A practice in the East Riding of Yorkshire area

3. Mrs L complains on behalf of her mother, Mrs N, about A GP Practice in East Riding of Yorkshire (the Practice) on 6 June 2025. She specifically complains: • she had to insist on a home visit • the Practice did not perform a physical examination • the Practice did not submit a prescription to the pharmacy.

4. Mrs L believes the poor consultation on 6 June directly contributed to her mother’s death on 9 June 2025.

5. Mrs L is seeking an apology, service improvements and a financial remedy.

6. On 4 June 2025 Mrs N requested a home visit from Mrs N’s GP Practice.

7. On 6 June a GP attended Mrs N’s home.

Home Visit

11. Mrs L complains on 6 June 2025 she had to insist on a home visit. She says the GP contacted her to ask why she had requested a home visit. She says the GP told her she should take her mother to hospital rather than the GP attending her mother’s home.

12. The Practice said the GP contacted Mrs L on 6 June at 11.25am. Mrs L said her mother had been taken to hospital, and was then sent home. Mrs L said her mother was very weak, unable to sit and unable to stop vomiting. The GP advised in their opinion her mother should be seen at hospital. The Practice said the GP confirmed they would be more than happy to see Mr L’s mother at home and the GP did make a home visit.

13. We have been provided with the call. The call is five minutes and 26 seconds long. We acknowledge Mrs L has said she had to insist on the GP to attend. We have considered how the GP conducted the call and if the actions are in line with national standards and guidance.

14. To help us consider the phone call, we have reviewed GMC Good medical practice. It says:

‘In providing clinical care you must: a) adequately assess a patient’s condition(s), taking account of their history, including symptoms c) promptly provide (or arrange) suitable advice, investigation or treatment where necessary

Treating patients fairly and respecting their rights 18. You must recognise a patient’s right to choose whether to accept your advice, and respect their right to seek a second opinion’

15. In the call the GP asked Mrs L for her mother symptoms. Mrs L explains her mother is weak and has been vomiting. Mrs L confirms her mother collapsed on Wednesday, 4 June. Mrs L’s mother attended hospital and was sent home.

16. At one minute 14 seconds the GP explains with Mrs L’s mother cancer diagnosis her mother needs to be hospital. The GP says if she doesn’t want to go hospital the GP is more than happy to come to see her. The GP says if they did attend it would be to make her mother more comfortable.

17. The Practice acted in line with GMC guidance. On the call a history of symptoms was taken, suitable advice was given to attend hospital. We acknowledge Mrs L asked the GP to attend. The GP confirmed they would. The GP recognised Mrs L’s right to choose to accept their advice.

18. At three minutes and 15 seconds the GP confirmed again, based on the symptoms Mrs L described, the best place for her mother would be a hospital. This was based on her mother vomiting and not passing urine. The GP said at three minutes 30 they could attend again. Mrs L said she would still like the GP to attend. At three minutes 40 seconds the GP confirms they will attend. They confirm however their honest opinion is she should attend hospital. The call ended amicably.

19. We acknowledge Mrs L requested several times on the phone call for the GP to attend. We understand she feels she had to insist. We have seen the GP recommended hospital admission but throughout the call accepted they would attend if this was Mrs L’s preference. We have not seen evidence the GP refused at any point to attended. We see no indication of a failing here.

Physical examination

20. Mrs L complains on 6 June a GP from the Practice did not complete a physical examination of her mother when they attended her home. She says the GP stood at the doorway with their hands in their pockets. She says she had to take her mother’s blood pressure, and the GP did not examine her mother’s chest.

21. The Practice said the GP on arrival stood back and took a history. The Practice said the examination included observations such as blood pressure and heart rate. The GP noted a physical examination did took place and was consistent and appropriate with Mrs N’s presentation.

22. There is a clear difference between what Mrs L and the GP say happened. We do not dispute Mrs L’s recollection. As we were not there, we have no way to say for certain what was said or if an examination took place. We can consider if the recorded examination was appropriate. To do this we will review the notes of the examination.

23. A copy of the consultation is recorded on 6 June. It is noted a history of symptoms were discussed. This included ongoing vomiting since going to hospital and then her discharge. Mrs L’s mother had no pain, no absolute constipation, no blood in stools and no fevers. Mrs L’s mother’s abdomen was noted to be soft and non tender. A blood pressure and heart rate were noted.

24. GMC Good medical practice says:

‘You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must work in partnership with them to assess their needs and priorities. The investigation or treatment you propose, provide or arrange must be based on this assessment, and on your clinical judgement about the likely effectiveness of the treatment options.’

25. The part of the GMC Good medical practice we set out in paragraph 14 is also relevant. In line with GMC Good medical practice the assessment the Practice provided was based on clinical judgment. The Practice assessed Mrs L’s mothers’ needs by assessing her condition, taking account of their history including symptoms. GMC Good medical practice does not say specifically what should or shouldn’t be included in a appointment or consultation.

26. Our advisor said the consultation was in line with GMC Good medical practice. The home visit reflects an assessment of a patient with ongoing vomiting. With the information provided there was no indication to examine further.

27. We acknowledge Mrs L was frustrated and upset with the consultation on 6 June. We understand she wanted the best care for her mother. Based on the evidence we have seen the home visit was carried out in line with GMC Good medical practice. We therefore will take no further action.

Prescription

28. Mrs L complains the Practice did not submit a prescription to the pharmacy. Mrs L says the GP prescribed electrolytes and they were told the prescription would be available later in the afternoon. She says on arrival at the pharmacy no prescription had been submitted.

29. The Practice said Dioralyte was prescribed. Dioralyte is an oral electrolyte powder used to treat dehydration caused by diarrhoea, vomiting, or excessive sweating in adults and children. The Practice said it had not been signed off immediately. The Practice say the prescription was complete at 3.57pm. The Practice apologised for this.

30. We understand Mrs L says the Practice did not submit the prescription. This appears to be correct. The Practice has acknowledged the prescription was not available right away when she attended the pharmacy. As soon as the Practice were made aware of this a prescription was made. It was completed by 3.57pm. We do not know the time the prescription was originally meant to be submitted.

31. We have considered the events of the day. Mrs L first spoke to the GP at 11.25am. After this phone call it was agreed the GP would attend Mrs N’s home. It is noted the GP was due to attend as soon as possible. It is likely the consultation occurred sometime shortly after the phone call. It is likely the gap between the consultation and the prescription being completed was four hours. We consider the prescription would not have been made available immediately. Therefore the gap between when it should have been ready and when it was is less than four hours.

32. As noted above, the Practice has issued an apology for this delay. We will consider if this is enough to remedy this head of complaint.

33. Our scale of injustice says a case will generally be level one if we consider the person affected has experienced a low impact injustice such as annoyance, frustration, or inconvenience, typically arising from a single (one-off) incidence We will usually consider an apology to be an appropriate remedy for these cases.

34. NHS Complaint Standards set out that an organisation should acknowledge and apologise when something goes wrong. We acknowledge Mrs L’s frustration when she attended the pharmacy the prescription was not immediately ready. We can see the Practice have accepted this. The Practice’s apology has remedied this complaint in line with NHS Complaint Standards. We will take no further action.

1. We have carefully considered Mrs L’s complaint about a GP Practice in East Riding of Yorkshire (the Practice). We are sorry to hear of death of her mother. We understand how difficult it is to deal with bereavement especially when you have questions about the care a loved one received.

2. After carefully considering all the evidence, we have not seen the Practice got anything wrong. We understand this decision may be upsetting and we are sorry for any distress it might cause.