A practice in the Southend-on-Sea area

4. Mrs B complains about the care her husband, Mr B, received from the Practice on 6 March. She says the Practice did not properly consider his history, symptoms and test results. She thinks that Practice should have sent him to hospital for further investigation.

5. Mrs B is concerned the Practice missed an opportunity to diagnose the early signs of a problem as her husband sadly died following a stroke around two weeks later. She feels the Practice could have prevented his death. Mrs B has explained how difficult and unbearable Mr B’s death has been on her. She has been dealing with feelings of guilt, anxiety and complicated grief disorder.

6. To resolve the complaint Mrs B would like an independent review of the care her husband received. She would like an apology for what happened and service improvements put in place to prevent this from happening again.

7. Mr B had long-term high blood pressure and saw his GP at the Practice on 1 Feb 2024 due to recent high blood pressure readings.

8. On 25 February Mr B recorded he experienced a ‘crushing extreme headache’ at home.

9. On 1 March he attended the Emergency Department (ED) at hospital due to head, neck and lower back pain and high blood pressure which had continued over several days. The hospital completed an electrocardiogram (ECG – a test that records the heart's electrical activity, measuring rate and rhythm) and sent him home that day as it did not identify a problem.

10. On 6 March Mr B attended the Practice as his symptoms persisted.

11. The GP completed several examinations including a cranial nerve assessment (an exam to evaluate the 12 pairs of nerves to the brain to check for stroke), a Romberg test (a neurological exam to assess balance) and a finger nose test (a neurological exam that assesses upper limb coordination often used to check for stroke).

12. The GP added an additional blood pressure medication at a low dose. It also arranged for a blood test which showed slightly raised C-reactive protein (CRP - the level of a protein produced by the liver, which rises in response to inflammation or infection) and monocyte levels (a measure of white blood cells where raised levels can show infection and inflammation). The GP took no action on this result.

13. Mr B had a stroke caused by a sudden bleed in the brain less than two weeks after his appointment at the Practice and he sadly died a few days later.

19. Mrs B complains the GP failed to diagnose and act upon clear signs her husband was having a stroke when he attended on 6 March. She does not believe the GP properly considered Mr B’s family history, his own suspicions or the fact he used a cane to help him walk when he attended his appointment.

20. Mrs B also says the GP did not properly consider the results of the tests it arranged following this appointment. She says her husband had raised CRP and monocyte levels, but the Practice took no action on the results.

21. She believes the Practice missed opportunities to send him to ED or arrange for further testing at hospital.

22. The Practice said the GP’s examination on 6 March did not reveal any red flag symptoms for stroke. It explained it appropriately arranged for a blood test and provided safety netting advice. The Practice said the blood test results were clinically unremarkable. The Practice’s view was Mr B’s death from a sudden brain bleed was unrelated to his earlier appointment.

23. Mrs B provided us with the notes her husband took into the appointment of 6 March, detailing his symptoms since their onset on 25 February. The main symptoms were an extreme headache with neck pain, dizziness and pain in his lower back and buttock.

24. The Practice’s notes from the appointment say Mr B reported a crushing headache, dizziness and pain in his lower back and buttock. Mr B also reported a fever around five days earlier.

25. We can see the GP asked Mr B about his symptoms and noted he had no weakness of limbs, slurred speech or facial droop. The GP recorded Mr B had a family history of strokes and had a recent ECG at hospital which did not show anything. It appears from the notes the GP considered Mr B’s symptoms and history.

26. The NICE summary lists several symptoms for which a clinician should suspect stroke. Our adviser told us that of these symptoms, those that would most commonly indicate a stroke are a weakness in the face or limbs, visual disturbances (such as sudden vision loss or blurred vision) and problems with swallowing. They explained headaches and dizziness, while listed in the NICE summary, are both less frequently a sign of a stroke and can have many different causes other than stroke.

27. The notes say the GP performed a full cranial nerve assessment. They found no issues during this examination which assesses (amongst other things) vision, facial sensation and symmetry, neck rotation and gag reflex and tongue movement. The GP also conducted other examinations for balance and limb coordination that are commonly used to identify potential strokes.

28. The notes also say the GP assessed there was ‘no focal neurology [deficit]’ (impairment of a specific body region (e.g. left-sided weakness), commonly caused by strokes), which our adviser explained would have included an assessment of limb weakness or incoordination.

29. Considering our advice about the most common symptoms of stroke, the GP appears to have done a thorough assessment of Mr B. This includes examinations which are specifically used to identify strokes.

30. Mrs B has questioned how the GP found there was no limb weakness when her husband walked into the appointment with a cane to help him walk. We would not consider the use of a cane alone to be proof of limb weakness, particularly given Mr B also reported back and buttock pain which might have affected his ability to walk. We can see the GP specifically asked about and checked for limb weakness which shows they did consider this common symptom of stroke.

31. The GP took Mr B’s observations of temperature, pulse, respiratory rate, oxygen saturations and blood pressure and our adviser confirmed these were all within a reasonable range.

32. Our adviser gave their opinion that the GP conducted a thorough assessment and neurological review which established no evidence Mr B was having a stroke at that time.

33. At the end of the appointment the GP provided safety netting advice for strokes, explaining to Mr B which symptoms should prompt a return to hospital. Our adviser confirmed this advice was appropriate and there was no indication the GP should have told Mr B to go to hospital at that time.

34. Mrs B is also concerned with the lack of action after Mr B’s blood test confirmed he had raised CRP and monocyte levels. She says while these levels were only slightly raised, in the context of his other symptoms, they should have prompted a response from the GP.

35. Our adviser explained raised CRP and monocyte levels are not an indicator for stroke and are primarily used to indicate infection. They explained while the levels were slightly raised the results were not clinically significant. We therefore have not seen indications the Practice got it wrong by not acting upon these blood test results.

36. Mr B’s records indicate the GP considered his symptoms and history, investigated whether there were signs he had suffered a stroke and gave appropriate advice. Having reviewed the evidence, we think the Practice acted in line with GMC guidance. GMC guidance says clinicians must assess a patient’s symptoms and history and carry out suitable investigations and provide treatment where necessary.

37. In summary, we have not seen any failings in the Practice’s consideration and approach when Mr B attended on 6 March or following his blood test. Based on what we have seen we have not seen any indication the Practice should have sent Mr B to hospital.

38. We would like to acknowledge the significant and lasting impact these events have on Mrs B. We hope our comments and consideration give her some answers regarding the care her husband received.

1. Mrs B asked us to consider her complaint about her husband’s GP practice (the Practice). We were very sorry to learn about Mr B’s death and know this has caused Mrs B a great deal of upset. She explained she has been left feeling the Practice could have done more to prevent this from happening, which has added to her distress.

2. We have carefully considered the evidence, and we do not think anything went wrong with the care the Practice provided to Mr B.

3. We know how important this complaint is to her and we have explained the reasons for our decision below.