GP+hospital appalling treatment of My mother 76 with pneumonia ...sent home still ill!

[BazzaS]

You can make a diagnosis (by percussion - tapping, and auscultation - stethoscope) of there being "something solid" there instead of "air in lungs". That might be a large cancer, a bleed, fluid (an effusion), or infection (empyema or pneumonia). Which one it is may well need a chest X-Ray to help distinguish, but as far as a GP can go by clinical examination : if the history fits with infection / pneumonia, it is reasonable, as a GP, to say "it's pneumonia" and treat for that first, if they aren't I'll enough to warrant hospital admission.

 

OP : As for the hospital: it would be unusual to make a diagnosis of "community related pneumonia": it is usually "community acquired pneumonia" ("CAP"), 'acquired', not 'related'.

 

Any patient admitted with a CAP should be assessed for severity by the CURB-65 scoring system:

Presence of Confusion,

Raised plasma urea

Increased respiratory rate

Lowered blood pressure and

Age 65+?

 

This gives a score 0-5. It is a "blunt tool" (an elderly person, usually confused, scores 2 even if their confusion isn't due to pneumonia!), which is why it should be used only for CAP's, but the CURB score can help identify who needs admission and how aggressive their initial antibiotic treatment should be.

[BazzaS]

 

You can make a good guess, the more experienced the closer that diagnosis might be, but not a definite diagnosos.

 

Does it matter (to the GP, and to what they do) if they make "a definite diagnosis"?

I think not, I think it matters that they "do the right thing" rather than "get the right name".

 

The GP can't confirm their working diagnosis of pneumonia without a chest X-ray or admitting the patient.

So, they either have to send the patient for a chest X-Ray as an outpatient or have them admitted.

They probably would do so if they practiced defensive medicine, but where GP's excel (over hospital Dr's who will often rely more on tests) is in making that judgement call....

 

If the GP is happy it is appropriate & safe to do so, and the patient can be safely treated at home, they'll make a presumptive diagnosis of pneumonia, and start treatment with oral antibiotics. No chest X-Ray, no hospital. They'll tell the patient to come back / make contact again if they are getting worse.

This way, not every patient gets sent in : if they sent every patient with pneumonia in the system (already stretched!) would grind to a halt. This is one of the GP's roles : as a "gatekeeper" to hospital admission.

 

If the GP doesn't feel it is safe to do this, they'll send them in, or if they aren't settling as expected.

 

Sure, there isn't a definite diagnosis (X-Ray confirmed and all) for the ones who get better and avoid hospital admission, but it depends on what your priorities are:

1) Appropriate management and settling for only a presumed rather than definite diagnosis for the ones who don't need admission, or

2) "Send them all in!", where they all get sent to hospital, and all get Chest X-rays..... Whether they are needed or not to be managed, rather than "needed to get a conclusive diagnosis".

 

The GP's are there to help stick to the first (who cares on getting a (chest X-Ray) CXR confirmation if they are well enough to get confirmation by their response to treatment),

If they don't respond to treatment, then they can send them in so that eg CXR to establish

A) is the diagnosis CAP, and if so do they need a change in treatment (higher dose antibiotics, or different ones) or

B) is the diagnosis something else.

 

The GP won't have the luxury of blood tests and CXR's for all.

Part of their role is deciding who needs those tests or to be admitted (send them in) and who can be managed (at least initially) without, in the community.

 

As for "ignore what the GP has said, ring the ambulance yourself" : if someone is going to do that anyway, why bother with the GP?

It negates the use of the GP's experience, and if you are going to call an ambulance anyway, call an ambulance, and leave the GP's slot open for someone else who can make use of the GP, rather than using the GP's slot when the outcome ("we'll call an ambulance") is already determined.

[BazzaS]

Was your Mum ever a smoker?

 

If so, how many "pack years" did she smoke?

https://en.m.wikipedia.org/wiki/Pack-year

 

An issue you may face is in establishing it is the GP's actions that have caused the COPD. Proving that COPD in October 2016 was caused by events in December 2014 will be tricky, even if she was never a smoker.

[BazzaS]

Needs a merge with:

http://www.consumeractiongroup.co.uk/forum/showthread.php?438487-My-mother-76-with-pneumonia-treated-appalling-by-GP-hospital...sent-home-still-ill!/page2

 

Nothing new here from that previous thread?

[BazzaS]

I note that you never answered / addressed my query from December 2016

 

Was your Mum ever a smoker?

 

If so, how many "pack years" did she smoke?

https://en.m.wikipedia.org/wiki/Pack-year

 

 

Given that what is felt to be pneumonia is sometimes COPD (and vice versa : sometimes it is impossible to tell the difference without a chest X ray or other imaging), and that you can have pneumonia even if you don;t have COPS (and again, vice versa) .....

 

An issue you may face is in establishing it is the GP's actions that have caused the COPD. Proving that COPD in October 2016 was caused by events in December 2014 will be tricky, even if she was never a smoker.

 

I also have to wonder what it is you want to achieve by complaining, both as:

a) it will help make sure the complaint is focused towards you getting what you want to achieve, but also

b)

i) You said in December 2014 you were going to write a complaint,

ii) You said in December 2016 you were going to write a complaint:

If this was really about you making sure 'the system improves' : surely the time to do so was in December 2014 (and /) or December 2016 .......

 

 

O.k, can I get request these on behalf of my mum, is there a template I can use to take to the surgery, the surgery receptionists are very akward, what if they refuse to take the printed request and insist on my mum coming to the surgery in person?

 

The incident in 2014 is approaching 3 years but the other incidents are not nearly 3 years - in other words the GP's have been ongoing since 2014, so do you think its worth drafting a letter now and sending that in or get the medical notes and if the 2014 incident is missed because its nearing 3 years deadline, then focus on other incidents after 2014?

 

I did ring the surgery for the cost of medical notes, the receptionist was very awkeward not wanting to tell me what the process was and kept saying the person who deals with it is on holiday.

 

Contact the GP's again. Note that their process shouldn't rely on one person (people take leave and go off sick .....), and that you were thinking of complaining to NHS England anyway (assuming you are in England ... otherwise the equivalent for where the practice is based).

Say words to the effect of "Of course, now I'll have to point out that your complaints / Data Subject Access Request process is flawed, too : if it is that the practice manager isn't available to deal with this, you might want to let the Senior Partner know that it is creating an NHS England complaint, both regarding the clinical complaint, and the process issue ...."

 

So he can't do the same to other patients, even on the surgery website he has a whole list of negative reports from other patients, so its not a new thing. He's gone downhill and is now complacent, so go the complaint route and if I was to try to sue, is that a different process compared to logging a complaint?

 

Complaints and suing are 2 independent processes.

 

Complaints got either to the practice, or NHS England.

 

http://www.nhs.uk/NHSEngland/complaints-and-feedback/Pages/nhs-complaints.aspx

 

You can't sue on your mother's behalf, she (or her estate if she dies before the complaint commences) needs to do so within 2 years of the event / harm (or 'constructive knowledge' of the event / harm).

[BazzaS]

You can't sue on your mother's behalf, she (or her estate if she dies before the complaint commences) needs to do so within 2 years of the event / harm (or 'constructive knowledge' of the event / harm).

 

Make that 3 years.

[BazzaS]

Hospital Doctors can be even more clueless than GP's.

 

Hospital doctors can have better access to tests / investigations than GP's, and better access to consults / opinions from other specialities.

(Commissioning groups have realised this can lead to GP's referring patients "just for tests", so have brought in 'direct access' schemes, so the situation for GP instigated tests is much better than it used to be........)

 

Hospital doctors can be of varying seniority / experience.

I was always bemused by people "going to A&E for a 2nd opinion", where the A&E doctor might be much less experienced than the GP

(Fair enough if it is A&E middle Grade / senior or for an "'A&E illness', rather than a 'GP illness'", but how often is this the case?)

 

So, if they are "clueless" depends on factors such as the underlying problem, the tests which would be useful (if any!), and the seniority / experience of the practitioner.

Ohh, and on the competence of the practitioner.

Sometimes they are "clueless" due to the situation, sometimes clueless because they are, well, clueless ......

[BazzaS]

I am very happy with our NHS where we have competent doctors and the service is FREE! Where we lived in Africa this sort of hospital treatment would have been unaffordable!

 

Absolutely. Praise the NHS for what it does and does well.

It isn't "free", though : just "free at point of delivery", for most things....

 

So, praise its strengths, and defend its ideals.

That shouldn't prevent complaints though, as justified complaints are opportunities for improvement.

[BazzaS]

crackling cough - which is a sign that there is fluid in the lungs.

............

 

Regardless of the 'pressures' GP's have in this case your GP failed in his duty of care

 

We just don't know that the GP breached their duty of care.

 

Back in December 2016 I noted (and asked)

Was your Mum ever a smoker?

 

If so, how many "pack years" did she smoke?

https://en.m.wikipedia.org/wiki/Pack-year

 

 

 

The OP hasn't answered about smoking, and 'pack-years'.

For a 76-year old with a 40 pack-year smoking history, crackles and cough would be the expectation.........

 

"Crackling cough is a sign there is fluid in the lungs" : again you just don't know that ........... nor that "crackling cough = pneumonia" in case you want to claim that too.

 

People with COPD can have chest crackles, and coughs. Pneumonia is different to "fluid in the lungs". Penumonia is consolidation (solid, rather than fluid), whereas there can be 'fluid in the lungs' ('pulmonary oedema'') that is unrelated to infection.

 

As I noted previously:

 

An issue you may face is in establishing it is the GP's actions that have caused the COPD. Proving that COPD in October 2016 was caused by events in December 2014 will be tricky, even if she was never a smoker.

[BazzaS]

Your GP gives you a letter which tells you to go to the wrong ward, this takes up valuable time, when he should have sent you to the elderly patient ward where your mum would been given prompt attention.

 

This shows your GP's lack of care and lack of knowledge.

 

Only after you kept on asking on the ward where you had been waiting a few hours, why no one had come to see your mum, does a member of staff realise your your GP has sent your mum to the wrong ward and she's towards the bottom of the waiting list. Yout mum is taken to the elderly ward, where she is diagnosed with community acquired pneumonia etc.

 

On your mums first visit alone to your GP he, sent your mother home without doing “basic” tests. Your GP failed to perform a percussion test, which involves tapping fingers on the chest to inspect for infection. Neither did he refer her to a paediatrician for an X-ray, which would also have been likely to detect the illness.

 

Your GP breached their duty of care.

 

For a start, some units have a combined medical assessment unit, and only after assessment do patients get sent to a medical ward or care of the elderly ward, so we can't be sure the GP "sent her to the wrong ward".

Follow that with that even if he did send her to the wrong ward, that should have been picked up on at the stage where she was booked into the ward on arrival, making it likely that it was the right place to send her (at least initially), or that it isn't the GP's error alone .......

 

Percussion? an essential test (yet, only essential if you are doing your medical school finals, or the MRCP practical exam).

However, if the GP has used their stethoscope, and reached a diagnosis, how is percussing essential? would it have changed anything (considering he referred her to hospital). Where is the harm caused by the absence of percussion?.

 

"Neither did he refer her to a paediatrician for an X-ray" ; a paediatrician?? I suppose that could be a typo but lets follow the "should have got an X-ray" path .....

 

What planet are you on?. If a GP's empirical diagnosis is of a community acquired pneumonia suitable for home antibiotics, why is an X-ray needed?

If the GP has decided to refer a patient to hospital, who can decide if an X-ray is needed, why does the GP need to arrange an X-ray?.

 

The thing is, it is possible the GP did wrong.

 

To get them held to account if they did do wrong, get access to the notes, get the information reviewed, and complain about what they did wrong.

Random complaints, including about what they haven't done wrong won't get them held to account. It risks the complaint being dismissed as unfounded, as what they might have done wrong gets submerged in the tidal wave of what is being complained about that gets seen as "unwarranted complaint"!

[BazzaS]

The GP did send my mum to the wrong ward, upon arrival to this ward, I gave my mothers details at the reception in the ward, my mothers had difficulty breathing, high temperature, not aware of her surroundings, in pain was told to sit in chair and someone would come see her. Nobody came for over 2-3 hours. I asked several members of staff because I was frantic with worry when someone would come to help my mum or even give her oxygen/nebulisers f from a machine as she was struggling to breath.

 

Around 2 hours passed and a health care worker that was passing through I managed to speak to her. I explained 2-3 hours had passed and nobody still had come to see my mother. She immediately said because of my mothers age and her having pneumonia she should not have been sent to this ward by the GP. The GP should have sent us to the elderly ward as she was a priority patient. She said in clear words the GP was at fault.

 

This was not a medical assessment unit - we were sent by the GP to the wrng ward and it would not have been picked up if I did not by luck speak to this health care worker that was passing by.

 

The medical assessment was done once we got to the correct ward - The elderly ward.

 

What was the nature of the ward, and (if not any sort of assessment / care of the elderly ward) why didn't the reception staff notice it wasn't the right place?.

 

Again, focusing on what the GP didn't do wrong, or did wrong (but that they'll say wasn't completely due to them and they'll share the blame with someone else!) isn't the way to get them held to account.

Focus on what they did wrong (if anything!) that had a major effect, that is wholly attributable to them.

 

If you focus on the ward issue, the most likely outcome even if you are correct is "yes, the GP apologizes for their error. However, the ward should have corrected it, so the effect of the GP's error alone should have been minimal" with the apology being the only outcome.

[BazzaS]

Complaints and suing are 2 independent processes.

 

Complaints got either to the practice, or NHS England.

 

http://www.nhs.uk/NHSEngland/complaints-and-feedback/Pages/nhs-complaints.aspx

 

You can't sue on your mother's behalf, she (or her estate if she dies before the complaint commences) needs to do so within 3 years of the event / harm (or 'constructive knowledge' of the event / harm).

 

Any court claim must be lodged within 3 years of the event / harm (or first 'constructive knowledge' of it).

 

That doesn't mean you have 3 years to complain, though. As noted complaints and suing are different processes.

 

http://www.nhs.uk/NHSEngland/complaints-and-feedback/Pages/nhs-complaints.aspx

You can complain in writing, by email or by speaking to someone in the organisation. You should make your complaint within 12 months of the incident or within 12 months of the matter coming to your attention. This time limit can sometimes be extended as long as it is still possible to investigate your complaint.

Anyone can complain, including young people. A family member, carer, friend or your local MP can complain on your behalf with your permission.

They may decline to investigate a complaint about the 2014 events as being 'out of time', in which case issuing a claim may be the only option if you still feel you have a provable case. Watch out for the time limits.

[BazzaS]

First of all the hospital would have performed a simple blood test when your mother arrived on the ward. It is called a CRP. ( C-Reactive protein) This test measures the level of inflammation. NICE as issued guidelines on what actions to take at differing levels. The scale goes from 4 to 285.

 

I had bilateral pneumonia and Septicemia my reading was 285...Basically I came very close to meeting my maker. The other simple test that would have done is taking your mother's oxygen Saturations. It is a small device placed on your finger. My own was 88% my lungs were barely working. I was placed on oxygen. The x-ray and CT scan came later.

 

My point is that pneumonia can be treated at home. This Christmas I went to the emergency centre after ringing 111. My CRP was 120, my Oxygen Saturations 97% so I was sent home on antibiotics. I had community acquired pneumonia. You need to find out what your mother's basic observations were. Pneumonia from my own experience was very painful.

 

Hospitals follow guidelines for both sepsis and pneumonia. If she had a lower CRP and good 02 Saturations then it's possible she would have met the criteria for discharge. I would advise you to check what they were. As for the actions of the porters and nurse etc that should have not happened.

 

 

CRP is a useful test, but not one of the markers used for initial assesement of severity of Community Acquired Pneumonia, which is the CURB-65 score

Confusion, Urea, Respiratory rate, Blood Pressure, and age over 65 or not. One mark for each present, so score of 0 to 5.

 

A young, fit, person with a CURB score of 1 (so likely suitable for home treatment with oral antibiotics) might have widely different CRP based on which bug is causing their pneumonia (Pneumococcal pneumonia likely being highest, as the capsule of pneumococcus is a potent stimulator of CRP production!) . So, CRP is part, but not all, of the picture.

In addition, if a GP decides someone is suitable for home treatment, they may not get a CRP performed........ why do the test, if they feel they already have enough information to make the decision!.

 

CURB65 isn't perfect (if misapplied, to someone who doesn't have pneumonia, but is over 65 and confused usually e.g. has dementia, they score 2 even in the absence of a pneumonia!), but is widely used, and if applied correctly is useful.

[BazzaS]

I’m uncertain, so perhaps you could clear things up: are the GMC complaints about events in 2014, 2017, or 2020 (&, if mixed, which are when?)

 

Also : will it be you, or your Mum, complaining to the GMC?