Failure to arrange face-to-face review demonstrated serious error in clinical judgment

What happened

Mrs Y lived alone in sheltered housing. She was unwell one morning and her cleaner called the GP practice to ask for a home visit. The cleaner spoke to Mrs Y's GP. The GP noted that Mrs Y had been unwell for two weeks and that she had a number of symptoms, including chest pain, and was feeling feverish, weak and lifeless. The GP diagnosed an infection and prescribed antibiotics over the telephone.

The cleaner and the GP give different accounts of what was said during the consultation. The GP says he asked the cleaner to let him know if there was no improvement and he would visit Mrs Y. The cleaner disputes that the GP suggested a home visit and says she told the GP that she was not Mrs Y's carer and would not be there later that day to let him know if Mrs Y did not improve. Mrs Y was found dead the next morning.

Mrs Y's daughter complained to the practice about the GP's decision not to visit her mother. The GP responded and maintained that he had acted appropriately.

What we found

The GP's decision not to visit Mrs Y or arrange some other form of face-to-face medical review was contrary to both the practice's internal protocols and professional standards. The GP made a serious error in clinical judgment.

The GP did not have enough information at the time of the telephone consultation to safely conclude that Mrs Y had an infection and did not require face-to-face review. There was also no evidence that the GP put an appropriate safety net in place.

Mrs Y's medical history and her reported symptoms, in particular her chest pain, should have alerted the GP to arrange a face‑to‑face medical review. Furthermore, the practice's own protocols state that if a patient (or a friend or relative) phones to say a patient has chest pain and a past history of heart problems, as Mrs Y had, the practice should call an ambulance and tell a GP. This did not happen.

Putting it right

The practice apologised to Mrs Y's daughter and prepared an action plan that described what it has done or planned to do to make sure that it had learnt from the complaint.

We felt that the GP's actions and his responses to the complaint showed a lack of insight into the failings in his care, so we shared information about our investigation with the General Medical Council.