A practice in the Hinckley and Bosworth area

3. Mrs O complains the Practice did not treat her late husband, Mr O, appropriately from 21 July 2024 up to his death on 25 July 2024.

4. She said she was very upset, distressed, angry, devastated and is still suffering grief. She said it also affected her own physical health.

5. She would like an acknowledgement of failing, apology, explanation, service improvements and financial remedy.

6. Mr O was a man in his 70s with a background of chronic obstructive pulmonary disease (COPD – progressive lung disease), atrial fibrillation (irregular heart rhythm) and heart failure (where the heart cannot pump effectively) for years.

7. Mr O contacted the NHS 111 service on Sunday 21 July 2024 at 6.24pm. Two doctors visited and assessed Mr O at 7.11pm that day. They considered his possible diagnosis was, ‘…general decline possibly multifactorial.?? low mood/ depression.’ Multifactorial means it is dependent on several factors which could be genetic or environmental.

8. Mr O attended a GP telephone consultation on Tuesday 23 July 2024. The GP discussed his blood test results and the plan was to try Mr O on mirtazapine (a type of antidepressant medication). The community therapy service telephoned Mrs O on 24 July 2024 where she reported Mr O’s walking frame had not arrived, so they chased it for him.

9. Mr O sadly died at his home on 25 July 2024.

13. Mrs O says she was not happy with the general lack of care and treatment from the Practice from 21 July 2024 up to the day of her husband’s death on 25 July 2024. She considers the Practice should have done more to care for him considering his current medical history and presentation at the time. In particular, she considers the Practice could have advised him to attend hospital, or a GP could have come out to visit him.

14. Mrs O says she made the NHS 111 service aware her husband was seeing things (hallucinating). She thinks the Practice would have known the NHS 111 service had been out to attend to him on 21 July 2024 and what was discussed at the time. She said Mr O had a heart condition, and the heart failure nurses stopped seeing him.

15. She considers the Practice must have been in contact with the NHS 111 service and heart failure nurses and have some involvement in its decisions about the care and treatment to her husband. The Practice said it reviewed Mr O’s consultations of July 2024 and concluded its GPs had done the best they could within the remit of NHS for his care.

16. It said it received no requests for home visits for Mr O in July 2024 and it followed up with care from other agencies as requested. The Practice said on 23 July 2024 Mrs O spoke to reception staff who added Mr O to a triage list. It said GPs triage and decide on next steps and if a house visit was indicated they would have arranged this.

17. The Practice said the paramedic notes on 25 July 2024 mentioned Mr O’s breathing got worse that day leading to his heart stopping and resuscitation sadly not working. Our adviser confirmed the only consultation Mr O had with the Practice between 21 July 2024 and 25 July 2024 was on 23 July 2024. They said it appears to have been a pre-booked appointment to discuss his blood test results.

18. They reviewed the records and could see Mr O had a background of frailty and poor mobility before the above period. The GP note of 2 July 2024 shows Mr O had a telephone consultation with the Practice. It recorded Mr O had low energy levels and confirmed his blood results at the time were stable. It said, ‘Would like ferritin levels checking as very low in energy.’

19. Ferritin is a protein that stores iron in the body. Low ferritin can impact energy levels. Mr O had an appointment to attend the musculoskeletal physiotherapy service on 4 July 2024. We can see these records show Mr O was frail and had poor mobility at the time. Our adviser said Mr O had a history of different medical conditions. To understand Mr O’s health at the time they looked at the telephone call with the NHS 111 service on 21 July 2024.

20. It recorded Mr O had not eaten much in the last two days, was very weak and confused. It noted he had worsening breathlessness, and this was a new symptom. The doctors’ impression of him that day was he had low mood and/or depression. This was a new concern since the appointment on 2 July 2024 said he eats well and had a good appetite. We then see Mr O’s telephone appointment with the Practice on 23 July 2024.

21. It said he had a loss of appetite recently but was drinking plenty. It acknowledged the out of hours (OOH) service had seen him over the weekend, and it considered he should take antidepressant medication. It said he had a banana that morning and was having soup for lunch. It said his mood was up and down and he had good days and bad days. The GP recorded to try mirtazapine medication to help with his mood and appetite.

22. Our adviser says neither of the consultations on 21 July and 23 July showed Mr O displayed any acute (severe) symptoms or that his symptoms got worse on 23 July 2024. They say there was nothing to suggest Mr O needed a home visit or to attend hospital especially since he was already assessed by GPs two days prior. His blood pressure, pulse and chest were clear as shown in the examination on 21 July 2024.

23. There were no concerns with his blood results on 23 July 2024. Our adviser says the paramedic notes clearly shows Mr O’s health had deteriorated rapidly. He continued to not eat and had a dry continuous cough. He continued to decline and spent most of the time in bed and had increased shortness of breath. The notes confirmed he had a cardiac arrest (sudden stop of heart function).

24. It further noted he had a significant cardiac (heart) history and COPD, increased frailty and he was unable to go out due to reducing mobility. The Practice’s response of 28 February 2025 said Mr O’s death was due to acute heart failure because of severe furring up of the blood vessels to his heart and a history of high blood pressure. It said Mr O was originally diagnosed with heart failure in 2015.

25. It said he was on medication to manage this, but heart failure is a chronic condition that cannot be cured. It said Mr O had been under heart nurses and a consultant cardiologist, but both had discharged him. We can see this was on 18 December 2023. The Practice said it explained this was because it had gotten his medication to the best possible and did not have anything else available to offer.

26. Our adviser referred to the NICE guidelines for chronic heart failure which says heart failure is a clinical syndrome with typical symptoms including breathlessness, ankle swelling, fatigue and signs including elevated jugular venous pressure, basal crepitations, and peripheral oedema. It further says:

• ‘Complications include arrhythmias, depression, cachexia, chronic kidney disease, sexual dysfunction, and sudden cardiac death.

• About 50% of people with heart failure die within 5 years of diagnosis, and about 40% of people admitted to hospital with heart failure die or are readmitted within 1 year.’

27. Our adviser highlighted the above guidelines says complications include depression, cachexia (progressive weight loss and muscle wasting) and sudden cardiac arrest. They said these are symptoms Mr O was experiencing. His low energy levels may have been an indication of cachexia. They said the guideline goes on to say, ‘In all people with confirmed heart failure:

• Screen for depression and anxiety should be undertaken.

• If depression is likely to have been precipitated by heart failure symptoms then reassess psychological status once the physical condition has stabilised. If depression co-exists with heart failure the person should be treated taking into account the potential risks and benefits of drug treatment.’

28. From review of the available information, we can see Mr O did not show any severe signs of deterioration from 21 July 2024. He had a longstanding cardiac issue. Therefore, the Practice treated Mr O appropriately due to an impression of low mood and depression in accordance with the NICE guidelines for chronic heart failure.

29. We can see the available information in the medical records mentioned in the above paragraphs supports this. Therefore, we do not consider there are any indications of failing and shall not consider this issue further.

30. We thank Mrs O for bringing this complaint to our attention. We are sorry to hear of the circumstances that led to her complaint and recognise our decision may be distressing to read. We wish her all the best in her health going forwards.

1. We have carefully considered Mrs O’s complaint about the Practice. We have seen no indication that anything went seriously wrong about the issue it did not treat Mr O appropriately from 21 July 2024 up to his death on 25 July 2024. We acknowledge it has been and still is an upsetting time for Mrs O.

2. We are sorry to hear about the circumstances of the final days of Mr O’s life. We have listened to Mrs O when she has described her concerns and the distress these events caused. We understand this is even more difficult when also grieving for a loved one.