A practice in the King's Lynn and West Norfolk area

3. Ms R complains the Practice declined to visit her mother, Ms L, in December 2022. Ms L was admitted to hospital a few days later and sadly died.

4. Ms R says if the Practice had visited sooner her mother’s death could have been prevented. She says she has been deeply affected by the sudden loss of her mother and has been unable to grieve because of her experience. She said she also has to coordinate the support and care of her brother, who lived with their mother, which has led to worry, stress and travel costs.

5. The outcomes she seeks are service improvements and a financial remedy.

6. Ms R told us about her mother’s health, and her living situation. She said her mother had mobility issues and numerous medical conditions. She told us that at the time complained about Ms L was bedridden and needed carers daily to complete her personal care.

7. The records show Ms L was reluctant to engage with services. She lived with her son who had his own health issues. Ms R contacted the Practice on the morning of a Friday in December, following a telephone call with her mother. She asked for a call back from the duty doctor and for someone to go out to see her mother that day.

8. The Practice called her back that afternoon and told her a visit would be arranged after the weekend. Ms R repeated her concerns and told us the Practice said it would send a prescription to the pharmacy for meal replacement drinks.

9. Ms L was seen by a nurse on the following Monday and was told she needed to go to hospital. She eventually agreed to this after speaking to the doctor. She sadly died a few days later, the main cause of her death being acute bronchopneumonia (a lung infection that affects small patches of the lungs).

10. Ms R told us she thinks if her mother had seen a GP when she called, she would very likely have been hospitalised much sooner, which could have potentially prevented her sad death.

11. The Practice complaint response said Ms L had been seen two days before the call, and the doctor who spoke with Ms R on the Friday made a clinical assessment that a follow up from Ms L’s usual GP and a visit on the following Monday was appropriate.

15. NHS England has produced the guidance ‘Prioritisation of general practice home visits’. This says:

‘When a request for a home visit is made, it is vital that general practices have a system in place to assess: • whether a home visit is clinically necessary • the urgency of need for medical attention.

This can be undertaken, for example, by telephoning the patient or carer in advance to gather information to allow for an informed decision to be made on prioritisation according to clinical need. In some cases the urgency of need will be so great that it will be inappropriate for the patient to wait for a GP home visit and alternative emergency care arrangements will be necessary.’

16. We can see the doctor who dealt with the phone call on the Friday acted in line with the guidance outlined above. They noted in the record Ms L’s recent medical issues – bed sores, blisters, not eaten in days - and that these issues were ongoing. They noted the concerns of the daughter, that her mother was declining personal care as she was in too much pain.

17. Our adviser told us it was reasonable and in line with the NHS England guidance that the doctor used their professional judgement to make a decision about what plan best met Ms L’s need for care and treatment, taking into account ‘whether a home visit is clinically necessary’ and ‘the urgency of need for medical attention’.

18. The issues raised in the call were mostly ongoing issues and were not urgent symptoms. The doctor noted the multi-disciplinary team already around Ms L, and that her usual doctor would be available in three days’ time to carry out a visit and an assessment.

19. The GMC guidance Good Medical Practice says:

‘15 You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you 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.’

‘33 You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.’

‘44a you must share all relevant information with colleagues involved in your patients’ care within and outside the team, including when you hand over care as you go off duty, and when you delegate care or refer patients to other health or social care providers.’

20. In the circumstances described in paragraph 18 it was reasonable and in line with the guidance quoted above for the doctor to explain to Ms R that her concerns would be passed to the usual GP on the following Monday.

21. Ms R raised a new concern about boils in her mother’s mouth and whether this would prevent her from eating. It was reasonable, and in line with 15a and b of the guidance for the doctor to prescribe fortified drinks for this.

22. Ms R told us there was no one available to collect these drinks. We know how frustrating this must have been and it is unfortunate that no one was able to collect these from the pharmacy. This is not an indication of a failing on the part of the Practice.

23. The records show there were many complex social issues, and this made the plan for a familiar doctor to carry out the visit three days later a relevant one. The decision was in line with the GMC guidance that says: ‘Work with colleagues in the ways that best serve patients’ interests.’

24. The doctor kept clear notes to inform Ms L’s usual doctor and made a contingency plan in case that doctor was not available. This was in line with 44a of the guidance.

25. To conclude, we know how difficult and worrying it was for Ms R to try and arrange support for her mother when she lived so far away. We hope we have properly explained why we have concluded that the Practice put together a plan for Ms L’s care and treatment that was in line with the relevant guidance.

1. We have carefully considered Ms R’s complaint. We did not see any indications of failings in the actions of the Practice. For this reason, we will not be taking further action.

2. We were sorry to hear about how much this experience affected Ms R. We hope our statement explains the reasons we have concluded there is no further action we need to take.