given by the Practice manager go some way to explain what caused the delay. The Practice has apologised and explained that it thought the response had already been sent in February. This is in line with our principles for ‘putting things right.’

45. We recognise it would have been a difficult and distressing time for Mr M and his family. The actions the Practice has taken in apologising for the delay when dealing with the complaint are in line with our principles for remedy. As well as this, our investigation has provided a more detailed explanation of why the response was delayed. Based on this, we consider we have provided a resolution for this part of the complaint and will take no further action.

1. We have carefully considered Mr M’s complaint about the Practice. We were sorry to hear about the circumstances of Mr M’s complaint and the impact he endured as a result of suffering from pneumonia and sepsis.

2. We have seen the Practice treated Mr M in line with guidance. We also consider our response provides a resolution to the complaint handling concern.