A practice in the Malvern Hills area

4. Mr A’s mother, Mrs B, was a patient at the Surgery. He complains the Surgery failed to:

• identify Mrs B had sepsis between 2 and 3 February 2021 • inform Mr A and Mrs B how unwell she was and the importance of attending hospital on 3 February 2021.

5. As a result, Mr A says:

• Mrs B’s death was avoidable, and she did not have the opportunity to receive lifesaving treatment. He says he has been left distraught at the premature death of his mother • if they were informed how unwell Mrs B was, she would have attended hospital and she would not have died.

6. Mr A is seeking an apology, an acknowledgement of failings, and a financial payment of over £10,000.

7. On 2 February 2021, Mrs B’s family contacted the Surgery as she was unwell at home. The GP held a telephone consultation and noted Mrs B was slurring words, hallucinating and her legs were infected. The GP prescribed co-amoxiclav (an antibiotic).

8. The GP visited her at home the following day as she remained unwell, and she had a family member present. The GP noted ‘a red flag symptom for sepsis’ and advised Mrs B to attend hospital.

9. Mrs B refused admission, and her family member was happy to watch and wait with a follow up from the GP the next day.

10. Mrs B’s condition deteriorated later that day and her family called an ambulance.

11. Mrs B sadly died on 4 February in hospital, after staff admitted her.

15. Mr A says the Surgery should have done more to identify how unwell Mrs B was and explain to their family how important it was she went to hospital.

16. GMC guidance for doctors, paragraph 15 says they ‘must provide a good standard of practice and care. If they assess, diagnose or treat patients, they must:

A, adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient B, promptly provide or arrange suitable advice, investigations or treatment where necessary C, refer a patient to another practitioner when this serves the patient’s needs.

17. During the telephone consultation on 2 February, the GP assessed Mrs B’s symptoms and noted she suffered from leg ulcers and had an inflamed leg. The GP also identified Mrs B had a possible urine infection due to cloudy urine. The GP prescribed an antibiotic which treats a range of bacterial infections and arranged a home visit for the following day. This was appropriate given the symptoms Mrs B’s family described at that time.

18. The Surgery says when the GP visited Mrs B the next day, she did not have a fever, or signs of a chest infection or severe cellulitis (a bacterial skin infection). It says she was alert and coherent, with mild hallucinations. We recognise this was a worrying time for Mrs B’s family.

19. She declined a hospital admission, and the Surgery says the GP assessed she had the capacity to make that decision.

20. NICE guidance sets out the warning signs a patient may have sepsis. It says:

‘Recognise that adults, children and young people aged 12 years and over with suspected sepsis and any of the symptoms or signs below are at high risk of severe illness or death from sepsis:

• objective evidence of new altered mental state • respiratory rate of 25 breaths per minute or above, or new need for 40% oxygen or more to maintain oxygen saturation more than 92% • heart rate of more than 130 beats per minute • systolic blood pressure of 90 mmHg or less, or systolic blood pressure more than 40 mmHg below normal • not passed urine in previous 18 hours • mottled or ashen appearance • cyanosis of the skin, lips or tongue • non-blanching rash of the skin’.

21. It advises clinicians to ‘assess temperature, heart rate, respiratory rate, systolic blood pressure, level of consciousness and oxygen saturation in young people and adults with suspected sepsis.’

22. Mrs B’s medical records show the GP was concerned Mrs B might have sepsis and checked her vital signs. We think the GP carried out the assessment described in the NICE guidance and referred her to hospital in line with paragraph 15c of GMC guidance.

23. Our adviser told us Mrs B’s blood pressure was low, however, all other observations were within normal ranges.

24. They explained Mrs B was showing some signs of possible sepsis (low blood pressure and altered mental state) but none of the other features such as raised pulse, abnormal temperature or reduced oxygen level which would mean she definitely needed hospital admission.

25. Nonetheless, it is clear the possibility of sepsis was a concern for the GP and they wanted Mrs B to go to hospital for further checks, and she refused.

26. We can see no evidence which suggests Mrs B did not have capacity to make this decision for herself, or that the GP failed to consider it.

27. GMC guidance also says that doctors must give patients the information they want or need to know in a way they can understand.

28. We recognise Mr A has concerns the GP did not communicate effectively with Mrs B’s family. We know the GP discussed going to hospital with a family member and they agreed to the watch and wait approach. Our adviser reviewed Mrs B’s medical records and felt the GP gave reasonable advice and communicated this appropriately at the time.

29. TGP also provided Mrs B appropriate strong, broad-spectrum antibiotics prior to the home visit, which would cover possible infections at home, in the absence of hospital treatment. This is in line with paragraph 15b of GMC guidance.

30. Considering all available evidence, we think the GP acted in line with the above guidance when they visited Mrs B. The GP identified Mrs B may have possible sepsis and communicated this appropriately, including their recommendation for her to go to hospital for further checks.

31. Taking the advice we have received into account, we have not seen any indication of failings. It appears the Surgery acted in line with NICE and GMC guidance when it assessed Mrs B.

32. We do not underestimate how difficult the loss of Mrs B has been for Mr A and his family. It is clear she was very important to them, and they feel their loss greatly.

1. We have carefully considered Mr A’s complaint about a GP Surgery in the Malvern Hills area (the Surgery).

2. We offer our sincere condolences to Mr A for the death of his mother, Mrs B. We were also sorry to hear of Mr A’s concerns about his mother’s care and of the profound impact these issues have had on him.

3. We have seen no indication that the GP failed to identify possible sepsis or inform Mrs B and her family she should go to hospital. We have therefore decided to take no further action on the complaint and explain the reasons for our decision below.