An investigation into the death of a 26-year-old man in the U.K. is shining a light on the limitations of telemedicine. Many health clinics and facilities limited or stopped offering in-person appointments during the COVID-19 pandemic, but some consultations are better carried out face to face.
According to official documents from the National Health Service (NHS), David Nash received four remote consultations over the course of three weeks while the pandemic restrictions were in place, but his doctors never offered him an in-person appointment.
Doctors failed to identify Nash’s ear infection during the four telemedicine appointments. The infection only got worse and eventually led to a fatal abscess on his brainstem.
Officials say he should’ve been offered an in-person appointment during one of the four consultations.
Nash first contacted the clinic in October 2020 after finding lumps on his neck. He sent the general practitioner a photo, but it was never examined.
He began to worry that his lumps were cancerous. His GP asked him a series of questions and reassured him that it probably wasn’t cancer even though she couldn’t rule it out entirely. She scheduled a blood test for two to three weeks later, but his health continued to deteriorate during that time.
He went on to speak with another GP and two advanced nurse practitioners over the next three weeks, but he was never offered an in-person appointment or video call.
His medical records show he spoke to a nurse on October 23 complaining of ear pain. He was prescribed ear drops for an outer ear infection after a five-minute consultation even though the infection was in his middle ear.
Five days later, Nash spoke with another GP with blood in his urine and a fever. The doctor treated it as a urinary-tract infection even though UTIs in young men tend to be rare. “You don’t seem to have any other signs of a urine infection,” the doctor can be heard saying during the call.
On November 2, he called for the last time with debilitating neck and sinus pain and a high fever. He was also slurring words. In this case, the nurse diagnosed him with a flu-like illness and prescribed pain relief for his neck.
“Pretty much every time my heart beats, I’m getting these pains,” David told the nurse.
That was the same day he was supposed to be seen in person by a GP for the blood tests ordered nearly three weeks ago, but the nurse canceled the appointment because she was afraid Nash had the coronavirus, despite a negative PCR test.
The NHS found “the overarching benefit [of this decision] was less than the risk with going ahead with blood tests.”
“What we know now,” said David’s father, Andrew Nash. “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.”
That was the last photo taken of Nash alive.
“I have no formal medical training other than first aid,” Andrew said. “But if I was to identify a picture of someone who was dying…”
David ended up calling 1-1-1, the emergency hotline, five times before an ambulance arrived. He was admitted to a hospital that day but died two days later.
“A face-to-face assessment should have been offered or organized to confirm the diagnosis and initiate definitive management,” the NHS added in its investigation.
“He 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 said.
“It’s been appalling care. I think they’ve completely let David down… at every single point,” added David’s mother, Anne. “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.”
NHS England, which investigated the case, offered its condolences to the family.
“We have investigated the family’s complaint regarding their son’s treatment within primary care and provided them with a response”, the trust said in a statement.
“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,” an NHS spokesperson added.
In June, the Nuffield Trust published a report 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,” the report said.
A Department for Health and Social Care spokesperson added: “We are clear that practices should respect patient preferences for in-person appointments where expressed.”