NHS officials ruled a man who died after his ear infection was not picked up in GP telephone consultations should have been seen face to face, a BBC Newsnight investigation has found.
David Nash, 26, had four remote consultations over three weeks during Covid restrictions but was never offered an in-person appointment. His infection led to a fatal abscess on his brainstem.
David first spoke to the practice on 14 October 2020, after finding lumps on his neck. He sent a photograph but was never examined.
With David worried 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.
In those three weeks, David would go on to speak to another GP and two advanced nurse practitioners but never face to face or via video call.
He was actually due to be seen in person at the GP surgery that day, for the blood tests booked some 19 days earlier, when he had presented with neck lumps. But - fearing he could have coronavirus, despite a negative PCR test - the nurse cancelled the bloods and asked David 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".
After five calls to NHS 111, David was taken to hospital in an ambulance that day but died two days later.
NHS England, in a finding seen by Newsnight, said: "A face-to-face assessment should have been offered or organised to confirm the diagnosis and initiate definitive management."
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Source: BBC News, 29 September 2022