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Part II—Full Text of Selected Cases

Case no. E.166/01-02 GP's failure to provide adequate care and treatment and to respond to the recommendations of an IR Panel

Complaint against: A GP in the Essex Health Authority area

Complaint as put by Mrs E

1. The account of the complaint provided by Mrs E was that she visited her former husband, Mr E, (then aged 75) in his sheltered accommodation on Saturday 3 July 1999. Mrs E was concerned about Mr E as she found him in bed, unable to pass urine. Mr E had been suffering from urinary problems and lower back pain radiating down his legs for about 12 months. Mrs E telephoned Mr E’s GP, Dr R, but there was no reply and no answerphone was activated. Mrs E then contacted a local authority support service that took over when the warden of the sheltered accommodation was off duty. Mrs E requested an ambulance and when it arrived the crew told her that Mr E needed a referral letter from a GP to be admitted to hospital. They advised her to contact the on call doctor. Mrs E did this and was told the on call doctor was Dr R and he would arrive in about 30 minutes. No doctor arrived so Mrs E rang ambulance control, who tried to contact Dr R but were unable to as his mobile telephone was switched off. Another doctor (the second GP) was therefore asked to visit and arrived at the same time as Dr R. The second doctor left and Mrs E explained that Mr E needed to go to hospital. Dr R did not examine Mr E and was reluctant to contact the hospital. When, at her insistence he did so, there were no beds available and Dr R suggested contacting the hospital again in the morning. Mrs E felt Mr E’s condition was too serious to leave and further contact with the hospital resulted in a bed being available. Dr R arranged for Mr E’s admission where it was confirmed he was suffering from urinary retention with incontinence due to overflow of urine from the bladder. On 5 July Mrs E complained to Dr R via South Essex Health Authority about the difficulties she experienced trying to contact him and the time it took him to visit Mr E on 3 July; his failure to examine Mr E and his reluctance to arrange for Mr E to be admitted to hospital. Mrs E remained unhappy with the responses to her complaints and was granted an independent review (IR). The IR took place in March 2000 and it made a number of recommendations in relation to Dr R’s contact arrangements and record keeping. The Health Authority later contacted Dr R on several occasions enquiring about the action he planned to take in response to the panel’s findings, but Dr R did not respond. Mrs E remained dissatisfied.

2. The matters investigated were that:

(a) on 3 July 1999, Dr R failed to provide Mr E with adequate care and treatment; and

(b) that Dr R failed to respond to the recommendations of the IR panel.

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Investigation

3. The statement of complaint for the investigation was issued on 30 July 2001. Dr R’s comments were obtained and relevant documents, including clinical records and taped telephone conversations provided by Essex Ambulance Service NHS Trust (the Ambulance Trust), were examined. The Ombudsman’s investigating officer took evidence from Mrs E, Dr R and the Practice Receptionist and Acting Practice Manager (the Receptionist). Two professional assessors, both general practitioners, were appointed to advise on the clinical issues in this case and their report is attached as an annex. 

Legislation and guidance

4. 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 and medical services of the type usually provided by medical practitioners. (2) The services which a doctor is required by sub-paragraph (1) to render shall include the following: … (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, for the provision of any other services under the Act …’

5. Guidance to doctors on good medical practice, issued in 1995 by the General Medical Council (GMC), includes:

‘…You must take suitable and prompt action when necessary. This must include:

an adequate assessment of the patient’s condition, based on the history and clinical signs including, where necessary, an appropriate examination;

providing or arranging investigations or treatment where necessary;

referring the patient to another practitioner, when indicated …’

The GMC’s guidance also includes:

‘In providing care you must … keep clear, accurate, legible and contemporaneous patient records which report the relevant clinical findings, the decisions made, the information given to patients and any drugs or other treatment prescribed.’

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Mrs E’s evidence 

6. Mrs E, a retired nurse, explained that she was divorced from Mr E about 30 years ago, but had maintained contact with him. She saw him occasionally at family events and sometimes he visited her home. In the last couple of years Mr E had stopped visiting because of being incontinent and the difficulties this created. Mrs E said her son and daughter visited him regularly and often found him in quite a state because of the incontinence.

7. Mrs E made an impromptu visit to Mr E on Saturday 3 July 1999 as she knew her daughter, who visited him regularly, was away. Mrs E arrived at his flat sometime in the late afternoon but there was no reply when she rang the door bell. After some time Mr E managed to get to the door but only after considerable encouragement and coaxing from Mrs E. Mr E was in a great deal of pain and could not stand up. It took considerable effort but eventually Mrs E helped him into bed and gave him paracetamol and a hot water bottle. Mrs E could not recall the exact sequence of events but thought she then rang a local authority support service and requested an ambulance.

8. An ambulance crew attended and advised that a doctor’s letter of referral would be required for Mr E to be admitted to hospital. The ambulance crew contacted their control room who then contacted the duty doctor who was Dr R. Mrs E recalled the ambulance crew telling her Dr R would be there in about half an hour. 

9. Mrs E waited but Dr R did not arrive. She tried to telephone Dr R’s surgery but there was no answer and no answering machine message came on. Mrs E did not have Dr R’s mobile telephone number. It was almost three hours before Dr R arrived and Mrs E could not recall exactly what happened during that time. She said the Ambulance Trust were very good and called her several times to check what was happening. At one point the Ambulance Trust told Mrs E they had tried to contact Dr R but his mobile telephone was switched off. During the time she waited for Dr R to arrive, Mr E settled but was very confused and at times became agitated, almost to the point of being delirious. Because of her nursing experience Mrs E knew he was suffering from water retention and needed to be catheterised. 

10. When Dr R arrived at about 8.30pm he did not speak to Mrs E and went into the bedroom where he asked Mr E how he felt. Mr E was half asleep but replied, ‘Dreadful’. Dr R stood away from Mr E at the end of the bed, he did not ask any further questions or carry out any examination. He then left the bedroom and went into the lounge. At that point the second GP arrived, requested by the Ambulance Trust when they were unable to contact Dr R. After a brief conversation with Dr R, the second GP left. Dr R stayed in the lounge and was silent. There was an awkward atmosphere so Mrs E asked him for a referral letter to admit Mr E to hospital. Dr R telephoned the hospital and Mrs E heard him repeatedly refer to Mr E as being incontinent. She knew this was not correct and that the hospital would not be able to provide a bed on that basis. When Dr R finished the call he told her there was no bed and someone would visit in the morning to assess Mr E. Mrs E explained she was Mr E’s ex-wife and could not stay the night. Mrs E insisted Dr R arrange for Mr E to be admitted and said if he did not, she would contact the hospital herself. There was further contact with the hospital and Dr R asked for a piece of paper to write a referral letter. He made arrangements for Mr E to be taken to hospital by ambulance and left the flat. 

11. Mrs E was absolutely certain that Dr R did not examine Mr E during the time he was in the flat as she did not leave him alone at any time. When the second GP arrived, the front door was open as it was a warm evening and he came in without Mrs E needing to go to the door. 

Dr R’s response to the complaint

12. In response to the statement of complaint, Dr R wrote a letter to the Ombudsman dated 30 September 2001 and stated: 

‘As far as I know [Mr E’s] urinary problems were reported in mid June … I discussed the position with him and asked him to come to the surgery for some blood tests and rectal examination. I also referred his case to the [incontinence] Nurse who was visiting him regularly. He was unable to come to the surgery and as far as I remember on Friday 2nd June [1999] [the Nurse] advised me to refer his case to hospital. On Saturday 3rd July I had a phone call from the ambulance services head office and advised that [Mr E] be taken to hospital. As I was unable to attend immediately I was told by the ambulance department that the patient did not want to go to hospital, and would I kindly visit at some time. Normally if the ambulance attendants think a patient needs to attend hospital they take them. In this particular case I cannot explain why they did not take him. I visited him as soon as I was able and found him lying in bed which was soaked with urine. I carried out the necessary examination and immediately spoke to the hospital for admission. They did not have a bed available but promised to admit him as soon as a bed became available. I was discussing the next step with [Mrs E] when I received a telephone call from the hospital (within 15 minutes) to the effect that they now had a bed for him.’

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Taped evidence

13. A tape containing eleven calls relating to Mr E was provided by the Ambulance Trust (AT). These are summarised below.

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Documentary evidence

14. The referral letter Dr R wrote on 3 July for Mr E to take to A&E was obtained from the hospital records. It says:

‘Dear Doctor

[Mr E] 23-10-23

I am very, very sorry that this silly problem dropped on to you. Ambulance man refused to carry him to A&E Centre in the first place. I tried to admit him in Geriatric Dept. They have no bed. This poor fellow has nobody to look after him through the night. Ex-wife wants him to be admitted. By the way he is incontinent.

Medication …

Thank you for your help.

[Dr R] 3-7-99.’

15. The hospital records show that Mr E was examined at 10.00pm and was found to be suffering from urinary retention. A catheter was inserted. Mr E’s GP medical records contain no reference to Dr R’s visit on 3 July, but include an entry dated 4 July which says ‘In hospital’.

Dr R’s evidence

16. Dr R said Mr E registered with the surgery in May 1997 and Dr R had a lot of contact with him. Mr E was lonely and isolated so Dr R told him he could telephone at any time. Dr R said they had a friendly relationship and he was happy to spend time with Mr E discussing shared interests. Dr R said Mr E’s health was poor, he was confused and depressed. Mr E never visited the surgery but Dr R made frequent home visits, on average two or three a month.

17. At about 5.30pm on 3 July 1999, Dr R was contacted on his mobile telephone by the Ambulance Trust and asked to visit Mr E. He recalled being told that an ambulance crew was on the scene; that Mr E had collapsed and that he did not want to go to hospital. Dr R said he told the Ambulance Trust it would be at least an hour before he could get there. Dr R said it was almost three hours before he was able to visit Mr E and that he was surprised to find Mr E was still at homehe thought the ambulance crew would have taken him to hospital. Dr R did not have Mr E’s telephone number with him so was unable to get in touch to say he was delayed.

18. Dr R said he found Mr E lying in bed soaked in urine. Mr E was drowsy and could not converse. Mrs E told Dr R Mr E was in pain and there was no one to look after him. Dr R said he carried out a superficial examination of the patient as he knew from the moment he saw Mr E he would need to go to hospital. Dr R said he put his hand on Mr E’s abdomen but could not feel his bladder and diagnosed a bladder disorder. Dr R was very concerned about Mr E’s general condition and the fact he had no one to look after him.

19. Dr R did not know why Mrs E said he did not examine Mr E and was reluctant to arrange for him to go to hospital. When Dr R first contacted the hospital there were no beds available but they then telephoned back to say there was a bed. Dr R called for an ambulance and wrote a referral letter. Dr R did not keep a copy of the letter but said his normal practice was to give the patient’s details, list the current medication and say that he had examined the patient and give his diagnosis. Dr R said he would have written that he had examined Mr E and that he had a bladder disorder.

20. In relation to his out-of-hours contact arrangements, Dr R explained that the surgery telephone had an answering machine that was switched on by the last person to leave the surgery. He said staff automatically put the answering machine on and he was not aware of any occasions when this was not done. The message on the answering machine gave several pieces of information including Dr R’s mobile telephone number. Dr R did not know why Mrs E had not heard the answering machine message when she rang the surgery on 3 July. He was aware that the Ambulance Trust contacted him without difficulty in the late afternoon, so wondered if Mrs E had dialled the wrong number.

21. Dr R was then, and continues to be, a casual subscriber to a GP deputising service. The recorded message at the time of the complaint gave his mobile telephone number and also the telephone number for the deputising service. Sometimes the hours patients were asked to contact the deputising service changed, and if Dr R was away a locum’s telephone number was given. Dr R said the arrangements worked satisfactorily so it was not necessary for him to have a pager or any other back-up arrangements. Apart from one or two complaints, there were no problems with the arrangements.

22. Dr R said that very occasionally there were problems with his mobile telephone when callers would hear a message saying the telephone was switched off even when it was not. Dr R learned that the message was activated even when the line was busy. To overcome this problem Dr R sometimes recorded a message telling patients that if they could not get hold of him, to wait half an hour and try again. At the time of the complaint, Dr R said his mobile telephone had been ‘cloned’. He only became aware of it when he received a huge bill listing calls that he had not made. Following that he bought a new mobile telephone. He said that he did not get many calls and as the arrangements generally worked he thought they were acceptable.

23. Dr R said details of home visits were usually entered in the patient’s notes the next day and he was confident the visits he made to Mr E would have been entered in his records. Dr R said anything in the notes in his handwriting indicated a home visit as Mr E never attended the surgery. However when shown a copy of Mr E’s records Dr R confirmed there were no home visits noted during the months prior to Mr E’s hospital admission in July 1999. The last entry in the notes in Dr R’s handwriting was on 9 November 1998. There was no entry in Mr E’s record for 3 July 1999. Dr R was unsure why that was the case. He thought it may have been because he went on holiday on 5 July and did not return to the surgery after seeing Mr E and before he left for holiday.

The Receptionist’s evidence

24. The Receptionist could not recall the exact out-of-hours contact arrangements current at the time of events in this case. She recalled that the answering machine message gave Dr R’s mobile telephone number and as far as she could recall, he was available almost 24 hours a day. If Dr R was away, other doctors covered for him and their numbers were given in the message. The answering machine message had to be switched on by the last person to leave the surgery. The Receptionist was aware that there had been occasions when the answering machine had not been switched on. The Receptionist did not know if that was the case on 3 July 1999 when Mrs E tried to ring the surgery and did not receive a reply. 

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Findings (a)

25. Mrs E has complained about the care and treatment provided by Dr R on Saturday 3 July 1999. In particular, she was concerned about the length of time it took Dr R to attend and that Dr R failed to carry out a proper assessment of Mr E when he arrived. In reaching my findings, I have taken account of the report of the independent clinical assessors (see annex).

26. I begin by considering the requests to Dr R to visit Mr E and Dr R’s out-of-hours contact arrangements. Dr R was called to see Mr E by the Ambulance Trust shortly after 5.30pm that day. The Ambulance Trust initially contacted his surgery and, after hearing the message on his answering machine, contacted Dr R himself on his mobile telephone. Dr R said he would visit Mr E. When he had still not arrived after almost two hours, Mrs E says that she tried to contact him but, for reasons I have not been able to establish, received no answer at the surgery. After she contacted the Ambulance Trust again, they telephoned Dr R on his mobile telephone, but simply heard a recorded message telling them that the telephone was switched off. 

27. Dr R’s arrangements for patients to contact him outside of surgery hours were to leave a message on the surgery answering machine giving several other telephone numbers which the patient could call. The first number given was that of NHS Direct, a telephone advice service, then Dr R’s own mobile telephone number. He has said that when he was using the deputising service, the recorded message would also give their number. Dr R has said that these arrangements normally worked satisfactorily, but that they fell down because, around the time when he was called to see Mr E, his mobile telephone had been ‘cloned’. The assessors have said that Dr R’s out-of-hours contact arrangements were inadequate in a number of respects. The system relied on staff switching on the answering machine before they left the surgery. The Receptionist said (paragraph 24) that there had been occasions when they forgot to do that (although the fact that the Ambulance Trust got through to the answering machine shows that it was activated on 3 July 1999). 

28. The answering machine message gave several telephone numbers which the caller could use to obtain advice or contact a doctor. The assessors have commented that there was a lot of information for the caller to take in in that message. I agree that that message was confusing. Generally speaking, it is better for answering machine messages to be short and simple, giving clear and reliable instructions for contacting a doctor when the surgery is closed. The assessors have also commented that it was inappropriate for Dr R to give his mobile telephone number as a second line of contact. As this case illustrates, mobile telephones are not always reliable and if, as in this case, the caller was not able to get through to the doctor, it was not clear what they should do. Further, it is not acceptable for callers to simply hear a message telling them to call back in half an hour. There will be occasions when callers will need advice from a doctor more quickly than that.

29. I turn next to the length of time it took Dr R to visit Mr E. The Ambulance Trust contacted Dr R at 5.37pm and asked him to visit Mr E. Dr R said that he would not be able to get there for at least an hour. In fact, he did not arrive until almost three hours later after the Ambulance Trust tried to contact him again, and another doctor had been called. The assessors have said that that was too long, given Mr E’s age, his medical condition, and the fact that, as the Ambulance Trust had told Dr R, he had collapsed. Further, from the information Dr R was given by the Ambulance Trust, it appeared that Mr E was alone at home. In the circumstances, it was completely unacceptable to delay so long in visiting without at least checking on Mr E’s condition.

30. What of Dr R’s actions when he did arrive? Mrs E has said that Dr R did not examine Mr E. Dr R on the other hand says that he examined Mr E’s abdomen, but could not feel his bladder. He thought that Mr E was incontinent due to a ‘bladder disorder’. When Mr E was examined in hospital an hour and a half later he was found to be suffering from overflow incontinence due to urine retention, and to require a catheter. The assessors have said that, in the circumstances, had Dr R examined Mr E he would have felt that his bladder was enlarged at that time. They have also said that, in that situation, it would have been appropriate to have checked Mr E’s blood pressure and chest, as well as carrying out a full abdominal examination. Indeed, Dr R’s referral letter (paragraph 14) gives no hint that he had examined Mr E. On the basis of the assessors’ advice, I must conclude that Dr R did not carry out an adequate examination when he saw Mr E.

31. Dr R and Mrs E also disagree about the arrangements for Mr E’s admission to hospital. Mrs E has said that Dr R only asked for Mr E to be admitted at her insistence. Dr R has said that he realised immediately that Mr E needed to go to hospital, but initially the hospital said they did not have a bed available. Whatever actually happened, I am satisfied that Dr R ultimately took appropriate action in referring Mr E to hospital. However, the assessors have expressed concerns about Dr R’s referral letter (paragraph 14). In particular, that letter suggests that the reason for referral was social rather than medical (ie there was no one to look after Mr E at home) and Mr E’s incontinence was mentioned almost as an afterthought. There was no mention of a likely cause and, as I have commented above, no reference to any findings on examination. That letter would not have been helpful to the doctors admitting Mr E to hospital. The assessors have also commented on the fact that Dr R did not record his visit to Mr E that day in Mr E’s medical records, nor had he recorded a number of other visits which he said he had made to Mr E in the preceding weeks. As the GMC’s guidance makes clear (paragraph 5) proper record keeping is required of every doctor and is an important part of continuity of patient care. 

32. The assessors have criticised Dr R’s contact arrangements, the delay in his visiting Mr E, his failure to examine Mr E properly and inadequacies in his referral letter and record keeping. On the basis of their advice, it is clear that the care Dr R provided on 3 July 1999 fell far short of the standard Mr E was entitled to expect. I uphold the complaint. In their report the assessors have made a number of recommendations relating to Dr R’s practice. I recommend that, as a matter of urgency, Dr R takes advice from the clinical governance lead of his local primary care organisation with a view to forming, implementing and then monitoring an action plan to implement the assessors’ suggestions.

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Complaint (b) that Dr R failed to respond to the recommendations of the IR panel

Documentary evidence

33. An IR of Mrs E’s complaint took place on 23 March 2000. Although the panel did not criticise the standard of care provided to Mr E on 3 July 1999, they criticised Dr R’s contact arrangements and record keeping. Their report included:

‘The Panel were not impressed by [Dr R’s] contact procedures. He needs to ensure that the details of how to contact him are on the surgery answerphone and that this system is automatically triggered when the surgery is closed … it was considered that he should have a more secure phone, and a bleeper message taker to ensure he can always be contacted.

‘…

‘The standard of note keeping was not considered adequate …The Panel considered that the doctor should review his present arrangements, and set up a satisfactory system of note taking and keeping.’

34. The Health Authority sent the panel’s report to Dr R on 6 July 2000. On 22 September the Health Authority wrote to Dr R asking what action he had taken in response to the panel’s recommendations. They asked him to reply within 28 days. Having received no response, the Health Authority wrote to Dr R again on 9 November. They sent him further letters on 6 March and 15 June 2001, once again asking him to respond within 28 days. The Health Authority wrote to Dr R again on 10 October telling him that his failure to respond to their earlier letters would be considered, to decide whether or not to commence disciplinary proceedings against him, as a possible breach of his Terms of Service. Dr R subsequently wrote to the Health Authority in January 2002.

Dr R’s evidence

35. Dr R said that the IR panel’s report contained some inaccuracies i.e. the time of arrival of the second GP on 3 July 1999. However, he accepted the criticisms regarding note taking were fair. He felt the criticisms about his contact arrangements were a bit harsh as on the whole the arrangements worked. Dr R did not discuss the panel’s findings with anyone but had since changed his mobile telephone and made more use of the deputising service. Dr R said he also wrote more details in patients’ notes.

36. Dr R said he had a number of letters from the Health Authority asking about the action he intended to take following the IR. He was in Australia in September 2000 and was then unwell for two weeks at the end of October. He was not sure what arrangements were made to deal with his post in his absence. His wife often collected mail and took it home. However, he was working when the Health Authority wrote to him in March, June and October 2001. Dr R could not explain why he had not responded to the letters but said it was not intentional or deliberate. Dr R said he had not read the letter from the Health Authority dated 10 October 2001. Dr R did not have that letter in his file and said he must have missed it. Dr R said if he had seen it he certainly would have responded.

37. Dr R was aware that it looked as though he had not co-operated with the Health Authority but stressed it was not done deliberately and he was sorry that he had not written back but said he did not realise the matter was quite so serious.

Findings (b)

38. The IR panel made a number of recommendations about Dr R’s practice and those were followed up by the Health Authority. Under complaint (a) above I have considered again the issues on which the IR panel made recommendations. My enquiries about Dr R’s practice since the panel reported have shown that he has made a number of changes to his contact arrangements, including making more use of the deputising service and buying a new mobile telephone. He has also said that he has improved his record keeping. However, Dr R failed to respond to the Authority’s requests for information, despite being sent five letters over a period of 11 months. This meant that although Mrs E’s complaint had been investigated and aspects of Dr R’s practice found to be wanting, she was not informed of the ultimate outcome. That was wholly unsatisfactory. In the course of this investigation Dr R was unable to provide an adequate explanation for his failure to reply. Indeed, by his own account, he did not do so because he did not believe that the panel’s recommendations were a serious matter. I uphold the complaint. 

39. I have made further recommendations above (paragraph 32) about Dr R’s practice in the areas criticised by the IR panel. I have also sent a copy of this report to Essex Health Authority. I hope that Dr R will seek their support in implementing my recommendations. I also recommend that Dr R write to Mrs E to apologise personally for the shortcomings I have identified and to tell her what he has done to address them. 

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Conclusions

40. I have set out my findings in paragraphs 25 to 32 and 38 and 39. Dr R has asked me to convey – as I do through my report – his apologies to Mrs E for the shortcomings I have identified and has agreed to implement the recommendations in paragraphs 32 and 39. 

Annex to E.166/01-02

Report by the Professional Assessors to the Health Service Ombudsman for England of the clinical judgments of the GP involved in the complaint made by Mrs E

In producing this report we have considered copies of:

• the Ombudsman’s statement of complaint;

• Mr E’s medical records;

• background papers including the report of an IR panel held on 23 March 2000;

• transcripts of telephone conversations which took place on 3 July 1999 from the Ambulance Trust;

• interview notes;

• Dr R’s formal response to the Ombudsman.

Background

1. Mr E joined Dr R’s list in 1997 aged 73. He had a history of general deterioration in his mobility, hypertension, mild Parkinson’s disease and depression. He lived alone in sheltered accommodation. Dr R thought Mr E was isolated and needed a higher level of support. Dr R said Mr E was more like a friend and they enjoyed talking together. Dr R felt Mr E was a lonely man so said he could call him at any time. As a result Dr R said Mr E telephoned the surgery regularly, often two or three times a week. Mr E was not able to attend the surgery so Dr R visited him at home when requested, sometimes two or three times a month.

2. Approximately a month before 3 July 1999, Dr R said he visited Mr E as he was experiencing incontinence. Dr R said he did not examine Mr E but advised him to attend the surgery for a full examination including rectal examination, and to have blood tests. Dr R said he thought the most likely cause of Mr E’s incontinence was a prostate problem but he did not feel the home environment was appropriate to conduct the required examination. A referral to the Continence Advisory Service was made on 28 May and pads and bed covers were supplied.

Events of 3 July 1999

3. Dr R was on duty when he received a telephone call from the Ambulance Trust at 17.37 hours on 3 July 1999 requesting him to visit Mr E. This call was made as a result of an ambulance crew attending Mr E at 17.31 hours and requesting a GP visit. The transcript of the telephone conversation between the Ambulance Trust and Dr R shows that Dr R was told that Mr E had collapsed; that he did not want to go to hospital and that the ambulance crew wanted a doctor to visit. He was not told that Mrs E, or indeed anyone, was with him. Dr R accepted the call but said it would be at least an hour before he could visit. He said he knew the patient well and the ambulance crew could leave, his words were, ‘let them go, let them go, don’t worry about it, I know him very well’.

4. The transcript of the next conversation between the control room and the crew who were still with Mr E shows that they were told it would be at least an hour before Dr R could visit and that they could leave.

Mrs E said the ambulance crew told her Dr R would visit in about half an hour, but having seen the transcripts of the telephone conversations, it is not clear why they would have said that.

6. After waiting for almost two hours Mrs E contacted the Ambulance Trust as Dr R had not arrived. It was possibly during this time that Mrs E attempted to contact Dr R’s surgery and got no response. The telephone conversation transcripts are very helpful and show that at 19.42 hours ambulance control contacted Dr R’s surgery and an answerphone message gave his mobile telephone number. When they rang the mobile telephone number they heard a recorded message saying that the telephone was switched off. Ambulance control then contacted the deputising service who also tried Dr R’s mobile telephone and got the same ‘phone switched off’ message. The deputising service then arranged for the second GP to visit. Both Dr R and the second GP arrived at the flat at about the same time, around 20.30 hours.

7. Dr R confirmed in interview that he did not contact Mr E in the period between receiving the request to visit and attending, either to obtain more information about Mr E’s condition or explain his delay.

8. When Dr R arrived at Mr E’s flat he found him in bed, soaked in urine. Exactly what took place cannot be established and there is dispute as to whether an examination took place. Mrs E said she was present the whole time and did not see Dr R carry out any examination. Dr R said he conducted a superficial examination in that he put his hand on Mr E’s abdomen but could not feel the bladder. Dr R said his reason for this was that he knew from the moment he saw Mr E he would need to be admitted to hospital as he was generally in a poor state. Dr R’s assessment was that Mr E had a bladder disorder even though he did not have a full bladder. He felt Mr E needed to be admitted to hospital for social as much as medical reasons. Dr R liaised with the hospital and Ambulance Trust to arrange admission and wrote a referral letter before leaving Mr E.

Comment

When Dr R accepted the call from the Ambulance Trust at 17.37 hours he was given very little information about Mr E’s condition. He was told that an ambulance crew was with Mr E and they were requesting a GP visit. Most doctors would assume from this that the ambulance crew’s assessment was that immediate hospital treatment/admission was not essential. The request for a GP visit however would indicate a certain level of concern. Dr R was also told that Mr E did not want to go to hospital which meant that it could not be assumed that Mr E’s condition was not serious.

The acceptable amount of time it takes to attend a patient following an out-of-hours call depends on a number of factors. The condition of the patient is however paramount and most GPs would aim to see a patient of Mr E’s age, medical history and reported as having collapsed, within one to two hours. If there was a delay in attending, most GPs would also make contact with the patient or those at the scene, to obtain up to the minute information, offer telephone advice and give a time when they expected to be there. Dr R said he did not have Mr E’s telephone number with him and this was the reason he did not make contact. This is inexcusable as Dr R could have obtained Mr E’s number from the Ambulance Trust who contacted him initially. Bearing in mind that as far as Dr R was aware Mr E was alone, a delay of almost three hours to attend was not acceptable. Equally, given those details, Dr R’s failure to make contact with Mr E during the time before he was able to visit was also unacceptable and his explanation for not doing so totally inadequate.

11. Faced with a patient in Mr E’s condition, the majority of GPs would have taken the patient’s blood pressure and carried out a chest examination to exclude a chest infection. In addition, a full abdominal examination would have been performed to establish the status of the bladder. It is our view that Dr R could not have examined Mr E’s abdomen because if he had, he would have noted an enlarged bladder. When Mr E was examined in hospital one and a half hours later, he was found to have a full bladder and an enlarged prostate that was causing urine retention with overflow. This condition was clearly well established and it seems certain that the full bladder would have been evident when Dr R saw him.

12. The referral letter written by Dr R made no reference to his diagnosis other than ‘not coping’ and a reference to Mr E being incontinent, appears to be something of an afterthought. Mrs E also said she heard Dr R say several times when he was on the telephone to the hospital that Mr E was incontinent. This was not the appropriate way to describe Mr E’s condition. We recognise that given Mr E’s social circumstances, hospital admission was inevitable but he was also in need of urgent medical attention which Dr R had not established because he had not carried out an adequate examination of the patient.

Conclusion

13. This investigation looked at the care and treatment provided by Dr R on 3 July 1999. As it was a Saturday he was only contactable through his out-of-hours arrangements. Dr R’s out-of-hours contact arrangements were therefore part of the care provided. They also had an impact on events on 3 July as both the Ambulance Trust and the deputising service unsuccessfully tried to contact him at around 19.45 hours and as a result, another GP was requested to visit Mr E, which subsequently proved to be unnecessary. GPs have a duty of care to their patients to have appropriate out-of-hours contact arrangements. Mrs E complained that she could not contact Dr R via the surgery although there is evidence that the surgery’s answering machine was operating as it was activated by the Ambulance Trust shortly after 17.30 hours and again at 19.42 hours. We were able to see a transcript of the message on the answering machine. It was lengthy and gave three pieces of information and three telephone numbers – NHS Direct, Dr R’s mobile and the deputising service. Dr R could only be reached on his mobile telephone and this is not recommended good practice. It is common practice for GPs to use an answering machine as the first point of contact for out-of-hours calls. However the use of mobile telephones as the second means of contact is not acceptable, as they are notoriously unreliable. A fixed landline with an answering service or transfer to the doctor’s home, is the contact method used by most GPs.

14. We note that Dr R’s contact arrangements were criticised by the IR Panel which considered Mrs E’s complaint and recommended that he improve his contact arrangements. Dr R continued to use a mobile telephone and, somewhat naively in our view, seemed to think that this was acceptable. We believe this is not acceptable practice and represents a failure to meet his basic obligations as a GP.

15. In relation to the time it took for Dr R to visit Mr E and his failure to attempt to make contact when he was delayed, as explained above, we believe Dr R’s actions fell short of what the patient had every right to expect.

16. In relation to what took place when Dr R was with Mr E, again as explained above, we do not believe he carried out appropriate examinations and correctly diagnosed Mr E’s medical condition. Even though his visit did result in Mr E being admitted to hospital, we feel that he failed to conduct appropriate examinations and provide an adequate standard of care.

17. Overall therefore we are in no doubt that Dr R’s contact arrangements, delay in visiting and conduct during the visit with Mr E on 3 July 1999 was inadequate.

18. In the course of the investigation, we became aware that Dr R’s record keeping was not adequate and that this was criticised by the IR. His failure to record when Mr E reported his incontinence and the details of home visits contravenes GMC guidance that states, ‘A GP must keep clear, accurate and contemporaneous patient records which report the relevant clinical findings, the decisions made, the information given to patients and any drugs or other treatment prescribed.’

19. Dr R failed to respond to the Health Authority in relation to the IR panel’s recommendations and we therefore do not know what action he has taken to improve his note keeping. In view of the way he appears to have disregarded the Health Authority, we hesitate to make further recommendations. However we feel we would be failing in our duty not to offer practical suggestions to assist Dr R to improve his practice and we therefore recommend that he;

a. Improve his record keeping by keeping adequate contemporaneous notes of every patient consultation, telephone message and visit. He should also ensure that a clear written protocol exists for his staff to follow when visit requests are made.

b. The answerphone message is made clearer as to how patients can contact the doctor. The practice of putting multiple telephone numbers on the answerphone causes confusion so the message should be clear and unambiguous.

Dr R immediately improves his out-of-hours contact method by either a back-up procedure using a pager in addition to his mobile phone or a more adequate arrangement with the out-of-hours provider for his area.

d. Dr R apologises to Mrs E for his failure to contact her to ascertain the situation on 3 July and give an indication of the expected visit time.

e. Dr R ensures he carries out adequate examinations of patients and that his referral letters contain pertinent facts.

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Last updated: 6 September 2005