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Selected Investigations Completed October 1999 - March 2000 > Part II, Case no. E.1329/98-99
Complaint against: Healthcall Services Limited and a GP in the Avon Health Authority area
Complaint as put by Mr K
1. The account of the complaint provided by Mr K was that during one night in February 1998 his daughter, Mrs H, woke with stomach pains and at about 1.30am telephoned the deputising service used by her general practitioner (GP) to deal with calls out of surgery hours. She was told that a doctor would visit her. At 2.40am Mrs H called the deputising service again and at 4.00am was visited by a doctor employed by the deputising service (the deputising doctor). He gave her a painkilling injection and a prescription and left at 4.20am. He did not refer her to hospital. Still in pain, Mrs H again telephoned the deputising service at 5.45am. About half an hour later the same doctor returned her call and advised her to go to hospital. There she was diagnosed as having a sigmoid volvulus (twisting of part of the colon or large bowel) and required an urgent operation.
2. Mr K complained to Mrs H's GP on her behalf on 7 March. The practice received a response from the deputising service by 21 May, and communicated that to Mr K. Mr K remained dissatisfied and a conciliation meeting was held on 21 July. On 1 August, still dissatisfied, Mr K asked the Health Authority's convener for an independent review of his complaint. The convener refused that request on 21 September.
3. The complaints investigated were:
(a) that there was an unacceptable delay between Mrs H's telephone calls and the deputising doctor's visit; and
(b) that the treatment provided to Mrs H by the deputising service on her GP's behalf was inadequate.
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Investigation
4. The statment of complaint for the investigation was issued on 28 January 1999. Comments were obtained from Mrs H's GP and the deputising doctor, and relevant papers were examined. A transcript of a tape recording of the telephone calls between Mrs H and the deputising service was considered. Evidence was taken from Mr and Mrs H, Mr K, the deputising doctor and staff of the deputising service. Two independent professional assessors (both GPs) were appointed to advise on the case. Their report is at paragraphs 25-45 below.
Complaints (a) and (b): unacceptable delay between Mrs H's telephone calls and the deputising doctor's visit and inadequate treatment provided
Guidance
5. The National Health Service (General Medical Services) Regulations 1992, Schedule 2, Terms of Service for Doctors states:
'12 (1) ...a doctor shall render to his patients all necessary and appropriate personal medical services of the type usually provided by general medical practitioners.
'(2) The services which a doctor is required ...to render shall include: ...(b) offering to patients consultations and, where appropriate, physical examinations for the purpose of identifying, or reducing the risk of, disease or injury; ...(d) arranging for the referral of patients, as appropriate...'
6. Under the National Health Service (General Medical Services) Amendment Regulations 1997 GPs are required to satisfy themselves that the deputising services they use provide services which are adequate and appropriate. They are responsible for the actions of doctors deputising for them, unless those doctors are themselves principals in general practice.
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7. A booklet on good medical practice, produced by the General Medical Council, states that good clinical care must include:
'an adequate assessment of the patient's condition, based on the history and clinical signs and, if necessary, an appropriate examination;
'providing or arranging investigations or treatment where necessary;
'taking suitable and prompt action when necessary;
'referring the patient to another practitioner, when indicated.'
The deputising service's training guidance
8. The deputising service's training material for operators includes guidance on handling urgent (priority) calls. It states:
'There are certain calls that MUST BE IDENTIFIED AS URGENT in order to avoid unnecessary deterioration, and/or anxiety, in a very sick patient.
'The very nature of a call should alert the operator to its urgency... It will be the operator's responsibility to extract the relevant information, and hopefully aid the medic in prioritising the call correctly.
'IF THE CONTROLLER IS VERY BUSY—IT IS ESSENTIAL THAT THE OPERATOR ALERTS HER/HIM VERBALLY TO THE URGENT CALL'
The guidance lists those symptoms which should be treated as urgent:
'1. Chest Pain
'...Previous history of angina or health problems in the patient increases the need for concern.
'HOWEVER, CHEST PAIN IN ANY PATIENT SHOULD BE ACCEPTED WITHOUT QUESTION AS A PRIORITY...'
'8. Abdominal Pain Severe abdominal pain, particularly of sudden onset, indicates inflammation of the lining of the abdomen.'
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Mr and Mrs H's evidence
9. Mrs H was uncertain about the precise details of her telephone calls to the deputising service. Her itemised telephone bill shows that she called them at 1.31 and 1.35am and then again at 2.40am. She thought perhaps she had missed some details from the first call so rang again almost immediately. At that time she felt as though she wanted to be sick or was going to have an attack of diarrhoea, although neither happened. The operator also asked to speak to her husband; he said he told the operator that his wife might have had a bit too much to drink or might be suffering from food poisoning. Mrs H telephoned the deputising service again at about 2.40am because a doctor had not arrived; the doctor finally came at 3.50am.
10. Mrs H said that by the time the doctor arrived she was feeling very unwell; in great pain with her stomach and her back from which she could get no relief. She could remember very few details of the visit although she knew the doctor examined her; he asked her to lie on the sofa, felt her stomach and asked her to take a few deep breaths. He gave her a morphine injection, which he said was his last ampoule, and some oral medication. She thought he also left a prescription although neither Mr nor Mrs H could remember the precise details of the medication prescribed. Mr H said the doctor was with them quite a while; he did not rush away. When he left he said nothing about calling again if the symptoms did not subside.
11. Mrs H said the morphine helped her back pain but did nothing to ease her stomach pains so she telephoned the deputising service again. The doctor returned her call and, after ascertaining that her husband would take her to hospital, he said he would telephone the hospital to let them know of her arrival.
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The deputising doctor's formal response to the complaint
12. In comments to the Ombudsman at the start of this investigation the deputising doctor wrote:
'[The call] concerning [Mrs H] was passed to my driver at 02.57 [sic] with the additional information that the patient had recalled. At the time I was attending another patient and when I emerged at 03.10 I had to choose between visiting [Mrs H] or ...a [patient] with a history of "heart attack" who was complaining of chest pain and difficulty breathing.
'In my view this took priority over [Mrs H's] call.
'[Mr K] states that I arrived at his daughter's house at 04.00 and departed at 04.20. This is incorrect as the log sheet clearly shows. In fact I attended [Mrs H] for nearly 40 minutes.
'...I gave her an intravenous injection of diamorphine 5mg [a pain killer], an intramuscular injection of metoclopramide 10 mg [to reduce nausea and vomiting]. In addition I gave her a tablet of diclofenac 50mg [a pain killer and anti-inflammatory] and some paracetamol tablets to take when the anti-emetic injection took effect. Trimethoprim [an antibiotic] was prescribed since at the time the symptoms and signs were suggestive of bilateral pyelonephritis [an infection of the kidneys].
'The cardinal sign of a sigmoid volvulus is massive distension of the lower abdomen caused by inflation of the twisted loop of sigmoid colon.
'This was not present when I examined [Mrs H].
'I specifically and emphatically told [Mrs H] and her husband to call again if the pain was not settling.
'When I spoke to [Mrs H] again the pattern of her symptoms had changed and was now clearly indicating a large bowel problem.
'My immediate aim was to admit [Mrs H] to hospital as quickly as possible for further investigation and pain relief.
'The ...hospital is less than 15 minutes drive. [Mrs H] was quite certain that her husband could take her there immediately. I called the casualty department straight away to advise them of her imminent arrival.'
Back to top Documentary evidence
13. I have examined the deputising service's log of calls received on the night in question and transcripts of Mrs H's telephone calls to them and the dockets relating to Mrs H's calls. According to the relevant docket, Mrs H first called the deputising service at 1.42am. She said;
'I've got ...raging stomach ache and burning back ache at the same time, I feel sick, I can't stand up, lie down, it suddenly came on during the night.'
14. The operator told Mrs H that they would send the doctor to see her. The docket shows that the call was passed to the doctor's driver at 2.47am. According to the log, three other calls were passed to him at about the same time, and the doctor was with another patient until 3.10am.
15. The log shows that Mrs H called again at 2.48am and said that her symptoms had got worse: she was vomiting. The operator told her that they would send round a doctor as soon as possible. The log records that the doctor visited Mrs H at 3.50am and left at 4.28am.The doctor's record of his visit notes that Mrs H had severe abdominal and back pain and includes a sketch of her abdomen showing that she was tender in both loins. A horizontal line has been drawn in a box against 'patient to call again if necessary'.
16. Mrs H called the deputising service again at 5.45am. According to the transcript of that call, the operator told her that the doctor was currently seeing another patient but that she would ask him to telephone Mrs H. The call was passed to the doctor's driver at 5.47am. The log shows that the doctor was with another patient at that time and returned to his car at 6.10am. The doctor called Mrs H back at 6.14am and she told him that the pain in her back had eased, but that her stomach was 'agony'. The deputising doctor told her that he had given her his last ampoule of morphine earlier and that the only thing likely to ease the pain was another injection of morphine. He suggested that she contact her own GP when he came on duty at 7.00am or, alternatively, that her husband should take her to hospital where she would be able to have an injection more quickly. He said that he would call the hospital to let them know that she was coming.
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The deputising doctor's evidence
17. In the course of the investigation the deputising doctor told the Ombudsman's staff that he considered that the night in question had been an exceptionally busy night with 16 calls, two of which came in during the previous doctor's shift. He said that if a doctor felt that he was becoming overloaded with patients and falling behind, he could he could ask for the deputising service's subscriber call-out system (ie subscribing GPs to be asked to visit) to be instigated, but the controller would decide whether to do that. If there was a real emergency, such as chest pain then he could call 999. He had not used the subscriber call-out system that night because there had been no need to do so.
18. When he arrived at her house, Mrs H was standing up and walking about the living room, obviously distressed and agitated, but able to give an oral history of pain across the whole of her stomach and back for the previous two hours, with vomiting. The deputising doctor said he took the history of how long the pain had been present, its site and radiation. He would also have asked the standard questions for a woman of her age about pregnancy and menstrual cycle. Before he carried out an examination he gave Mrs H an intravenous injection of diamorphine because she was in so much pain. He waited about five minutes, then examined her as she lay on the sofa; he definitely examined her abdomen. She was tender in both renal angles (part of the back which lies in an area defined by the angle between the backbone and the lower edge of the ribcage; the kidneys are situated within deeper tissue below this area) but there was no obvious distension of the abdomen. He said that it was often part of his routine examination to listen to bowel sounds but he could not remember if he had done so in this case. He took Mrs H's temperature but did not believe her temperature was 36°C, as shown on the thermometer, because she felt warm to the touch. Her pulse rate was high. He had not taken her blood pressure although he recognised he should have done. However, given her agitation and distress the blood pressure reading may well not have been accurate, and Mrs H had no past history of problems with her blood pressure. Mrs H volunteered no urinary symptoms and he had not tested her urine. He would normally test a patient's urine, if they could provide a sample, but on this occasion he had run out of testing strips.
19. His grounds for diagnosing pyelonephritis were the presenting symptoms of vomiting; radiating abdominal pain; tenderness on palpation of kidneys; and fever (although that was not always present with pyelonephritis). His treatment plan was pain relief, antibiotics and metoclopramide to reduce the vomiting. At that time he did not think Mrs H had a bowel problem. Follow-up arrangements consisted of either Mrs H telephoning her own doctor or calling back the deputising doctor, which she did. He told the investigator that the line in the box (paragraph 15) meant that he had told the patient to call back if necessary. When he spoke to Mrs H for the second time, the pattern of her symptoms had changed: the back pain had eased and she now had severe pain in her abdomen. The deputising doctor said that if he had not had a call to a case of asthma then he would have visited Mrs H again at which time he might have administered more diamorphine had he had any. Instead, he had advised her to go to hospital.
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Evidence of staff of the deputising service
20. The present branch controller at the deputising service (who was a supervisor at the time, though that post no longer exists) said that at night there were two operators on duty, one of whom was also the 'box controller', passing calls to doctors. When a call came in, the operator took the patient's personal details and recorded them on a docket. The time of the call was electronically recorded on the docket (that might be done before the information was obtained from the caller, during the telephone conversation or after the call had been completed) and the information was passed to the box controller. The box controller checked to see which deputising doctor could take the call and whether that doctor was mobile or stationary. It was normal practice, unless the call was very urgent, to wait until the doctor was stationary before passing a call. Once the driver had received the call he would log that on his record sheet and, after completing the visit, the doctor would call in with details of the diagnosis and treatment and the controller would enter that on the docket. The branch controller did not know why there had been a delay between Mrs H's first call being received and it being passed to the driver. There might be various reasons: busyness, if the doctor was mobile, that Mr H had said his wife had been out for a drink, or if Mrs H's voice had not had a sense of urgency in it. However she said that the call should have been passed on earlier than it had been.
21. The operator who had taken Mrs H's telephone calls said that she did not really remember them and knew nothing about the delay in passing the first call to the deputising doctor.
22. The box controller who had been on duty when Mrs H telephoned said that she could not remember the particular night in question. However, from the driver's log sheet it appeared that when the deputising doctor had come on duty at 11.30pm, two calls were still outstanding from the previous shift. Five further calls then came in before Mrs H's. She accepted that abdominal pain was one of the symptoms which should be treated as urgent according to the deputising service's training manual. However, she thought that, because the deputising doctor already had seven calls waiting, there would have been no point in passing on Mrs H's call immediately. She said that, unfortunately, Mrs H had not been told how busy the deputising doctor was that night and that there would be a delay in her receiving a visit. After midnight there was no doctor available at the base to give advice.
23. The deputising service's branch manager said that calls should be passed to the doctor as soon as reasonably possible and then the doctor could make the decision when to visit. He accepted that, in Mrs H's case, there had been a delay in the call being passed to the deputising doctor and that should not have happened. That night 77.6 per cent of calls had been dealt with in one hour and 91.4 per cent within 2 hours. He felt reasonably content with that.
24. The deputising service's local medical director said that he did spot checks on medical care provided and on response times. Since Mrs H's case, operators have been reminded of the need to pass calls to drivers or doctors as quickly as possible. A new training manual was being prepared.
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The assessors' report
Introduction
25. We were asked by the Ombudsman for an opinion on the standard of general practice care given to Mrs H by the deputising service on behalf of her GP.
26. In producing this report we have considered documents made available by the Ombudsman's office, including the deputising service's records, a transcript of a tape recording of the telephone calls between Mrs H and the deputising service; and the deputising service's training manual for operators. We also considered notes of interviews carried out by the Ombudsman's staff. We took part in the interview with the deputising doctor.
27. The facts in this matter do not seem to be in contention, other than some minor variations in timings explained by the fact that the deputising service's operators often time calls at their conclusion rather than at their commencement. The medical treatment said to have been given by the deputising doctor is in accord with Mr K and Mrs H's recollection.
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Assessors' comments
28. A number of issues arise and we will comment on them in chronological order.
Delay in passing the call to the deputising doctor
29. There was a long delay between the call being received by the deputising service and it being passed to the deputising doctor, and we note that the deputising service's own training manual notes that abdominal pain is an emergency requiring prompt treatment. Furthermore we can see no advantage in holding back calls from the duty doctor, and are concerned that this can be done without any form of triage or assessment by a clinically qualified person.
30. We are not clear whether the delay was in passing the message from the operator to the box controller, or was by the box controller, but we would recommend that the duty doctor should always be made aware of requests for visits promptly and without undue delay. The delay of in excess of an hour does not in our opinion reach an acceptable standard.
31. We do not feel that an assessment by a lay person is appropriate and would point out that alcohol can mask features of serious disease and should never be taken as a reason to delay a call. When excessive alcohol has been taken (which was not the case here) assessment can be all the more difficult and require additional prudence and care.
Back to top Further delay of 40 minutes by the deputising doctor
32. The deputising doctor received the call from his driver on returning to his vehicle along with three others and prioritised the calls, placing Mrs H's second after chest pain in a known cardiac patient. We consider that that was an appropriate prioritisation.
33. Despite the volume of work on that night the deputising doctor reached Mrs H within 40 minutes of his being made aware of her visit request and this was in our opinion acceptable given the clinical details.
34. We have considered the matter of whether the deputising service's resources that night were adequate for the volume of calls and note that a back up doctor was available, and also that subscriber call-out could be activated if the volume of work exceeded safe margins. Although the night in question was unusually busy with 16 calls, we do not consider that the ensuing delays were such as to warrant activation of these back-up systems although we were pleased to note that they were available and that the deputising doctor was aware of this.
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Management offered on the first consultation
35. The issue in question is not an expectation of the deputising doctor making diagnosis of a very rare condition (sigmoid volvulus) but rather whether he performed an assessment which was adequate and would allow him to recognize an acute abdomen requiring admission to hospital.
36. We note that his assessment was lengthy and that he spent 38 minutes with Mrs H, first administering diamorphine to settle her so as to allow him to examine her. He then made a diagnosis of pyelonephritis without urine analysis, but on the basis of vomiting, radiating abdominal pain, renal tenderness and fever, with no signs of bowel problems.
37. He should ideally have tested her urine to obtain support for his diagnosis and did not do so because he did not have appropriate testing strips. We are of the opinion that such strips should be carried but do not consider that, had he been able to test her urine, the findings would have led to rejection of the diagnosis. Centrally he did examine her abdomen and did not at this early stage find signs referable to her bowels nor indications of the need for urgent surgical treatment.
38. The deputising doctor states that he invited Mrs H to call again if concerned and his note has a mark in the relevant box. It is contested that such advice was given. However Mrs H did in any event call again a few hours later and so it may be that little turns on this factual dispute.
Back to top 39. Mrs H telephoned again at 5.34am and her call was promptly passed on, the deputising doctor calling her back within four minutes of his receiving the call. It is our view that it was appropriate that her call was passed to the deputising doctor who had recently seen and examined her.
40. It is agreed that he advised that she could attend Accident and Emergency and she did so. According to Mr K's account the hospital referral was because the deputising doctor had run out of diamorphine, whereas the deputising doctor says it was also because he was unsure of the diagnosis given the progression of symptoms which were more bowel orientated at the time of this call.
41. We did consider that the decision to refer her to hospital was reasonable on the basis of failure to improve, and whilst it would be acceptable for him to have first visited her, the decision to refer her without the delay that a visit would cause was equally acceptable and in the event saved time.
42. The deputising doctor did not keep a controlled drugs register at the time, though he does now. This lack of a register is not acceptable, as it is a legal requirement. His failure in that respect is below an acceptable standard of clinical practice.
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Conclusions and Recommendations
43. We recommend that the deputising service review their office procedures to ensure that messages are passed to the duty doctor without delay so that a clinical assessment as to the urgency of calls can be made by a clinically qualified person. The only acceptable alternative would be if a clinically qualified person (doctor or nurse) triages (assesses) calls and affords priority. We would suggest that it is not appropriate that lay operators be permitted to decide that delay is safe and appropriate as they cannot have the required knowledge to determine this safely.
44. Whilst we are not critical of the deputising doctor's standard of treatment, his failure to maintain a register of controlled drugs is indefensible. We note that he now does so. We would also suggest that simple urine testing strips are an essential part of his out of hours equipment and he should ensure he carried sufficient of these when he begins duty.
45. We appreciate the necessity of only carrying minimal quantities of drugs prone to abuse such as diamorphine, and whilst it is regrettable that circumstances led the deputising doctor to run out on the night in question we are not critical of this aspect of the case.
Back to top Findings
Complaint (a) There was an unacceptable delay between Mrs H's telephone calls and the deputising doctor's visit
46. Mrs H made two telephone calls to the deputising service at about 1.40am but the deputising doctor did not visit her until around 3.50am, after Mrs H had made a further call to the service (paragraphs 13-16). I begin by considering the delay in the deputising doctor receiving details of Mrs H's first telephone calls. According to their records, the deputising service took Mrs H's first telephone call at 1.42am (presumably the time of the end of the second of the two calls she made in quick succession), but there is no evidence of any attempt to pass it to the doctor until around 2.50am, a delay of well over an hour. I have not been able to establish with any certainty why it took so long for the call to be passed to the doctor, but it seems likely that the box controller held it back because the doctor had a number of other calls to deal with. It is also possible that the staff were, wrongly, influenced by the mention that Mrs H had had some alcohol. The independent assessors have expressed concern that that decision was taken by staff who were not clinically qualified and that the doctor was prevented from making a judgment at an early stage about which of the callers he should see first (paragraph 31). I share their concern that Mrs H's call was held back, given her obvious distress and the fact that she reported symptoms which, according to the deputising service's own guidance, should have been treated as urgent. I note that, since Mr K's complaint, the deputising service's local medical director has reminded operators of the need to pass calls to doctors or their drivers as quickly as possible (paragraph 24). I welcome that.
47. What of the further delay of 40 minutes between the deputising doctor receiving details of Mrs H's call and his visiting her? Mrs H's was one of four calls which were passed to the doctor at the same time. He decided to visit her second, after seeing a patient with a history of heart problems who had reported chest pains. The deputising service's guidance lists both chest pain and abdominal pain as symptoms which should be treated as urgent (paragraph 8).The independent assessors have concluded that the doctor's decision to prioritise the call from the patient with chest pains was reasonable (paragraph 32). I accept that. In summary then, I criticise the deputising service for the delay in passing Mrs H's call to the doctor, but I find that, on receiving details of the call, the deputising doctor responded within a reasonable time. I uphold the complaint against the deputising service to the extent described above. I do not hold Mrs H's GP responsible for the administrative delay by deputising service, and do not uphold the complaint about him.
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Complaint (b) The treatment provided to Mrs H by the deputising service on her GP's behalf was inadequate
48. Mr K has complained that the deputising doctor's treatment was inadequate. The sigmoid volvulus from which Mrs H was suffering and which later required surgery, is a rare condition. The question for me is not whether the doctor should have reached that particular diagnosis, (I have no doubt that that would be an unreasonable expectation) but whether the assessment he carried out was adequate (paragraph 35). The assessors found that, crucially, the doctor had examined Mrs H's abdomen and had, at that time, found no clear signs of a problem with her bowels and no urgent need for surgical treatment (paragraph 37). They considered that the doctor should have tested Mrs H's urine in support of his diagnosis of pyelonephritis, and that he should have been carrying testing strips to enable him to do that. They also criticise his lack of a controlled drugs register. However neither of those failings appear to have affected the assessment and diagnosis significantly. I note that the doctor does now maintain a register and commend the advice of the assessors that he should carry simple urine testing strips. The assessors concluded that, in the other and significant respects, the deputising doctor's assessment had been adequate and his care reasonable. I agree.
49. The deputising doctor has said that, before he left Mrs H he told her that, if her symptoms did not subside, she should call the deputising service again. The doctor marked the relevant box on the form. Mrs H has said that he did not tell her to call again. I am not able to reconcile those conflicting accounts. As the assessors point out, in view of the fact that Mrs H did telephone the deputising service again, the disagreement on that point is not crucial (paragraph 38). The assessors have also found that the doctor acted reasonably when, after Mrs H called the deputising service again at 5.45am, rather than visiting her again he called her back and suggested she should go to hospital (paragraph 41). In summary then, I do not find that the deputising doctor's treatment of Mrs H was inadequate. I do not uphold that part of the complaint against either the deputising service or Mrs H's GP.
Conclusion
50. I have set out my findings in paragraphs 46 to 49. Healthcall Services Limited have asked me to convey through my report—as I do—their apologies to Mr K and Mrs H for the shortcomings which I have identified.
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