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Selected Investigations Completed October 1997 - March 1998 > Part II, Case no. E.1430/96-97

Part II - Full Texts of Selected Investigations

Case No. E.1430/96-97 - Inadequate hospital care, discharge to care home and handling of complaint

Matters considered: Inadequate care - discharge to wrong type of care home - response to complaint inaccurate and delayed - convener exceeded role and took no clinical advice.

Complaint against: James Paget Hospital NHS Trust, Great Yarmouth

Complaint as put by Mrs X

1. The account of the complaint provided by Mrs X is that on Saturday 22 June 1996 her mother, Mrs Z was in a great deal of pain as she had become unable to swallow the morphine which had been prescribed for her by her general practitioner (the GP). Mrs X contacted a local hospice (the hospice) who told her they had a syringe-driver (a device for administering medicine subcutaneously), which they would provide if authorised to do so by her GP. As the GP's surgery was closed, Mrs X telephoned an emergency number (the out of hours service), explained the situation and that the hospice had offered to help. The out of hours service telephonist (the telephonist) called back and told Mrs X that the GP had said that the family would have to manage over the weekend and to contact him on Monday morning to make an appointment for him to visit Mrs Z. Mrs X asked whether the GP was going to contact the hospice, as she had originally requested. The out of hours service said that they would contact her again about this, but they did not do so. Later that evening Mrs X called out a deputising doctor, who injected her mother with morphine. Mrs Z died on the morning of 23 June. Mrs X complained about the GP. Conciliation was attempted but Mrs X remained dissatisfied. Mrs X requested an independent review; but that was refused by the convener.

2. The matters subject to investigation that the GP:

acted inappropriately in his response to Mrs X's telephone calls to his out of hours answering service; and

failed to make sure that the arrangements to communicate emergency calls to his surgery were adequate.

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3. The summary of complaint for the investigation was issued on 11 March 1997. I obtained the GP's comments and relevant papers were examined. One of my investigators took evidence from Mrs X the GP and staff from the out of hours service involved. I appointed two independent professional assessors to advise me on the clinical issues in this case and their report is attached at appendix A.

Complaints (a) and (b)
The GP acted inappropriately in his response to Mrs X's telephone calls to his answering service and failed to make sure that the arrangements to communicate emergency calls to his surgery were adequate

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 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. The National Health Service (General Medical Services) Amendment Regulations 1995 states: '13(3) Outside normal hours the doctor shall consider, in the light of the patient's medical condition, whether a consultation is needed, and if so, when. (4) If in the doctor's reasonable opinion a consultation is needed before the next time at which the patient could be seen during normal hours, he shall render the relevant services [at] (5)(a) the place where the patient was residing 5(b) such other place as the doctor has agreed to visit and treat the patient'

6. At the time of this complaint The National Health Service (General Medical Services) Regulations 1992, Schedule 2, Terms of Service for doctors, stated: '20 (1) a doctor is responsible for all acts and omissions of (b) any deputising service while acting on his behalf: and (c) any person employed by, or acting on behalf of, him or a deputising service'

7. Guidance to doctors on good medical practice issued in 1995 by The General Medical Council included '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'

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The GP's formal response

8. On 8 March 1997 the GP wrote to my office setting out his formal response to the summary of complaint. He said:

'I visited [Mrs Z] on 17 June 1996 and prescribed oral morphine and because of her difficulty in being able to swallow solid food, prescribed a liquid diet supplement I was bleeped [on 22 June] by the Deputising Service and informed by the receptionist that [Mrs X's] family was asking if they could have a syringe driver I was aware that the only way of obtaining a syringe driver was via an emergency admission to hospital. I was also aware that [Mrs Z] and her family were not keen for her to be admitted to hospital and as the message was not requesting a visit I felt the best course of action was for [Mrs Z] to continue with the treatment I had previously prescribed and for me to visit the following Monday I was totally unaware that [Mrs Z] was not able to swallow her medication and was in pain. Had I known this I would have immediately visited. My understanding was that the family was merely requesting a syringe driver to administer the morphine.

'I am sorry that [Mrs Z] and her family suffered so much distress as a result of poor communication. I believe it is unacceptable that they were placed in this position and that [Mrs X] is justified in raising this issue.'

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Mrs X's evidence

9. In her letter of 24 June 1996 to Wolverhampton Community Health Council (the CHC) Mrs X wrote:

'...My mother's health deteriorated rapidly during the course of the week, until, on the morning of Saturday 22 June, she was incapable of swallowing the morphine prescribed for pain relief. She was in extraordinary pain and was screaming whenever she was moved. I called the hospice and they said that they would provide a syringe-driver and also help administering it, on condition that my mother's GP authorised their intervention. They informed me that a telephone call from [the GP] would be sufficient to procure their services.'

'I telephoned [the GP's] surgery and was given [the number for the out of hours service] as the surgery was closed. I called this number and spoke to [the telephonist] who informed me that it was in fact [the GP] who was on emergency duty that day. I asked if I could speak to [the GP] in order to explain my mother's condition and then explained, to [the telephonist] that my mother was in agonising pain and could no longer take the morphine orally. I also informed [the telephonist] about [the hospice's] offer of help. She said that she would contact [the GP] herself and call me back. When she did call back she told me that [the GP] had said that we would have to manage somehow over the weekend, until Monday, when we were to contact [the GP] in order to make an appointment for him to visit my mother. I asked whether [the GP] was going to contact [the hospice] as I had requested, and reminded [the telephonist] that all they required was a telephone referral in order to obtain their help. [The telephonist] informed me that she would telephone [the GP] again and that she would call me back to confirm his intended actions.'

'Dismayed that neither [the GP] nor his telephonist had attempted to contact us during the course of the afternoon, we then called [the out of hours service] again in the evening, as we were concerned that my mother would not be able to manage during the weekend, and we worried about turning her without pain relief being administered. My mother was visited by a deputising doctor who injected her with morphine. He said that my mother was unconscious and contacted [the hospice] on our behalf. He was told that a referral from my mother's GP was necessary. My mother was unconscious during the night and when we wanted to turn her at 5 am we called in an emergency doctor for fear of inflicting pain during the manoeuvre. This doctor told us that my mother was unconscious and further administration of morphine was unnecessary and that death would occur during the next 24 hours. My mother died at 8.10 am...'

10. Mrs X told my investigator that, when she learnt that it was Mrs Z's GP who was the emergency doctor she said she wanted to speak to him to explain fully the situation. She said that the GP was aware that Mrs Z was against staying in hospital and that her family provided her with all the care and attention she needed. However, had a stay in the hospice been Mrs Z's only means of pain relief then Mrs X would have agreed to it.

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Evidence of staff of the out of hours service

11. The office manager told my investigator that her company provided two services for GPs. The first was a deputising service, when any patient requesting a visit would be visited by the doctor on duty. The second was a message handling service through which the company passed messages from the patients to their GPs, who then should decide how best to respond. Under the latter service, if a patient asked for a visit, this information would be passed to the doctor, or if the patient wanted advice, the doctor would be told this and asked to contact the patient. The message handling service would not pass on any advice from the doctor to the patient.

12. The telephonist who took Mrs X's call on 22 June could not remember what had been discussed. My investigator showed the telephonist the deputising slip that she had completed at the time. As well as including details of the caller and patient, it also states, 'p increase med. 5mg morphine. Advice. syringe driver.' The slip also shows that the telephonist paged the GP at 11.45 am and passed the message to him when he rang back at 12 noon. My investigator read to the telephonist Mrs X's account of her call as recorded in her letter of 24 June to the CHC (paragraph 9 of this report). The telephonist considered that the information written on the deputising slip was in accord with Mrs X's account. The telephonist echoed the office manager's statement that it was not part of a telephonist's duty to pass information to patients from doctors. Doctors are told explicitly that they must speak to patients themselves. That being so, if the GP had said that Mrs Z should continue with the medication over the weekend, the telephonist was clear that she would have told him to ring the patient himself. The GP would have been aware that when covering his own calls as conveyed to him by the message handling service it would have been for him to decide whether a home visit was necessary.

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The GP's evidence

13. The GP told my investigator that he used the out of hours service after surgery as a message handling service between 7pm and 10pm on Mondays to Fridays and until 1pm on Saturdays, and as a deputising service for the rest of the time until surgery. On Saturday, 22 June he was, as usual, covering his own calls until 1pm.

14. He had been Mrs Z's GP for 17 years and considered that he was familiar with her state of health in the weeks before her death. He could not remember clearly his visit of 17 June to Mrs Z and made no entry in her medical notes. He did remember that he prescribed oral morphine because she was in pain and prescribed a liquid diet supplement because she was eating little and was having difficulty digesting food. He was unable to remember whether she was having difficulty swallowing. [I have seen a letter to the GP dated 14 June 1996, from a consultant dermatologist who had visited Mrs Z at home that day. The letter includes '[Mrs Z] is finding it difficult to eat solid food and I wonder whether a dietary supplement may be useful.']

15. On 22 June while he was 'in town' he was contacted by his message handling service and asked if it was possible for Mrs Z to have a syringe-driver. The telephonist did not say that Mrs X wanted him to visit Mrs Z, and he did not ask. It was not common for a patient to request a syringe-driver; and he presumed that the request was made because Mrs Z was still in pain and wanted more treatment. The GP did not contact Mrs X because he asked the telephonist to tell her that Mrs Z would need to be referred to hospital to have a syringe-driver and could not have one at home. As far as he was aware, Mrs Z was still taking oral medication. The GP had offered admission to hospital for Mrs Z in the past, but her family did not want her to go. [The above mentioned letter of 14 June 1997 from a consultant dermatologist (paragraph 14 above) contains the words 'I did offer hospital admission but [Mrs Z] is not happy to come into hospital at present.'] In the case of a different patient with the same information, the GP would still not have visited.

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16. The GP knew that the telephonists employed by the out of hours service have no medical training and are not permitted to give medical advice to patients or families. His understanding, however, was that though they would not personally give medical advice, they would pass on advice given by a doctor. He did not consider that 'continue taking morphine' was medical advice. After receiving Mrs X's complaint he did not contact the out of hours service to discuss it. Although he considered that there had been a breakdown in communication with the service, he did not think he needed to address this, as it had been a 'one off' incident.

Findings (a)

17. In reaching my findings, I have taken into account the report at appendix A prepared by the independent professional assessors I appointed to advise me on the clinical issues involved in this case, in addition to the oral and written evidence I obtained during my investigation.

18. Mrs X's complaint is that the GP acted inappropriately in his response to her calls to his out of hours answering service. I have considered Mrs X's account of these calls, as set out in her letter of 24 June, only two days after the events complained about. The telephonist's brief note of the call Mrs X made to the out of hours service on 22 June states that Mrs Z was experiencing increased pain and that a syringe-driver was being requested. I have no reason to believe that the telephonist did not pass this message to the GP; and indeed he agrees that he received the request for a syringe-driver that day (paragraphs 8 and 15 of this report). The GP told my investigator that, at the time of Mrs X's call, he was using the out of hours service as a message handling service. His responsibility, therefore, was to judge how best to respond.

19. Did the GP respond appropriately to the message given to him by the out of hours service? I do not believe so. I have been advised by independent assessors that a decision by a GP to visit a patient must, on all occasions, be dictated by the clinical circumstances operating at the time. The GP had been Mrs Z's GP for 17 years and he told my investigator that he was familiar with her state of health at the time of the events. I am confident, therefore, that the GP had in his possession all the facts which should have led him to visit Mrs Z or, at the very least, to contact the family to find out what had caused them to ask for a syringe-driver, regardless of what he presumed the family's reaction would be. He knew that Mrs Z was gravely ill and deteriorating, and that effective pain control was critically important to her care. Despite this, the GP failed either to visit or to contact the family personally. In my judgment, his inaction fell well short of the professional service which Mrs Z and her family had a right to expect in these circumstances. I strongly criticise the GP for that and uphold this complaint.

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20. The standard of the GP's medical record keeping was not part of my investigation save only to the extent that it was relevant to the issues I considered. I do not believe that it necessarily affected the GP's judgment on 22 June. However, I note his failure to record anything about his visit to Mrs Z on 17 June, and the serious concerns about the adequacy of his records expressed in paragraph 18 of the attached independent assessors report. I recommend that the GP should ensure that, in future, his clinical decisions are always based on an appropriate personal assessment of the patient's current condition, and on sound and complete medical records; and that, particularly when working with a message answering service, he should actively seek any further information he might need in order to come to an informed clinical decision as to how to proceed in any particular case.

Findings (b)

21. At the time of Mrs X's call on 22 June, the GP was using the out of hours service as a message handling service, and he was covering his own calls. I am confident that the arrangements in place were sufficient to ensure that, in an emergency such as the one that presented on 22 June, the GP would have received sufficient information on which to base a clinical judgment as to how best to proceed. However, I am not confident that the GP was sufficiently aware, at the time, of his own responsibilities when covering his own calls and, to that extent, I uphold this complaint. I recommend that the GP should, if he has not already done so, familiarise himself with the working of the out of hours service and that his management of patients out of hours should take account of the scope and limitations of the service provided. He should note also that it is his responsibility to ensure that the message handling or deputising service he uses provides him with a satisfactory service, and should follow up any concerns he may have about the service's performance.

Conclusion

22. I have set out my findings in paragraphs 17-21. The GP has agreed to act on my recommendations in paragraphs 20 and 21 and has asked me to convey to Mrs X - as I do - his apologies for the shortcomings which I have identified.

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Annex A to E.1253 96/97

Report by external professional assessors (EPAs)

Name: the 1st EPA

Relevant Experience

General practitioner for 14 years. Currently in urban fund holding practice with one other general practitioner. Also consultant in primary care in an accident and emergency department of a hospital.

Name: the 2nd EPA

Relevant Experience

General practitioner for 28 years. Currently in single-handed fund holding practice. Also works as a hospital practitioner at a District General Hospital.

Introduction

1. In this matter we are asked by the Health Service Commissioner (Ombudsman) for an opinion on whether:

the GP acted inappropriately in his response to Mrs X's telephone calls to his emergency answering service and if he failed to make sure that the arrangements to communicate emergency calls to his surgery were adequate,

and if

the GP response was a reasonable and responsible exercise of clinical judgment of a standard the patient could be reasonably entitled to expect.

Mrs X has claimed that on being informed through the emergency answering service that her mother (now deceased) - who had previously been prescribed Oral Morphine for her excruciating pain - had deteriorated and could no longer swallow morphine and needed this to be administered by a syringe-driver to relieve her of her pain, the GP had simply arranged for the answering service to inform her that the family would have to manage over the weekend and to contact the GP on Monday morning to make an appointment for him to visit Mrs Z.

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Basis of our report

2. In formulating our report we have perused a bundle of documents which have been kindly made available to us by the Office of the Health Service Commissioner for England (Ombudsman) and which have included:

• Mrs X's original letter of complaint dated 24 June 1996.
• the GP's response to the statement of complaint dated 4 July 1996.
• Mrs X's additional statement dated 22 July 1996 in response to the GP's letter.
• the GP's letter of 2 September 1996 addressed to Mrs X.
• Mrs X's letter of 12 September 1996 addressed to Wolverhampton Community Health Council.
• the GP's letter to Mrs X of 15 October 1996 offering clarification.
• Mrs X's letter of 17 November 1996 to Wolverhampton Community Health Council following the decision of the convener of the Health Authority not to convene an independent review panel.
• Mrs X's letter of 10 December 1996 addressed to the Office of the Health Service Commissioner.
• The GP's reply to the Health Service Commissioner dated 8 March 1997.
• records and correspondence from the Deputising Service.
• GP records.
• records of the notes prepared by the Investigator (dated 1.7.97) following her interview with the Office Manager of the Deputising Service on 25 June 1997.

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We have, in addition, been supplied at our request a copy of a letter sent to all GPs in the area by the director of the Primary Care and Service Development of the Wolverhampton Health Authority dated January 1997.

3. We have not interviewed either parties on this matter and have based our conclusion on the information gained from the perusal of the documents and have confined our comments to the specific matters to which our attention has been drawn by the Office of the Health Service Commissioner.

Basis of our report

4. It would appear from perusal of a letter, sent to the GPs by the director of Primary Care, that the policy operational at the time at [the] Hospice was for the patients to be first referred by the completion of a referral form and that weekend support for patients with severe pain was available only to those who had already been referred and had previously been assessed by the Home Care Team. It would seem that syringe drivers were also made available to those patients who had already been assessed.

5. It is conceivable, therefore, based upon the information we have that the GP, who had previously worked at the Hospice, did in fact know of the existing operational policy at the Hospice with regard to the issue of syringe drivers and believed it to be for the issue to such patients at the weekends who had previously been referred and assessed.

6. It would appear that the Deputising Message Service did not at the time either keep detailed reports of the messages received by patients nor were there, at the material time, any arrangements for the messages to be recorded so as to substantiate the accuracy of any messages received or conveyed by the Service to either the doctors or the patients or their representatives. It is, therefore, hardly surprising that the duty receptionist at the time was not able to recall with any degree of confidence the substance of the message received from Mrs X.

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7. We are not convinced that Mrs X did actually make a request for a home visit as she claimed to do in her letter of 17 November 1996 as she made no mention of such a request in her original letter of complaint dated 24 June 1996. Notwithstanding that, we do believe that the message that her mother had deteriorated; had difficulty in swallowing and did indeed need the syringe driver was adequately conveyed to the answering service.

8. We think it is possible that Mrs X assumed that a syringe driver could be made available to her by the Hospice at the weekend if only her GP authorised it, not realising that such a request could not be acceded to by the Hospice where the patient had not been previously referred by her GP or assessed by the care staff at the Hospice. We are prepared to accept, however, that she did in good faith say to the receptionist that the syringe driver could indeed be made available if only the GP authorised it. We are not sure, however, if this information was indeed conveyed to the GP who nevertheless did not believe it possible that he could make such arrangements over the weekend.

9. We are not impressed by the GP's assertion that he could not initiate a request for the provision of a syringe driver before discussing the matter with Mrs Z or her family as he did not in fact make any efforts himself to contact the family. Moreover, we think he should have himself first assessed the need for a syringe driver and discussed the matter with the family.

10. We do not accept the GP's argument that he did not make a home visit himself as he had not been asked to do so by the Deputising Service. We believe that the onus of deciding whether or not to visit a patient rests solely on the general practitioner. A decision by a GP to visit a patient should not be dependent upon a request for a visit being made but must on all occasions be dictated by the clinical circumstances operating at the time.

11. The GP, in his correspondence, does concede that Mrs Z had not been well for a long time; had been in severe pain to the extent that oral morphine had been prescribed by him and, by his own admission, had swallowing difficulties previously which had induced him to recommend fluids for her nutrition.

12. On the basis of the information made available to him he was under an obligation under his terms of service to place himself in a position to exercise proper judgment on whether or not to visit a patient or make attempts to further explore the situation by either asking for more information from his message service or by contacting the family himself to ascertain the current state of affairs.

13. The GP did know and should have known that a request for the use of a syringe driver in a patient who is already on morphine mainly arises either because the patient is not able to swallow medicine orally or because the pain control for the patient is not adequate. For such a patient to be left over the weekend without further exploring personally the nature of the problem or to make any attempt to assess the person himself does not reflect well on a doctor's professionalism or his reputation as a caring practitioner.

14. We have noted with concern the wide disparity between the accounts given by the two parties who describe the events affecting the deceased, on 22 June 1996. If Mrs X is to be believed - and we have no reason not to do so - she gave a very clear account of her anxieties about her mother's condition over the phone to the deputising service seeking assistance for her pain relief believing that her message would be communicated to the GP, and did, herself, attempt to speak to him by telephoning the emergency number that had been made available to her.

15. The GP, on the other hand, remembers only a request for the provision of a syringe driver with no explanation of the circumstances concerning such a request.

16. We have noted (by perusing a note prepared of a telephone conversation between an officer of the Health Authority and the deputising service) that the receiver of the call from Mrs X on Saturday morning 'vaguely remembers her call but not sufficient to recall discussion'. However, a note prepared by the receptionist at the time (call No. 1790 dated 22.6.96, received at 11.45 and passed on at 12, which forms part of a bundle of papers we have received) clearly records 'p increased' from which we assume that the message the telephonist did receive from Mrs X made it clear that the patient did indeed experience an increase in the severity of her pain, a message which was almost certainly communicated to the GP at the time.

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17. We view with concern the paucity of records kept by the GP on his patient. The information contained in them about the patient's illness, state of health, medication prescribed or any future plan of action is grossly inadequate.

18. We have noted the view held by the Deputising Service that at the material time they were not deputising for the GP but merely acting as a message service. We accept that by informing the doctor that the patient was in increased pain and that a request for a syringe driver had been made the message service did, in fact, give the doctor sufficient information to come to his own conclusions on his responsibility to the patient.

19. Under paragraph 20 of the Terms of Service, however, a doctor is clearly responsible for ensuring that any arrangements for deputising services on the doctor's behalf are adequate and the GP must, therefore, bear the responsibility for any inadequacies that may have existed at the time in conveying proper messages from and to the patients and cannot simply rely on the information he claimed was given.

20. The GP failed to place himself in a position to exercise judgment as to what action he ought to take about his patient by failing to explore further the reason for the request for a syringe driver when he did know that his patient was already in pain to the extent that he had, himself, previously prescribed morphine.

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Conclusion

21. We are of the opinion that on being informed of a patient who was known to be deteriorating and had been in severe pain and was already on oral morphine, the GP under the circumstances, did not respond in a reasonable manner and by not visiting the patient or contacting the relatives to explore the situation further, did not place himself in a position to exercise clinical judgment.

22. We do not think that the GP's response in asking the family to continue to use oral morphine, without exploring the situation further to ascertain the reason for the request for a syringe driver, was reasonable and responsible exercise of clinical judgment of a standard the patient could be entitled to expect.

23. We are of the view that by expecting the deputising services to communicate his message to the family on his behalf, the GP expected a higher degree of skill and responsibility than the deputising services were able to offer. The GP should bear responsibility for the failure of communication that resulted in his patient not being assessed at the appropriate time.

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Last updated: 24 January 2006