Bisoprolol prescription and review
16. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any indication that something has gone wrong.
17. Miss P told us the Practice prescribed bisoprolol to manage Mrs P’s atrial fibrillation since 2014. She said the GP believed it was for her blood pressure.
18. Miss P said the Practice should not have stopped Mrs P’s bisoprolol abruptly. She told us instead the Practice should have reduced the dose slowly. She said stopping the dosage abruptly led to Mrs P’s heart rate increasing and her developing fluid on her lungs. She told us this fluid caused her mother’s death in January 2023.
19. The Practice said of the medications Mrs P was taking, bisoprolol was the only one that could cause lower blood pressure. It told us it felt it was reasonable to stop bisoprolol as her heart rate was normal.
20. The GMC guidance says doctors providing clinical care must prescribe drugs only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.
21. Our clinical adviser explained bisoprolol is selective beta-blocker, which slows down the heart rate and reduces blood pressure. The NHS atrial fibrillation website says beta-blockers are used to treat atrial fibrillation, with the aim to reduce a patient’s heart rate to below 90 beats per minute at rest.
22. BNF bisoprolol guidance says bisoprolol can cause several side effects. These include bradycardia (slow heart rate), confusion and postural hypotension (low blood pressure on standing). It is used to treat high blood pressure (hypertension), heart failure, angina (chest pain caused by reduced blood flow to the heart) and atrial fibrillation.
23. Medical records confirm Mrs P had atrial fibrillation for which she was taking bisoprolol at a dose of 2.5mg.
24. Medical records show, during the 27 October 2022 home review, a GP recorded Mrs P’s heart rate at 65 beats per minute. Her blood pressure was 104/57.
25. Our clinical adviser said there were no specific guidelines for stopping bisoprolol. It would be a clinical judgement, considering the patient’s health and other available information.
26. Our clinical adviser said Mrs P’s blood pressure was fairly low (usual blood pressure is between 90/60 and 120/80). They said this low blood pressure could have been the cause of Mrs P’s light-headedness.
27. We can see the visiting GP discussed the case with another GP at the Practice. The GPs decided that it was likely bisoprolol that was causing Mrs P’s dizziness and light-headedness when standing. They thought the medication was causing these symptoms by the lowering her blood pressure too much.
28. Our clinical adviser said the Practice’s decision was part of an overall review of Mrs P’s health. They said, as with other beta-blockers, the risk of stopping bisoprolol was that Mrs P’s heart rate and blood pressure would rise. This would increase the risk that Mrs P’s atrial fibrillation would worsen.
29. Our clinician adviser told us, at 2.5mg, Mrs P was taking the lowest dose tablet used for heart rate control in atrial fibrillation patients.
30. In our view the Practice has followed GMC guidance when removing Mrs P’s bisoprolol. This is because the medication was no longer suitable for her needs as her heart rate was normal and it appears the medication was causing her low blood pressure. The low blood pressure could have been causing Mrs P to feel lightheaded when standing, and could increase her risk of falls.
31. Miss P also said the Practice did not review her mother after a month of stopping the bisoprolol. The Practice said it reviewed Mrs P on 9 November, when her blood pressure was still low and her heart range within a normal range.
32. NICE medicine guidance says medication reviews consider whether medications are still suitable for a patient’s needs. The objective of a review is to reach an agreement with the person about treatment. A review should optimise the impact of medicines and minimise the number of medication‑related problems.
33. Our clinical adviser said there was no formal guidance on the timings for reviewing a patient after a medicine has been stopped or changed. They said determining when to review a medication change must be on a patient-by-patient basis.
34. As we have seen in paragraph eight, medical records show the Practice planned to review Mrs P in a month, or sooner if the family had concerns about her. The NHS atrial fibrillation website says if bisoprolol is stopped, it will take two to three days for it to be completely out of a patient’s body.
35. Medical records show the Practice reviewed Mrs P on 9 November following a fall. This was around two weeks after the medication change. It found she was still dizzy and lightheaded on standing, even after stopping the bisoprolol. As we have seen in paragraph nine, the hospital saw Mrs P later that day for a CT scan of her head.
36. Our clinical adviser said Mrs P’s blood pressure and pulse rate were in the normal ranges when assessed by her GP and at the hospital. They said her observations did not indicate the need to restart bisoprolol. They also noted the hospital did not restart her bisoprolol when it discharged her home.
37. Our clinical adviser said there was no indication that the stopping of bisoprolol had any impact on Mrs P. They also said there was no indication her atrial fibrillation was not under control.
38. NICE medicine guidance says doctors should review patients to optimise the impact on patients and minimise medication related problems. In our view the Practice has done this as it reviewed Mrs P on 9 November and did not find any issues with her heart rate.
39. In summary we have seen no indication the Practice failed to follow the GMC guidelines by stopping Mrs P’s bisoprolol on 27 October. We have also seen no indication the Practice failed to follow NICE medicine guidance around arranging and completing a medication review.
40. Because we have seen no indication something has gone wrong here, we will not be considering this part of the complaint further. We appreciate this may be disappointing for Miss P. We hope our consideration provides insight into the reasons for our decision, and provides some reassurance about the care provided to Mrs P.
Complaint handling
41. As set out above, we have first looked at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any indication that something has gone wrong.
42. Miss P told us the Practice lied in its complaint response letter. She said the Practice suggested it had reviewed Mrs P in November 2022. She also said the Practice told her it had sent its response in July 2023. She told us both claims were untrue.
43. The Practice said its records indicated it had responded to the complaint in July 2023. It apologised that Miss P had not received a response and for any additional upset the delay had caused.
44. Our Complaint standards say staff should provide complainants with open and honest answers. It should also explain when things go wrong and identify suitable ways to put things right for people.
45. As we have seen in paragraph 35, we have seen that the Practice did review Mrs P in November 2022. The Practice took blood pressure and heart rate observations. We have seen no indication the Practice should have restarted bisoprolol. Considering this we have seen no indication the Practice provided false information about reviewing Mrs P in November.
46. We have seen the Practice dated its complaint response 9 July 2023. We have seen no evidence to suggest this date is incorrect. We have concluded the Practice’s complaint response was ready to be issued in July.
47. The complaint file shows Miss P chased a complaint response from the Practice. The Practice sent an email to Miss P dated 19 December 2023. It included a copy of its July complaint response. It said its records indicated it had already sent its complaint response in July. It apologised for the error and delay.
48. We asked the Practice to provide evidence to confirm whether it sent its complaint response to Miss P in July. The Practice said it could not provide any evidence to confirm it sent its response in July.
49. It told us a GP, who was not involved in the care of Mrs P, wrote the complaint response. It said an internal breakdown in communication between the GP and the Practice manager, coupled with a period of annual leave meant the Practice did not send a response to Miss P until December 2023. The Practice said this error was not an attempt to deceive Miss P.
50. In our view, we have not seen any indication to suggest the Practice purposefully lied to Miss P in this email. The evidence we have seen indicates the Practice believed it had sent the complaint response in July. We have seen no indication the Practice failed to follow our Complaint standards, which call for organisations to provide open and honest answers.
51. We understand the delay in the Practice providing its response has caused Miss P distress. We appreciate why this would be distressing to her, especially when dealing with the loss of her mother.
52. The Practice told us it has internally agreed a safety-netting process to avoid this delay happening again. It said the practice manager would communicate with the complaint handler (normally a Practice GP) and ask them to complete a complaint response. It said if the GP did not provide this, the Practice would hold a partnership meeting to discuss what further steps to take.
53. In our view this change should provide a level of oversight on the Practice’s complaint process. This will help ensure complaint responses are issued by the Practice promptly once individual GPs have completed them.
54. We appreciate how distressing it must have been for Miss P to wait months for a complaint response from the Practice. We hope the Practice’s actions to reduce the risk of this happening to someone else, provides comfort to Miss P.
55. As set out above, we have seen no indication the Practice lied in its response to Miss P’s complaint. Because of this, we will not be considering this part of the complaint further. We appreciate this may be disappointing to Miss P, particularly considering the distress she has told us the Practice’s complaint handling caused her.