A practice in the Fareham area

6. Miss T complains that on 25 May 2023 the Practice failed to carry out a full assessment of her brother, Mr T’s symptoms.

7. Miss T feels that if the Practice had completed a full assessment of her brother, it would have contacted the ambulance service to take her brother to hospital.

8. Miss T says her brother died only a few hours after his consultation on 25 May 2023 and feels that if the Practice had done more his life could have been extended.

9. Miss T says the sudden death of her brother had a huge impact on the family.

10. Miss T seeks a financial remedy.

11. On 25 May 2023, Mr T attended the Practice again (having also attended two days previously) with his ex wife, Mrs Y, with complaints about his breathing and his finger nails had turned purple. The Practice arranged for a N-terminal pro-B-type natriuretic peptide (NT PRONT PROBNP, a peptide which is released when the heart muscle is stretched) and troponin (an indication of heart muscle damage) blood test to be carried out.

12. The same day Mr T’s blood results were returned and both his NT PRONT PROBNP and troponin levels were elevated. The Practice contacted Mr T by telephone to tell him he needed to seek urgent medical treatment.

13. Mrs Y called for an ambulance with an ambulance arriving at Mr T’s home at 5.50pm. When the paramedics arrived Mr T had sadly already died.

19. Miss T has raised concerns the Practice did not carry out a full assessment of her brother during his consultation on 25 May 2023.

20. We understand Mr T attended this appointment with his ex-wife due to her and her family’s concerns about his health. We therefore understand how difficult it is has been to feel he did not receive the care and treatment he needed.

21. The Practice says it carried out the correct investigations and tests based on the symptoms Mr T was suffering with.

22. Mr T’s medical records show he attended the Practice on 25 May 2023 with a family member as they were worried about his breathing and his finger nails had turned purple. Mrs Y says Mr T was suffering severe breathlessness and fatigue, so much so he had to stop several times walking from his car to the Practice.

23. Within the consultation, a GP at the Practice tested for blood clots and also consulted a medical consultant who worked at a local Trust for advice on whether Mr T needed to attend a hospital. The advice the medical consultant gave was to await the result of the NT PRONT PROBNP, which measures heart strain.

24. The Practice therefore requested Mr T’s NT PRONT PROBNP to be tested. This was completed and results provided the same day.

25. The NICE guidance says,

26. ‘Take a history and perform a clinical examination and tests to confirm the presence of heart failure.

27. Measure N-terminal pro-B-type natriuretic peptide (NTproNT PRONT PROBNP) in people with suspected heart failure.’

28. We consider the Practice acted in line with the NICE guidance by requesting a NT PRONT PROBNP test.

29. The Practice also requested for Mr T’s troponin levels to be tested. This tests for any heart damage from either a heart attack or an impending heart attack.

30. Our GP adviser says this is usually only tested for when a patient is in hospital to see if they are having a heart attack. Whilst there is no guidance to suggest the Practice should have requested a troponin blood test at this point, we consider the Practice carried out tests to help understand why Mr T had the symptoms he did.

31. As stated previously Mr T’s blood tests were completed the same day and the Practice were also made aware of the results on the same day. Both Mr T’s NT PRONT PROBNP and troponin were elevated. It is at this point, the Practice telephone Mr T and advised him to seek urgent medical help.

32. This is in line with the GMC guidance which 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 patientb. promptly provide or arrange suitable advice, investigations or treatment where necessaryc. refer a patient to another practitioner when this serves the patient’s needs.’

33. However, whilst the Practice was correct to test for NT PRONT PROBNP, Mr T’s medical records show during his consultation the Practice tested his heart rate ‘Normal hr today’ but there is no documentation to suggest the Practice tested Mr T’s other vital signs such as blood pressure, examination of swelling in the legs or checked his chest for congestion.

34. This should have been done in line with the above GMC guidance and we therefore consider this to be a failing as the Practice did not have a full understanding of all of Mr T’s symptoms at this point.

35. We will therefore consider the impact of this on Mr T.

36. Miss T says if the Practice had carried out a thorough and appropriate assessment of her brother on 25 May 2023, he could have attended hospital sooner and his life could have been extended. We recognise how distressing not knowing is for Miss T.

37. We need to consider whether we will ever be able to know if Mr T’s vital signs would have been abnormal if the Practice had appropriately assessed these during the consultation. If we can say Mr T’s vital signs would have been abnormal, we can then look to see if he should have been sent to the Trust sooner and then what his treatment and prognosis would have been then.

38. Our cardiology adviser says Mr T suffered from a sudden fatal irregular heartbeat at home, around three hours after his GP consultation.

39. Our cardiology adviser says it is not possible to say for certain whether the vital signs or examination would have been abnormal. However, they also say it is likely Mr T was in active heart failure during the time of the consultation due to his worsening breathlessness, peripheral oedema and his NT PRO BNP level being elevated at 5000pg/ml. The NICE guidance says a normal NT PRO BNP level is between 400 and 2000 pg/ml.

40. Our cardiology adviser importantly added however, Mr T could have been in active heart failure and still had normal vital signs at the point of his consultation.

41. As we were not there at the time and there is no further information on how severe his symptoms were, we still cannot say whether he should have been sent to hospital straight from his consultation. Our cardiology adviser says more severe symptoms would mean a referral to A&E. From the information we have, including Mrs Y’s account of how Mr T was struggling on the day, we cannot say whether Mr T’s symptoms were severe enough to warrant this.

42. We are unable to say whether Mr T should have been sent to hospital directly from his appointment at the Practice. We cannot say his vital signs would have been abnormal and we do not know how severe his swelling and breathlessness was.

43. We therefore cannot say whether Mr T’s prognosis would have been any different. We cannot link the failing to the impact of a missed opportunity for Mr T’s life to be extended if the Practice had done things differently.

44. We consider the Practice should have carried out an assessment of Mr T’s vital signs during the consultation and recorded the results. Whilst we cannot say because of this Mr T should have been straight to hospital, we do consider it will be upsetting for Miss T and her family to know her brother was not fully assessed by the Practice just a few hours before his death.

45. We recognise her brother’s sudden death was devastating for Miss T and her family. We consider they were caused additional distress by not knowing whether if things may had been different if Mr T had been seen earlier at hospital.

Recommendations

46. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services.

47. Our Principles for Remedy are reflected in the NHS Complaints which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

48. We consider the Practice should acknowledge the uncertainty caused to Miss T by not knowing what her brother’s vital signs were at the consultation and whether he should had been sent directly to hospital. We also consider the Practice should apologise to Miss T for the distress this uncertainty has caused.

What we found

49. Through investigating this complaint, we found:

• The Practice failed to appropriately assess Mr T’s vital signs during a consultation on 25 May 2023. Whilst we do not know if this would have led the Practice to sending Mr T straight to hospital from his consultation, we do consider it will be upsetting for Miss T to know her brother was not fully assessed by the Practice on the day of his death.

What the organisation should do

50. Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship.

• Write a letter to Miss T acknowledging the failing and the impact to Miss T and apologising for this.

• send us evidence it has done this within one month of the date of this report.

1. We consider the Practice failed to appropriately assess Mr T’s vital signs when he attended a consultation on 25 May 2023. Tragically, we will never know if Mr T’s vital signs during this consultation would have been abnormal and whether he should have been sent for emergency medical attention sooner.

2. Whilst we can never say if Mr T’s care should have been different, we understand the impact of never knowing whether she could have had a few extra days with her brother has caused upset and distress to Miss T, her brother’s ex-wife Mrs Y, who attended the Practice with him on 25 May 2023, and the rest of their family.

3. We therefore partly uphold this complaint.

4. To help put things right for Miss T and her family we are recommending the Practice write to her to acknowledge the failing identified and apologise.

5. We understand how upsetting and traumatising this time has been for Miss T and her family and we thank her for allowing us the time to investigate her concerns. We know how difficult it is to continue to talk about these events. We also understand how disappointing our findings may be in that we will truly never know what should have happened to her brother following his consultation. We hope however, our report goes someway in explaining what happened on that day and how we have come to this decision.