A practice in the Dacorum area

4. Miss U complains about care and treatment the Practice provided her father, Mr U, between October and November 2024. She raises concerns that a GP: • did not identify a stuck bile duct stone on a CT scan in November • failed to prescribe her father antibiotics despite receiving an urgent request from the two-week wait pathway team • advised monitoring rather than immediate treatment despite her father being jaundiced and experiencing vomiting.

5. Miss U says it was obvious from her father’s symptoms and scan results that he had a stuck bile duct stone and infection. She says the GP’s failure to diagnose this meant he experienced a delay in treatment that led to his gallbladder bursting.

6. She considers the Practice’s actions caused her father’s death as she says it could have prevented his gallbladder from bursting and him developing sepsis if it prescribed antibiotics. She explains witnessing her father suffering has caused her significant distress.

7. In bringing the complaint to us, Miss U would like the Practice to admit it made mistakes and recognise the impact this had. She would also like it to make service improvements

8. Mr U was in his eighties. On 21 October 2024 he had a face-to-face appointment with a GP as he had been vomiting, lost his appetite and looked jaundiced. The GP noted most of his symptoms had settled but he appeared mildly jaundiced (when the skin or whites of the eyes turn yellow) and had no appetite.

9. On 28 October Mr U had another face-to-face appointment with a GP who noted gastroenterology had recently discharged him. Since this Mr U had become more jaundiced, had lost weight and was feeling tired. The GP referred him to secondary care on the vague symptoms cancer two-week wait pathway.

10. On 11 November Mr U had a CT scan. The Practice received the results on 14 November which showed mild cholecystitis (inflammation of the gallbladder) and an enlarged spleen.

11. On 15 November a consultant at an NHS Trust saw Mr U in the fast-track suspected cancer clinic.

12. On 19 November Mr U had a telephone consultation with a GP as he had been vomiting for two days and had not had a bowel movement. The GP said they had contacted gastroenterology and haematology for their opinion on the CT scan results. The GP presumed Mr U’s symptoms were because of a viral episode and told him to call back if this did not settle.

13. On 20 November the hospital’s clinical navigator discussed the CT results with Mr U. They shared the results with him and explained the consultant had referred him back to upper gastroenterology for review. The same day the clinical navigator contacted the Practice to explain the consultant had discharged Mr U back to his GP and asked the GP to prescribe antibiotics.

14. On 21 November Mr U had a face-to-face appointment with a GP as his daughter considered he had deteriorated. The GP noted he needed urgent antibiotics and had possible red flag symptoms of sepsis. He went into hospital shortly afterwards.

15. Between 23 November and 28 November Mr U underwent surgery in hospital. He remained in hospital and sadly died on 10 December.

CT scan

19. Miss U complains a GP did not identify a stuck bile duct stone on a CT scan.

20. The relevant guidance for this aspect of complaint is the GMC’s Good Medical Practice. This says doctors must promptly provide or arrange suitable advice, investigations or treatment where necessary.

21. Our adviser said the clinician who requests a scan is responsible for reviewing its results and deciding what happens next. In this case a consultant at an NHS Trust requested the scan. This means the consultant was responsible for interpreting the results and passing on any required actions to the Practice.

22. Clinical records show the CT scan took place on 11 November and the Practice received the scan report on 14 November. The scan report stated Mr U had mild cholecystitis and an enlarged spleen. Cholecystitis is an inflammation of the gallbladder often caused by a blockage (usually gallstones) which can result in an infection. The report did not contain any required actions for the Practice to carry out.

23. The consultant reviewed the scan results on 15 November and asked the hospital’s clinical navigator to ask Mr U’s GP to carry out blood tests and prescribe antibiotics. The navigator emailed the Practice at around 3pm on 20 November. A GP saw Mr U at around 10am the following day.

24. Miss U considers the GP missed signs of a stuck stone on the CT scan. We understand GPs do not receive copies of images from scans and only see scan reports. The scan report did not identify a stuck stone, and we have seen no evidence to suggest the GP should have interpreted the scan differently.

25. In these circumstances the GP’s role is to act on any instructions the consultant provides. We can see a GP did so within 24 hours of receiving the navigator’s email. Sadly, by this point Mr U had deteriorated and needed a hospital admission.

26. We understand how distressing this experience has been for the family. Mr U’s condition deteriorated quickly, his gallbladder ruptured and he sadly died. We recognise how these events may have led Miss U to believe that earlier action on the CT scan results could have prevented what happened.

27. In reviewing all available evidence, we consider the Practice acted in line with GMC guidance when responding to the CT scan results.

Monitoring

28. Miss U complains that during an appointment on 19 November a GP recommended monitoring. She considers her father needed immediate treatment.

29. GMC guidance says doctors must provide a good standard of practice and care. If they assess, diagnose, or treat patients they must adequately assess the patient's conditions, take account of their history and where necessary examine the patient.

30. In its response to the complaint the Practice says a telephone assessment was not appropriate for Mr U’s symptoms on 19 November and a GP should have seen him in person. Our adviser agreed with this and said the decision to review him over the phone was not in line with GMC guidance.

31. Our adviser said the decision to carry out a telephone assessment meant Mr U missed an opportunity for earlier assessment as a GP did not see him face to face until 21 November. By which point he had deteriorated and needed hospitalisation.

32. Miss U says her father needed immediate treatment on 19 November. She considers receiving this would have changed his clinical outcome.

33. The evidence suggests Mr U needed clinical input on 19 November in the form of a face-to-face assessment. The fact that this did not occur means a clinician did not physically assess him and we do not know what his clinical condition was.

34. CT scan results from 14 November show mild cholecystitis which our adviser said means Mr U may not have been severely unwell on 19 November. We can see on 21 November a doctor noted Mr U had possible signs of sepsis. This can develop quickly, and our adviser said he may not have had this on 19 November.

35. Our adviser confirmed a GP should have seen Mr U in person on 19 November. We cannot say whether he needed specific treatment as we do not know how unwell he was, and the Practice had yet to receive the consultant’s recommendations.

36. We recognise the missed opportunity for a face-to-face review on 19 November will have caused Mr U’s family some distress. We understand Miss U considers a lack of immediate treatment on 19 November contributed to her father’s deterioration and death. We have not been able to link the impact Miss U describes with the indications of failing we have seen.

Antibiotics

37. Miss U complains a GP did not prescribe her father antibiotics despite receiving an urgent request from the two-week wait pathway team.

38. Clinical records show the Practice received the request at around 3pm on 20 November. It did not act on this until Mr U had a face-to-face appointment with a doctor at around 10am on 21 November.

39. GMC guidance says doctors must promptly provide treatment where necessary.

40. The Practice took around seven hours to prescribe Mr U antibiotics after it received the request. It recognised it could have actioned the request sooner. We have seen indicated failings here.

41. Miss U considers her father may have had a different clinical outcome if he received antibiotics sooner. For us to link the impact she describes we would have to be able to say with certainty her father’s outcome would have changed if he received antibiotics sooner.

42. At the point the consultant made their recommendations for treatment on 15 November Mr U had mild cholecystitis. Clinical records show this had progressed to acute cholecystitis by 21 November. This indicates Mr U’s condition deteriorated at some point during this period. Clinicians diagnosed Mr U with sepsis when he went into hospital on 21 November. This is a condition that can develop suddenly.

43. We understand Mr U sadly died in hospital. Miss U considers the outcome may have been different if her father received antibiotics sooner. The earliest date a GP could have prescribed antibiotics was 20 November when the Practice received the consultant’s recommendations. By this point the evidence suggests Mr U’s condition may have already been deteriorating for several days.

44. We recognise the delay in Mr U receiving antibiotics caused his family distress. He did not see a GP on 20 November which means there is no clinical assessment from that day to tell us how unwell he was. Our adviser explained that any deterioration may have occurred during the period before the Practice received the consultant’s advice.

Conclusion on deterioration

45. There is not enough evidence for us to say the Practice’s actions caused or contributed to the deterioration in Mr U’s health. This is because of the sudden nature of sepsis and the uncertainties about his condition between 15 and 21 November. For this reason, even on the balance of probabilities we cannot link the impact Miss U describes with the indications of failing we have seen.

46. Our Complaint Standards explain when something has gone wrong organisations should take steps to understand what happened and make improvements to prevent this happening again.

47. We can see the Practice carried out an investigation into Miss U’s complaint, apologised for what happened and discussed this as a significant learning event at a clinical meeting with GP partners. We consider these to be sufficient steps to take in line with our Complaint Standards.

48. The Practice has taken steps to put things right by apologising and identifying learning to improve its service. This is in line with our Complaints Standards, and we do not consider any further action is needed.

49. We appreciate how difficult it must have been for Miss U to witness her father’s deterioration and how unexpected his death was. We recognise the events described in our statement have been very distressing to her. We hope we have been able to provide some reassurance that we have carefully considered Miss U’s concerns, and we thank her for bringing this complaint to our office.

1. We have carefully considered Miss U’s complaint about a GP practice in the Hertfordshire area (the Practice). We are sorry to hear about her father’s death. We recognise the impact this has had and continues to have for Miss U and her family.

2. We have seen no indication anything went wrong with the way a GP responded to a CT scan and have decided to take no further action in this part of Miss U’s complaint.

3. We can see an indication something went wrong in the time it took a GP to prescribe antibiotics and the decision to carry out a telephone review. We have not been able to link this with the impact Miss U describes. We have decided the Practice has already done enough to remedy any remaining impact to Miss U.