Dying patient should have seen GP.

NHS officials ruled that a man who died after his ear infection was not diagnosed in GP telephone consultations should have been granted a face-to-face appointment, a BBC Newsnight investigation has found.

Leeds man, David Nash, 26, had four remote consultations in three weeks during Covid pandemic restrictions but was never offered an in-person appointment and his infection led to a fatal abscess on his brainstem.

Medical documents and recordings of the consultations suggest David Nash should have been given an in-person appointment on one of the four consultations he had, according to NHS England.

David Nash first spoke to the practice on 14 October 2020, after finding lumps on his neck. He sent a photograph but was never examined.

As he was worried that the lumps might be cancerous, the GP asked a series of questions about his health and reassured him that, while she could not rule it out completely, she was not worried about cancer.

She suggested he booked a blood test for two to three weeks' time. During this time, David Nash would spoke to another GP and two advanced nurse practitioners but this was never face-to-face or by a video call.

BBC Two's Newsnight programme has heard the calls and seen documents relating the case. These confirm that:

• On 23 October: David Nash spoke to a nurse, reporting ear pain and, after a five-minute consultation was prescribed ear drops for an outer-ear infection. In fact, he had a middle-ear infection.
• On 28 October: David reported blood in his urine and a fever, which the doctor treated as a urinary-tract infection. This was despite the fact UTIs in young men are "generally uncommon", according to National Institute for Health and Care Excellence (NICE) guidelines, and the doctor himself stating in the call: "You don't seem to have any other signs of a urine infection."
• On 2 November: In the fourth and final call, David said he had debilitating neck pain preventing him sleeping, pain in his sinuses, had had fever for 10 days and was slurring his words. The nurse he spoke to diagnosed a flu-like illness and prescribed pain relief for his neck. David told the nurse: "Pretty much every time my heart beats, I'm getting these pains."

He was due to be seen in person at the GP surgery that day, for the blood tests booked 19 days earlier, when he had developed lumps in his neck but, fearing he could have coronavirus, despite a negative PCR test, the nurse cancelled the bloods and asked David Nash to retest for Covid.

In its investigation, NHS England found "the overarching benefit of this decision was less than the risk with going ahead with blood tests."

David's father, Andrew Nash, told Newsnight: "What we know now is that a couple of days previously, he more than likely started to develop a brain abscess that was triggered by his ongoing infection in his ear.”

Two-and-a-half hours after that call, David took a selfie of himself to send to a friend.

On seeing the photograph, the last of his son alive, his father said: "I have no formal medical training other than first aid but if I was to identify a picture of someone who was dying..."

After five calls to NHS 111, David Nash was taken to hospital by ambulance that day but died two days later.

In a finding seen by Newsnight, NHS England said: "A face-to-face assessment should have been offered or organised to confirm the diagnosis and initiate definitive management."

Andrew Nash added: "David made numerous attempts to access treatment and there were so many opportunities where, had he been seen face-to-face, things would have been different."

Andrew's mother, Anne, added: "It's been appalling care. I think they've completely let David down… at every single point. I am absolutely convinced, as David's mum, that if he'd been seen on that last consultation, he would still be with us today."

An inquest into David's death, scheduled for early next year, is expected to also examine what his family say were failures once he had been admitted to hospital.

In documents seen by Newsnight, an independent GP expert who has examined the case in detail said there were "several points in time where David should have been reviewed face to face.”

Dr S L Brown, a GP since 1984, said he could not determine whether David being seen earlier would have changed the outcome but to prescribe pain relief when he had been so unwell "was a breach of duty."

In a statement, David's surgery said: "We would like to again extend our condolences to Mr Nash's family and our thoughts are with them at this difficult time. It would not be appropriate to comment further as the inquest is ongoing."

An NHS England spokesperson said: "The NHS has made it clear that every GP practice must offer face-to-face as well as telephone and online appointments, and that clinical judgment alongside patient preference must be considered."

The Nuffield Trust published a report in June this year that found "the clinical risk from remote consultations is not yet well understood.

"Remote consultations also carry some risks, missed or delayed diagnoses due to loss of information from visual clues, physical examination and 'door-knob' concerns -  fresh issues raised by patients towards the end of face-to-face consultations - missed signs of safeguarding risk, lost opportunities for public-health interventions and increased use of investigations and referrals to other services."

A Department for Health and Social Care spokesperson said: "We are clear that practices should respect patient preferences for in-person appointments where expressed."

Harrowells partner in the firm’s Catastrophic Injury and Clinical Negligence team, Kim Daniells, says: “This tragic case highlights many issues of concern including the safety of remote consultations and consistency of care when patients are perhaps assessed by multiple individuals who learn of the symptoms presenting on that day and not the pattern that has developed over weeks.

"These are issues that are familiar to us from the accounts we hear from clients who are struggling to access effective primary care. Very sadly, in some cases, it is these issues that result in missed opportunities to treat serious illness and save lives."