A practice in the Calderdale area

6. Mrs F complains on behalf of her sister, Mrs K, who sadly died on 28 December 2024. She says the Practice did not give her sister appropriate advice, medication, or a GP appointment when she contacted on 27 December despite her presenting symptoms and personal circumstances. Instead, it signposted her to a pharmacy for advice on her symptoms and treatment.

7. Mrs F also complains about the Practice’s poor complaint handling.

8. Mrs F says the post-mortem confirmed Mrs K had developed influenza which progressed into a bacterial infection resulting in pneumonia. Her death certificate states cause of death as pneumonia. She says the Practice’s failure meant her sister went without the care and treatment she needed. This could have prevented her death.

9. She also says the Practice’s prolonged response times and lack of clear, open, and transparent communication with the family has caused significant distress and made an already challenging situation more difficult.

10. By bringing this complaint to us, Mrs F would like the Practice to: • apologise for its failings and acknowledge the impact it had • make service improvements to prevent the same failings from happening again.

11. Mr K contacted the Practice on 27 December 2024 due to her ill-health. The Practice referred her to a community pharmacist for follow-up advice regarding her symptoms.

12. On 28 December 2024, Mrs K sadly died – rest in peace.

13. On 31 December 2024, Mrs F made a formal complaint to the Practice, and it provided her with a response on 6 January 2025.

14. Mrs F was unhappy with the Practice’s response, so she approached the Integrated Care Board (ICB) responsible for the Practice and asked it to investigate her concerns. Unfortunately, the ICB caused significant delays and eventually informed Mrs F that it could not re-investigate her concerns as the Practice had already provided a response.

15. Following this, Mrs F returned to the Practice with her outstanding concerns. At this stage, the Practice stated it could not provide Mrs F with a further response to her concerns as it deemed her as an unsuitable complainant as she was not the person affected.

GP appointment and advice

19. Mrs F says the Practice did not give her sister a GP appointment when she contacted it on 27 December 2024 despite her presenting symptoms and personal circumstances. Instead, it signposted her to a pharmacy for advice on her symptoms and treatment.

20. Mrs K contacted the Practice at approximately 8.30am on 27 December 2024 and described a two-week history of a cough and feeling weak due to not eating properly.

21. In its complaint response, the Practice explained that its reception team uses a triage process to direct patients to the most appropriate service.

22. The call note indicated that staff told Mrs K that the community pharmacy would contact her that afternoon to give further advice and support for her symptoms.

23. The Practice says this was appropriate and no GP appointment was necessary as Mrs K’s symptoms fulfilled the appropriate criteria for the community pharmacy service.

24. The NHS ‘Long Term Plan’ highlights the need to boost out-of-hospital care and to reduce pressure on emergency hospital services. Further, its plan is to move to a new service model in which patients get more options, better support, and properly joined-up care at the right time in the optimal care setting. One of its commitments is to make greater use of community pharmacists’ skills and opportunities to engage patients.

25. NHS ‘Cough’ webpage explains that there is usually no need to see a GP if you have a cough. This is because it will usually clear up on its own within three to four weeks. It also gives information and advice on how to manage symptoms at home. Additionally, it recommends asking a pharmacist for help and advice.

26. NICE CKS ‘How do I diagnose the cause of cough?’ guidance recognises the differential diagnosis of a cough is wide-ranging and can include many diseases. It says knowing the duration of the cough can help guide diagnosis but understands it is not possible to predict which coughs may or may not progress into sub-acute or chronic stages.

27. Our adviser explained that, given the wide-ranging diagnosis that can be attributed to a cough, along with the need to determine the most appropriate service for a patient, it is important to ask specific questions about a patient’s symptoms. This is similar to the 111 service and the NHS symptoms checker website service.

28. The Practice’s system gives the reception team questions to ask to help to determine the severity of the patient’s symptoms and what is the most appropriate action for the patient as a result. Dependent upon the answers to these questions, the reception team could make a referral to a community pharmacist, book a GP appointment, refer to hospital, or request an ambulance.

29. This NICE CKS guidance says, for patients who present with a cough less than three-weeks in duration, it is important to assess whether the person has clinical features of the most common cause, such as cold and flu. Further, to assess whether the person has clinical features of other possible causes, including symptoms such as breathlessness and fever.

30. During the telephone call to the Practice on 27 December 2024, Mrs K reported a two-week history of a cough. She explained she was a little breathless and was taking small breaths rather than long breaths. She stated she did not think she had a fever.

31. Based on the symptoms described by Mrs K, our adviser says the Practice’s reception team appropriately used NICE CKS to determine the severity of Mrs K’s symptoms. The answers provided by Mrs K did not indicate that a GP appointment was necessary at that time. This is because the symptoms described would potentially indicate a viral infection, such as a cold or flu.

32. NHSE ‘Community Pharmacy advanced service specification: NHS Community Pharmacist Consultation Service’ guidance gives a list of symptoms groups identified for referral to a community pharmacist. This includes low acuity minor illness conditions, such as a cough.

33. The flow chart within this guidance explains what can be done when a patient with a minor illness is referred to a community pharmacist. This includes patient consultation, which could be face to face or via telephone, and the pharmacist would check the patients care records and consider guidance as necessary.

34. This guidance explains that community pharmacist can give: • self-care advice only • sale of over-the-counter medication • refer to a local commissioned service • refer a patient for urgent appointment with own GP or signpost to other urgent care options.

35. Our adviser explains the Practice’s reception team made an appropriate referral to the community pharmacist. Making this referral would allow the pharmacist to complete a clinical assessment and further advice to be given, or a follow-up referral made. This could have included a referral for an urgent appointment if it was felt that this was clinically needed at that time.

36. We recognise how difficult it is for Mrs F to understand how her sister could be categorised as not being significantly ill when she died 36 hours after contacting her GP for advice and support for her symptoms.

37. Having taken everything into account, we consider the Practice did act in line with NICE and NHSE guidance. It asked Mrs K pertinent questions to help to determine the severity of her symptoms and to ensure she received the most appropriate service to support this at the time. We consider the referral to the community pharmacy was the most appropriate service based on the answers and information Mrs K gave regarding her symptoms.

38. Mrs F also says the Practice did not give appropriate advice to her sister when she called for care and treatment on 27 December 2024.

39. GMC ‘Good Medical Practice’ guidance explains that communication should be effective. This means that information given to patients is clear, accurate, up to date, and based on the best available evidence.

40. The Practice’s referral process states that patients should be offered a choice of pharmacies. It says it should be made clear that most pharmacies operate on a 48-hour call back service, but there is an option for the patient to be referred to one with a same-day call back service.

41. We can see from the transcript that during the call, the Practice did not ask Mrs K which pharmacy she wished to be referred to. This is not in line with the Practice’s referral process.

42. The transcript shows that the Practice stated that the pharmacy would call Mrs K back that afternoon. The Practice do not have any evidence to show which type of referral it made (48-hours or same-day call back service). The pharmacy has also been unable to provide any evidence of this referral.

43. The Practice informed us that the pharmacy had notified it of Mrs K’s death. This was because it had made an attempt to call her and had been told of her sad passing. Therefore, on balance, we can say the pharmacy did receive the referral. However, we cannot say what type of referral was made but it appears the call back was not made on the afternoon of 27 December as Mrs K had expected.

44. Our adviser says the Practice should have asked Mrs K for her preferred pharmacy and provided her with the contact details to call should she not receive a call back within the specified time. They also say the Practice should have clearly communicated with Mrs K what she should do if her symptoms and health deteriorated further.

45. Taking all available evidence into account, we consider the information the Practice provided to Mrs K was not clear and was not in line with GMC ‘Good Medical Practice’ guidance. We consider this to be an indication of a failing.

46. We recognise the distress this has caused Mrs F to learn that her sister did not receive a call, or an appointment, to further discuss her condition and possible treatment.

47. We understand Mrs K’s condition deteriorated rapidly and she sadly died 36 hours after contacting the Practice.

48. We consider that clearer communication could have helped Mrs K to determine her follow-up actions when her symptoms deteriorated. That said, we cannot say she would have followed the advice as her symptoms deteriorated. Additionally, follow-up actions such as contacting her GP, the pharmacy, an ambulance, or attending hospital, were all options available for Mrs K to have taken when she did not receive a call from the pharmacy.

49. Therefore, we cannot say Mrs K’s death was avoidable because she did not receive clearer communication with the Practice. This is because, as above, there was no indication from the symptoms provided by Mrs K that she needed to be seen urgently, and when she did not receive a call, if she felt worse, she could have sought further advice or assistance.

50. As such, we consider the unclear communication may have caused Mrs K some confusion, and it has been distressing for Mrs F to know that her sister should have been given better information and advice.

51. We contacted the Practice regarding its communication and requested it consider improvements to its service to ensure the communication and advice given to patients is clear. This is because we consider this will avoid confusion and will help patients understand what actions they should take if further care and treatment is required.

52. The Practice confirmed that it has changed its computer and telephony systems and there has been a slight change to how its referral process works. This is now fully electronic. The Practice shared with us its new referral process. We consider that this ensures that there is electronic evidence stored so we can see what information is supplied in the referral and whether it has been received by the specific service.

53. The process also highlights the importance of ensuring patients are provided with a choice of pharmacy, information about the 48-hour call back, and about the option for a same-day call back with a specific pharmacy.

54. The Practice says it will ensure its staff are fully aware of it process and that contact information is supplied to the patient along with safety-netting advice should the patients symptoms deteriorate.

55. We consider these changes provide a more consistent and reliable process which ensures referrals are accurately received and processed within the specified timeframe. This will reduce the risk of any delays or errors being made.

56. Our ‘NHS Complaints Standards’ explain when things go wrong, we expect organisations to apologise and ‘see complaints as an opportunity to develop and improve its services.’

57. The Practice has agreed to write to Mrs F to apologise for her and her sisters experience and for the impact it had. It has also agreed to inform Mrs F of the service improvements it has made in this area. We consider this to be in line with Our NHS complaints standards and resolves this part of Mrs F’s complaint. Therefore, we will not be taking any further action.

Medication

58. Mrs F says her sister had a past medical history of chest infections around that time of year, which she says always required antibiotics. She says in December 2024 the Central Alerting System (CAS) advised General Practices to give antivirals and antibiotics to patients presenting with flu-like symptoms. She says the Practice failed to give her sister this important medication which could have saved her life.

59. NHS ‘Antibiotics’ webpage explains that antibiotics do not work for viral infections, such as colds and flu, or for most coughs. It also explains that taking antibiotics when a person does not need them can mean they will not work for them in the future.

60. Our adviser said that antibiotics are not routinely prescribed because antibiotic resistance is a big problem. Therefore, they would usually only be given if a secondary bacterial infection develops.

61. As stated above, our adviser explains the Practice’s reception team made an appropriate referral to the community pharmacist based on Mrs K’s reported symptoms and this was in line with the NHSE guidance. Making this referral would allow the pharmacist to complete a clinical assessment and further advice to be given and a follow-up referral made if needed.

62. Our adviser explained that, although the pharmacy could not write a prescription, it could have made a referral for an urgent appointment if it was felt that this was clinically needed at that time. If a referral for an urgent appointment was made then the clinician could have given a prescription of antibiotics if it felt that Mrs K was suffering from a secondary bacterial infection or if relevant guidance at the time, such as CAS, recommended its use.

63. We understand that Mrs F is concerned that the Practice did not consider her sister’s past medical history, or the important information outlined in the CAS, when deciding what course of action to take.

64. We consider the Practice made an appropriate referral based on Mrs K’s presenting symptoms at the time in line with NHSE guidance. For this reason, we do not consider the Practice needed to prescribe antibiotics, or any other medication, at this time.

65. We consider Mrs K could still have received any medication via this route if it was deemed necessary. Therefore, we will not take any further action regarding this part of Mrs F’s complaint.

Complaint handling

66. Mrs K sadly died on 28 December 2024. Mrs F made a formal complaint to the Practice on 31 December 2024 about the lack of care and treatment provided to her sister.

67. The Practice promptly responded to Mrs F on 6 January 2025. It explained that the call was handled appropriately and gave the reasons behind its decision not to offer Mrs K a GP appointment, or medication, and why it had signposted her to a pharmacy for ongoing care and treatment for her symptoms.

68. Mrs F was unhappy with the response, so she approached the ICB responsible for the Practice and asked it to investigate her concerns. Unfortunately, the ICB caused significant delays and eventually informed Mrs F that it could not re-investigate her concerns as the Practice had already provided a response.

69. Mrs F went back to the Practice to ask it to respond to her outstanding concerns, but she was met with resistance. This was because she was not the person affected and the Practice said she did not have the consent it needed to respond. This was despite providing a response previously.

70. Our NHS complaints standards recognise the importance of ensuring complainants are suitable to bring about a complaint. It says it is important to consider what the complainant wants to achieve by raising their complaint and assess the risk of investigating it. It considers concerns and complaints should be investigated wherever possible and a response provided as it helps people to feel listened to and helps them find closure, especially during difficult times. This should be done if the complaint can be responded to without releasing confidential and personal information and without sharing additional information that the complainant is not already aware of.

71. The Practice did not do this and told Mrs F that it would not respond without considering whether it could provide a further response without sharing additional personal information. This is not in line with Our NHS Complaint Standards and is an indication of a failing.

72. During our consideration of this complaint, we spoke to the Practice about Mrs F’s experience and how its lack of clear, open, and transparent communication with the family about the complaint process had caused significant distress and made an already challenging situation more difficult.

73. The Practice understood how important it is for patients and their families to feel heard, supported, and treated with compassion, particularly during such difficult times. It said it was never its intention to cause further distress in the circumstances.

74. The Practice has agreed to provide a further letter apologising for Mrs F’s experience and for the impact this had.

75. The Practice explained that it has gone through a period of improvement since Mrs F’s original complaint. It says it now has a dedicated Complaints Officer to ensure that concerns and complaints are listened to carefully, investigated thoroughly, and responded to appropriately. It says it also enables it to identify trends, learn from patient feedback, and continually improve the care and service it provides.

76. The Practice also confirms that it will ensure it uses the information provided by us regarding assessing suitability of a complainant. This means that the person complaining does not have to be the executor of the will or a representative. It has agreed to assess on an individual basis with each complaint it receives.

77. Our NHS Complaints Standards explain when things go wrong, we expect organisations to apologise and ‘see complaints as an opportunity to develop and improve its services.’

78. The Practice has agreed to write to Mrs F to apologise for the impact caused, and outline in its letter the additional improvements it has made since her complaint. We consider this in line with our NHS complaints standards and resolves this part of Mrs F’s complaint.

79. Although we cannot change Mrs F’s experience. We hope she feels reassured that the Practice has acted on her experience and made necessary changes to improve its service going forward. We hope our decision has provided Mrs F with much-needed answers and closure on what has been a difficult period for her.

1. We are very sorry to hear about the death of Mrs F’s sister, Mrs K. We understand this was a sudden and unexpected death and we recognise what a sad and difficult loss this has been for Mrs F and her family. We also appreciate the further upset and distress caused by the complaints process.

2. We have carefully considered Mrs F’s complaint about a GP Practice in the Calderdale area (the Practice). Having considered all available evidence, we consider the Practice did not do anything wrong by not offering a GP appointment or medication to Mrs K and instead referring her to a community pharmacy.

3. We consider the Practice should make improvements to its communication going forward to ensure there is no confusion and patients are clear in what follow-up actions they have available to them.

4. Additionally, we consider the Practice should make improvements to its complaint handling. This is to ensure other people do not have the same negative experience Mrs F had when raising a complaint on behalf of her sister who had sadly died.

5. The Practice has agreed to write to Mrs F to apologise for her and her sisters experience and for the impact it had. It has also agreed to inform Mrs F of the service improvements it has made in these areas. We consider these actions are appropriate to put things right and resolve this complaint. We explain this in more detail below.