SPSO Individual Decisions

Mrs C had a complex medical history including undergoing brain surgery in 2004. She continued to experience a variety of symptoms that were very concerning, and she complained about aspects of the care and treatment she received from her medical practice in 2013 and 2014 in relation to medication and communication. We took independent advice from one of our medical advisers. We found that the practice communicated with Mrs C in a reasonable way in that they attempted to explain treatment decisions. We also found that the practice took reasonable steps to explore the possibility of a link between Mrs C's previous surgery and her current symptoms, and that the medication they had prescribed was reasonable. Related reading View Decision Report 201405041 as a PDF (10.94 KB) Updated: March 13, 2018

Mrs C complained about the care the treatment her late mother (Mrs A) had received from the medical practice in the months prior to her death. Mrs A had been admitted to hospital as it appeared she had suffered mini strokes. However, following her admission she was diagnosed with metastatic cancer (cancer that spreads to other parts of the body), and died shortly thereafter. We took independent advice from one of our GP advisers, who said that Mrs A had been suffering from anxiety symptoms and memory problems for which she had been prescribed medication. Our adviser considered that Mrs A had been regularly reviewed by the practice, and there was no pattern or evidence to suggest Mrs A had an underlying diagnosis of metastatic cancer or the medication she had been prescribed masked any symptoms of metastatic cancer or strokes. Although we considered the care and treatment Mrs A received was mostly reasonable, we found certain aspects of her care fell below this standard. While, generally, the medication Mrs A was prescribed and its monitoring was appropriate, one of Mrs A's medications which had been stopped was still being prescribed. We found a failure to action the results of a liver function test result although we accepted the result would not have triggered any concerns of underlying metastatic disease. While communication with Mrs A's family was of a reasonable standard, we found that one of the doctors had used insensitive and inappropriate language during a home visit to Mrs A, and the practice could have done more to ensure that they had complied with a specific request from Mrs A's family to be present during a home visit given Mrs A's memory problems and that they were her carers.

Mr C complained about the care and treatment that his late mother (Mrs A) received from her GP. Mrs A had attended her GP with symptoms of breathlessness and the GP arranged an x-ray, took a blood sample and prescribed antibiotics. The x-ray result was reported as normal. Mrs A died four days after the consultation from a pulmonary embolus (a clot in the blood vessel that transports blood from the heart to the lungs) caused by deep vein thrombosis. Mr C felt that the GP had taken insufficient note of his mother's breathlessness and should have taken urgent action to establish a further diagnosis as the x-ray had been reported as clear. We took independent advice from a GP adviser and found that Mrs A's GP had acted reasonably by conducting appropriate investigations in order to establish a diagnosis and that there were no signs that Mrs A would suffer a pulmonary embolus a few days after the consultation. We also found that there was no delay by her GP in their consideration of the x-ray result. We did, however, note that the GP's record-keeping was not as thorough as it could have been and that the GP should reflect on this. We did not uphold the complaint. Related reading View Decision Report 201406539 as a PDF (11.19 KB) Updated: March 13, 2018

Ms C, who suffers from back problems, attended the practice as she had pins and needles in her foot. Hospital anaesthetists had previously advised her to contact her GP if she had any symptoms affecting her legs, bladder, bowel or back. She said that when she went to an appointment, the GP did not appear interested, prescribed inappropriate medication and failed to examine her legs. Ms C complained to the practice, who said that the GP had suggested the medication as it could assist with nerve-related symptoms and that he was aware that Ms C already had an urgent neurology referral. The GP also advised Ms C to seek further medical assistance should her symptoms worsen. Ms C brought her complaint to us. After taking independent medical advice from our GP adviser we upheld the complaint that the GP failed to adequately examine Ms C despite her reported symptoms and known medical history. We found that the GP should have carried out a more thorough examination which should have involved testing reflexes and muscle strength in the feet and legs; checking for loss of anal tone by performing a digital rectal examination; checking for numbness in the perineum (region between the thighs); and checking the location of the pain to see if it ran along the sciatic nerve.

Mrs C went to her medical practice with a thickened and discoloured toenail. The GP suspected a fungal nail infection and sent clippings for testing but the results were negative. The practice took no follow-up action until, after seeing a private podiatrist (foot specialist), Mrs C went back to her GP almost a year later. At the recommendation of the podiatrist, the GP made an urgent referral to a dermatologist (skin specialist). Mrs C was diagnosed with a malignant melanoma (a type of skin cancer) and her toe was later amputated. She complained that the practice unreasonably failed to refer her for further diagnostic tests. She also complained that the practice did not respond appropriately to her complaint about this. Mrs C had complained by phone to the practice manager. During the call she said that she did not want to speak to the GP. Despite this, the GP called Mrs C a few minutes later. Mrs C spoke to the manager again the following day, who confirmed that she had passed Mrs C's message to the GP but that he had phoned her anyway, thinking that it would be of help. Mrs C then complained in writing and the GP responded but Mrs C did not receive the letter. About four months later, she chased up the response and was provided with a copy. Our investigation, which included taking independent advice from a medical adviser, found that the cancer was very rare and difficult to diagnose, and that national guidelines confirmed this. The adviser commented that in general practice it is usual for patients who are having investigations to be told to return for review when the results are available. The GP had noted on Mrs C's record 'RV [review] with results' when the nail clippings were sent for investigation. Mrs C did not return for review but our adviser said that as the results were normal, no further investigation was required at this time. When Mrs C did return, having been reviewed by a podiatrist, the GP then took appropriate and timely action to follow the pod

Ms C, who is an independent advocate, complained on behalf of her client (Miss A) that the medical practice did not respect Miss A's wish to use an advocacy service. She also complained that the quality of communication from the practice was poor, and that they unreasonably removed Miss A from their patient list. We took independent advice from a medical adviser and a mental health adviser. The mental health adviser said that Miss A had a right to use an advocacy service and that the evidence showed that, although the practice had tried to engage with Ms C, they had not properly understood the role of the advocacy service and had not respected Miss A's wishes. The medical adviser said that the standard of correspondence fell below a reasonable standard. Letters from the practice were emotive and unprofessional and the practice failed to maintain a professional level of distance. The mental health adviser said that in his view they had not taken enough account of Miss A's mental health issues. We, therefore, upheld the complaints about the practice's engagement with the advocacy service and that the standard of their communication was below that which Miss A had a right to expect. We also found that they failed to direct correspondence to Ms C, despite Miss A's clearly stated wish that this should happen. We took the view, however, that the practice's decision to remove Miss A from their patient list was reasonable, noting that they had complied with the terms of the standard general medical service contract, by giving written warning to Miss A that they intended to take this action unless she provided them with an emergency contact phone number. We did not find this unreasonable, and did not uphold the complaint as we found that they acted in accordance with national guidelines.

Mrs C complained to us on behalf of her grandson (Mr A) about Mr A's medical practice. Mrs C did not feel that the practice had taken the appropriate steps to diagnose her grandson's illness. Mr A had attended the practice for consultations for about two months saying that, among other things, he had difficulty swallowing and a feeling of a blockage in his throat. Over the course of these consultations, blood tests were taken and Mr A was treated for anaemia. His symptoms did not improve and the practice referred him to a stomach specialist who found nothing and asked him to return two weeks later. However, Mr A went to A&E and was admitted to hospital, where an underlying heart condition that would require surgery was diagnosed. While awaiting this surgery, Mr A suffered a stroke. Mrs C said that if the heart condition had been identified more promptly, then Mr A might not have had the stroke. Although we understood this had been very difficult for Mrs C and Mr A, our role was to consider whether the steps the practice took were reasonable in the circumstances at the time. As part of our investigation, our GP medical adviser reviewed the medical notes and provided us with independent advice. Although he acknowledged how significant Mr A’s stroke had been, he explained that the symptoms had not suggested the underlying heart condition that Mr A actually had (which was a very rare condition in otherwise healthy individuals). The adviser also noted that the practice had listened to Mr A’s heart when he attended there, and this would have reduced any suspicion of Mr A’s underlying condition being heart-related. In light of this advice we did not uphold Mrs C’s complaint. Related reading View Decision Report 201304591 as a PDF (11.48 KB) Updated: March 13, 2018

Miss C's mother (Mrs A) went to a medical practice with abdominal (stomach) pains. She was repeatedly referred for an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body), but did not attend on three separate occasions and no further appointment was made. Ten months later, Mrs A again went to the practice and was treated for a suspected infection. However, Miss C was very concerned about her mother's weight loss and took her to A&E, where she was treated for a suspected urinary tract infection and discharged. Two months later, Mrs A went again to the practice with worsening back pain, nausea and weight loss. A GP told Mrs A that it was possible she had cancer, and arranged for x-rays, which showed that Mrs A had arthritis. However, as no cause for Mrs A's weight loss had been found, the GP arranged for an urgent abdominal scan, which showed possible cancer of the liver. Further tests confirmed this diagnosis and Mrs A died six weeks later. A few days before Mrs A's death, the GP visited Mrs A at home and there was an altercation between the GP and the family. Miss C and the GP gave slightly different versions of what happened, including what was said about Mrs A's treatment and whether the GP intended to leave without prescribing pain relief. Miss C then complained that the practice had failed to investigate Mrs A's symptoms appropriately, causing a delay in accurately diagnosing her cancer, and that the GP did not appropriately communicate with Mrs A and her family during the home visit. After taking independent advice from one of our medical advisers, we did not uphold Miss C's complaints. Our adviser said that the practice had acted correctly in referring Mrs A for a scan each time she went to them with abdominal pain. However, Mrs A had decided not to go for the scans. Once a scan was carried out, the practice acted promptly in making the appropriate referrals to confirm the diagnosis and arrange tr

Mr C had a long-term history of ulcerative colitis (an inflammatory condition of the intestines). He complained that there was a delay in his medical practice appropriately investigating his symptoms when he suffered a flare-up of his condition. Mr C also complained that the handling of his complaint about this was unreasonable. Mr C had previously taken a particular drug to relieve his symptoms but was not taking it at the time of the complaint, as his condition had been under control. When he began to suffer symptoms that he thought were indicative of a flare-up, he went to his GP and asked to be prescribed the drug. The GPs Mr C saw undertook various investigations, including blood tests, which were inconclusive. Because of this they felt unable to prescribe the requested drug. Mr C was referred to a specialist for further investigations, including a colonoscopy (where a camera is inserted into the intestines). The investigations eventually confirmed Mr C's view that he was experiencing a flare-up of his condition and the specialist prescribed him the drug he had requested. Our investigation included taking independent advice from one of our medical advisers, who is an experienced GP. The adviser said that it was reasonable, and in line with the guidance issued by the General Medical Council (the regulatory body for doctors in the UK), for the GPs not to prescribe the drug Mr C was requesting. The guidance says that doctors should only prescribe medication when they are confident they have sufficient knowledge of the patient's condition and that the medication in question is in their best interests. The adviser said that, in Mr C's case, the initial tests were inconclusive and there are other conditions with similar symptoms, which could have been made worse had he taken the drugs he was requesting. We took the view that the actions of the GPs were reasonable. There were some delays in Mr C receiving the colonoscopy but the GPs had no control over thi

Ms C suffers from a blood condition - Factor V Leiden - which increases the risk of blood clots. Ms C complained that her medical practice had not taken sufficient account of this condition, in that they had not monitored her blood on an ongoing basis, they had given her an inappropriate contraceptive injection and when she went to them with a possible blood clot in her calf they had not referred her to hospital. Ms C's concerns started when she attended the practice suspecting that she had a blood clot in her calf. Her GP referred her to hospital to see whether she had a DVT (deep vein thrombosis). The assessment showed some superficial clots, but no DVT. Ms C later had an contraceptive injection at the practice, which she continued to receive on a quarterly basis for the following year. A year after she first went to the practice with pain in her leg, Ms C went back for the same reason. The GP did not refer her to hospital this time, on the basis that no DVT was found on the previous occasion. However, the next morning Ms C woke with pains in her chest, and subsequent investigations found that Ms C was suffering from pulmonary embolisms (clots in the blood vessel that transports blood from the heart to the lungs). We took independent advice on this complaint from one of our medical advisers, who is a GP. After considering Ms C's medical records, he explained that her blood condition did not require ongoing monitoring. He also said that her contraceptive injections were the most appropriate for her. Finally, he considered whether Ms C should have been referred to hospital when she presented with pain in her calf on the second occasion. He said that, although this was a finely balanced judgement, the GP had acted reasonably given the evidence he had available to him at the time. Related reading View Decision Report 201302473 as a PDF (11.49 KB) Updated: March 13, 2018

Mrs C attended the medical practice as she had a swollen, discoloured and painful varicose vein in her right leg. She was initially seen by the practice nurse, who prescribed antibiotics (drugs to treat bacterial infection) and anti-inflammatory medication after consulting one of the practice doctors. The following day, as Mrs C’s leg continued to be very painful, she again phoned the practice and was advised by one of the doctors that she had not allowed enough time for the medication to work. Over the next 12 days, Mrs C was visited at home twice, as she felt she was not improving. On the afternoon of the second home visit, the doctor who visited Mrs C arranged for her to be seen by a vascular specialist at hospital. Mrs C requested an ambulance to take her there. She was offered a non-emergency ambulance but due to the possibility she might wait a number of hours for it and miss the appointment, the practice told her that she might wish to make her own travel arrangements, which she did. At the hospital, an ultrasound scan of Mrs C's right leg revealed a blood clot from the ankle to the groin, and she required emergency surgery. Mrs C was admitted to hospital the same day and discharged several days later. Mrs C complained that the practice failed to appropriately assess and treat her symptoms, and that she should not have had to make her own way to the hospital. She was dissatisfied with the explanations provided by the practice and the way in which they dealt with her concerns and complained to us, saying that she had no faith in them. We took independent advice on this case from one of our medical advisers. The advice, which we accepted, was that the practice had not failed in their care of Mrs C. Indeed, the adviser considered the prompt referral of Mrs C to a vascular surgeon was evidence of excellent practice. The adviser also said that Mrs C did not need an emergency ambulance to take her to hospital and the reason that she was given as to why

After Mr C was discharged from hospital following an operation on his bladder, he complained that his GP failed to visit him to review his wound or to provide him with treatment for a urine infection. The clinical records showed that when Mr C contacted the practice, the GP had asked a district nurse to visit him to dress his wound. When the nurse attended, she noted that Mr C was feeling well. She visited again a couple of days later and noted that he was still improving. When the GP called him six days later, Mr C reported that he was still feeling well, but when the GP mentioned that a urine infection had been noted after an initial post-discharge district nurse's visit, Mr C became upset. Two days later Mr C contacted the practice to complain of significant pain and cloudy urine. He was then prescribed antibiotics. We took independent advice on this case from one of our medical advisers, who is a qualified GP. He said that it was appropriate for Mr C's wound to be dealt with by district nursing staff. He also advised that it was reasonable, given the continued improvement in Mr C's condition, that the practice did not initially prescribe antibiotics for the urine infection. As the care provided by the GP was reasonable, we did not uphold the complaint. We did, however, make a recommendation to ensure that in future patients are kept fully informed about test results.

Mrs C complained that her GP had failed to diagnose her heart condition, and that as a result she had suffered a heart attack and had needed hospital treatment. Our investigation found that Mrs C had gone to her GP with symptoms of postural hypertension (changes in blood pressure, caused by changes in position, such as moving from sitting to standing). After taking independent advice from one of our medical advisers, we did not uphold the complaint, as we found the treatment she received was appropriate for this condition. There was no evidence that the GP had failed to identify symptoms of an imminent heart attack. Related reading View Decision Report 201204338 as a PDF (10.91 KB) Updated: March 13, 2018

Miss C was diagnosed with chronic kidney disease (CKD) in 2007. She complained that a GP at her medical practice incorrectly advised her to stop taking high blood pressure medication after she reported experiencing side effects. The GP had prescribed the medication for Miss C in 2008 because her blood pressure was elevated and this could have affected her kidney function. Miss C also complained that her kidney function continued to decrease but nothing was done to address this. In addition, she was unhappy that the GP did not properly investigate pain she had reported having in her side. After taking independent advice from one of our medical advisers, we did not uphold Miss C's complaints. Our investigation found no evidence that the GP had advised Miss C to discontinue the blood pressure medication. We considered that this was unlikely to have affected the progression of her CKD because she was managed in accordance with the national guidelines for the condition. Had Miss C been diagnosed with high blood pressure and had a significant amount of protein in her urine then it would have been appropriate for her to have remained on the medication. We also considered that there was no indication that the GP needed to make an urgent referral in relation to the backache Miss A had reported and that appropriate pain relief and a referral to physiotherapy was made. Related reading View Decision Report 201203630 as a PDF (11.34 KB) Updated: March 13, 2018

Mr C went to the practice because he had lower back and left leg pain, together with numbness. After his second visit, he was referred for physiotherapy, and then to hospital for a consultant opinion and an MRI scan (a scan used to diagnose health conditions that affect organs, tissue and bone). The hospital, however, returned the referral to the practice on the basis that there were no 'red flag' symptoms (symptoms indicating a possible serious condition). Three days after being referred, Mr C went to a hospital accident and emergency department with increasing pain and numbness. He was ultimately given a scan that confirmed a central prolapsed disc (where the centre of a disc in the spine pushes out into the spinal column) which required emergency surgery. Mr C questioned the treatment he had been given by the practice, as he believed they should have done more. He claimed that as a consequence, his outcome was poorer than it would have been. To investigate this complaint we considered all the available documentation and relevant clinical records. We also obtained independent advice from one of our medical advisers. We did not, however, uphold Mr C's complaint. Our adviser said that, overall, Mr C's care and treatment had been entirely appropriate and reasonable. The adviser also said that the practice had correctly identified red flag symptoms and made an appropriate, immediate referral, which the hospital had declined to accept. Related reading View Decision Report 201204914 as a PDF (11.45 KB) Updated: March 13, 2018

Mr C complained to the medical practice about the level of treatment he had received there over a period of a few years. They responded, acknowledging that there had been communication difficulties with Mr C, and that actions of and comments from the GPs had been made with the best of intentions. It was their view that Mr C had misinterpreted these. However, as a result of the complaint, the practice said that they had learned that they should be more sensitive and vigilant towards any patient who is dissatisfied or unhappy with any member of staff. Our investigation found that the medical records confirmed the information in the practice's response to Mr C, and that they had carried out a thorough investigation into his complaint. Related reading View Decision Report 201204535 as a PDF (11.05 KB) Updated: March 13, 2018

Mr C's daughter (Miss A) who was three years old, was taken to her medical practice because she was vomiting. Mr C complained that GPs there failed to appropriately investigate Miss A's symptoms and that this led to a delayed diagnosis of a brain tumour. Miss A's parents had taken her back three days after the first visit, and further vomiting was reported. The GP recorded that a referral to a paediatrician should be considered if the current pattern of vomiting continued. Miss A's parents brought her to the practice again three months later. It was recorded that she had a viral infection and that she had had a few episodes of vomiting. She returned to the practice again nearly eight weeks later. It was recorded that the vomiting had continued for a number of months and that she vomited approximately every two weeks. The GP prescribed medication for stomach problems. Miss A was taken to the practice again ten days later, which was her fifth visit about vomiting. It was recorded that she was vomiting as before and this had been for a few months on and off. She was prescribed further medication. It was recorded that her parents should call the practice if this was not working and she would then be referred to a paediatrician. Two weeks later, Miss A was referred to a paediatrician in view of the unexplained vomiting. This was noted as a routine (not an urgent) referral. Miss A attended the practice again two weeks later, before she had seen a paediatrician. It was recorded that the vomiting was on-going and that she had been tired lately and had a bradycardia (slow heart rate) when lying down. A referral was made to a private paediatrician, as her parents had private health insurance. Mr C's wife phoned the practice later that afternoon, however, as Miss A's condition had worsened and she was now more drowsy. It was arranged that Miss A would be taken to hospital for assessment, where she was admitted. The next day, another hospital phoned the practi

Mr A had several consultations at the practice over four months, complaining of ongoing and increasing pain in his hip and knee. Mr A was then admitted to hospital and was diagnosed with lung cancer that had spread to his liver and bones. Mr A died a month after being admitted. Mr A's wife (Mrs C) complained that if her husband been diagnosed sooner, he could have lived longer and had better pain relief. As part of our investigation, we took independent advice from a medical adviser. The adviser said that the practice had carried out and arranged for appropriate investigations in an attempt to establish the reasons for Mr A's pain. They arranged chest and hip x-rays at an early stage, but these did not show any signs of cancer. The practice had prescribed stronger pain relief and referred Mr A to an orthopaedic specialist when the pain continued. Although the practice did not re-check a slightly abnormal blood test result within the specified period of a week, the adviser did not consider that the actual delay of ten days was unreasonable. The practice acted promptly when this was identified and we did not consider that the ten day delay would have affected what happened to Mr A. In addition, we could not say whether re-checking this sooner would have resulted in Mr A receiving more adequate pain relief or being admitted to hospital more quickly. Related reading View Decision Report 201200903 as a PDF (11.37 KB) Updated: March 13, 2018

Miss C had her tonsils removed. After the procedure, she was in a great deal of pain and unable to eat and drink. Five days after the procedure, she went to see her GP about these symptoms. Miss C said that her GP just looked at the back of her throat and did not take her temperature or carry out any other tests. Miss C also said that her GP suggested she should go to the ear nose and throat (ENT) ward if she had any further problems, although her understanding was that she could not do this. The GP diagnosed post-operative pain and muscle spasm and prescribed strong analgesia (pain relief) and anti-inflammatory gargles (solutions used to treat throat conditions). We upheld Miss C's complaint and made two recommendations. Our investigation found that, while the GP's diagnosis and the medication prescribed were reasonable, his advice to attend ENT was not helpful.

Mr C complained that when his late father (Mr A) went to his medical practice in December 2011 they did not fully assess his condition and showed a lack of urgency in following up with his father. Mr A had a history of myeloma (cancer of the bone marrow) and had received treatment, including a stem cell transplant, between 2009 and 2011. In late 2010 and in November 2011 Mr A was told there was no trace of the disease left. In late November and early December 2011 Mr A started to complain of breathlessness, weight loss, decreasing energy levels and back pain. His son and wife were concerned and persuaded him to speak to his GP on 6 December, as he was due to attend the practice that day for blood tests. Mrs A accompanied Mr A to the surgery and when she realised that Mr A was only due to see the practice nurse for the blood tests, asked that Mr A be seen by a GP. One of the GPs (not Mr A's regular GP) saw Mr A as an emergency appointment. Although they examined him and made notes, our investigation found that there was no record of the presence or absence of anaemia (iron deficiency) or of the standard observations of pulse, temperature, respiration rate etc that would be expected for a patient reporting the symptoms that Mr A was suffering. The GP diagnosed a chest infection and prescribed an antibiotic. He told Mr A to make a follow-up appointment for seven days time, at which blood tests would be taken if there was no improvement in his symptoms. Mr A forgot to make the follow-up appointment but six days later his son was so concerned that he tried to speak to Mr A's regular GP but was unable to do so. He did manage to speak to her the following day and she arranged urgent blood tests. The laboratory that conducted the tests were so concerned by the results that they contacted the local out-of-hours GP service that evening. A GP reviewed the results and notified the practice, but considered that a full GP review could wait until the next day. Mr A saw

Mr C complained when his local medical practice decided to remove him from their patient list. His new medical practice is located some miles from his home and getting to it causes him inconvenience and expense. Mr C said that he did not understand why he had been removed from the practice list. Our investigation found evidence that the practice had properly explained their decision, and the reasons for it, to Mr C and had then removed him from the list. However, we upheld the complaint because they had not issued Mr C with a warning about his behaviour in the twelve month period leading up to the decision, which they were contractually obliged to do.

Ms A requested that her first appointment with a new medical practice be longer than usual. Ms A was late for the appointment, and when the GP refused to see her she became upset. She wrote a letter about the situation while she was in the practice but this was not responded to. Within a few days she was informed that she had been removed from the practice list. Ms A's representative (Ms C) complained to the practice on her behalf. They replied, saying that their views about the length of the scheduled appointment, how late Ms A had been and the behaviours she had displayed were different from those of Ms A. Ms A was dissatisfied with their response and raised her complaints with us. We decided that the practice had reasonably fulfilled a request for a prescription and passed Ms A's records to her new practice. However, as they had not met the requirements of the relevant regulations for the immediate removal of a patient from a treatment list, we upheld Ms A's complaint that her removal had been inappropriate. We also upheld Ms A's complaint that the practice did not respond reasonably to complaints submitted about this matter.