SPSO Individual Decisions

Ms C complained on behalf of her mother (Mrs A) about the way her medical practice managed the medication for her thyroid condition. Mrs A had a condition called hypothyroidism (where the thyroid gland is underactive and does not produce enough thyroxine hormone) and had received treatment for this for a number of years. Mrs A had attended the practice for a blood test to measure her levels of thyroxine. When the test results showed that her thyroxine level was too high, a GP at the practice advised Mrs A to stop taking her thyroxine replacement medication and to attend the practice in six weeks to have the levels checked again. Shortly before Mrs A was due to return to the practice, she had a seizure and was hospitalised. Doctors at the hospital concluded that the seizure was caused by profound hypothyroidism following the withdrawal of thyroxine medication. Ms C complained that the medication should have been reduced more gradually and that follow-up tests should have been arranged sooner than they were. She also complained that Mrs A was not informed of the side effects of withdrawing the medication. We took independent advice from a GP adviser who said that there were a number of risks associated with high thyroxine levels. In view of this, they considered that the GP's decision to cease thyroxine medication and review Mrs A in six weeks was reasonable. They did not consider that Mrs A's rapid development of hypothyroidism followed by a seizure was predictable, and noted this was a rare complication of her condition. While there was no evidence that discussion of side effects had taken place, the adviser did not think it was unreasonable had the GP not discussed the rare complications of a seizure in the circumstances of this case. We did not uphold this complaint. Related reading View Decision Report 201604254 as a PDF (11.46 KB) Updated: March 13, 2018

Mrs C complained that the treatment the board provided to her son (Mr A) was not of a reasonable standard. The board carried out investigations about the role of their staff in the complaint. They found that Mrs C had not advised the board's staff of concerns about her son's health, and had only notified Mr A's social worker. Mrs C subsequently accepted that there was no complaint to pursue against NHS staff, and the investigation with our office was not taken any further. Related reading View Decision Report 201607896 as a PDF (10.82 KB) Updated: March 13, 2018

Mr C complained on behalf of his wife (Mrs A) that her medical practice failed to refer her to hospital for an audiology review as agreed during an earlier consultation. The practice apologised, but advised that the GP involved had no recollection of this agreement, nor was it recorded in Mrs A's medical notes. As we could find no additional evidence to allow us to conclude whether or not a referral was agreed, we did not uphold the complaint. Related reading View Decision Report 201603663 as a PDF (10.82 KB) Updated: March 13, 2018

Mr C complained that his GP practice failed to provide him with a GP appointment and a medical certificate for sickness absence. Mr C said he could not get a same day appointment when he phoned the practice in the mornings. We found there were other means of getting an appointment, such as booking online or booking an appointment for later in the same week. An audit of the practice’s appointment records showed there were appointments available in the week Mr C phoned the practice. We took independent advice from a GP adviser, and in their view the practice’s appointment system was reasonable. Mr C said because he could not get an appointment he could not get a medical certificate and, when he spoke to a GP by phone, the GP refused to issue a certificate. We found that the GP asked Mr C to make an appointment for review, given that his circumstances had changed. In the adviser’s view, the GP acted in line with the General Medical Council's guidance, and the care provided to Mr C was of a reasonable standard. We did not uphold Mr C’s complaints. Related reading View Decision Report 201606782 as a PDF (11.1 KB) Updated: March 13, 2018

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mr A). Mr A said that his medical practice had not provided him with reasonable care and treatment regarding blood tests and referral for specialist opinion. Mr A attended the practice from 2011 with a low platelet count and a lymphocyte (a type of white blood cell) count that was intermittently rising but still within the range that would be considered normal. Mr A was referred to the haematology department in 2012. He then attended the practice for blood tests several times from 2012 to 2015. The practice had requested advice from haematology in relation to follow-up and further tests but had not received this advice. The results of the blood tests carried out at the practice were similar to those in 2011 until 2015 when the lymphocyte count increased and tests indicated possible lymphoma (a type of cancer). We took independent medical advice from a GP adviser and found that the practice had acted reasonably in relation to blood taken and analysed at the practice, so we did not uphold the complaint. The practice had carried out an analysis of the events surrounding Mr A's case. The outcome of this was that advice requests to specialists would now be made in a way that would ensure a response regarding follow-up and advice.

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mr A) about the care and treatment provided by the practice to his late wife, (Mrs A). Ms C complained that the practice missed an opportunity to diagnose Mrs A with pancreatic cancer and that they failed to send her for a scan. During our investigation, we took independent advice from a GP adviser. We found that the symptoms Mrs A had presented with were not consistent with pancreatic cancer and, therefore, there was nothing that would alert the practice to the need to arrange further investigations or scans. Therefore, we did not uphold Ms C's complaint. Related reading View Decision Report 201601925 as a PDF (10.91 KB) Updated: March 13, 2018

Ms C complained about the care and treatment provided to her late mother (Mrs A) by her GP practice. Mrs A had hypertension (high blood pressure) and was prescribed multiple medications for this. Ms C expressed concern that this medication was not reviewed, despite it failing to control Mrs A's blood pressure. Ms C felt that this contributed to Mrs A suffering kidney failure and heart problems. We took independent GP advice and found that Mrs A had multiple health conditions, and that her treatment and blood pressure control were complex. The adviser noted that some of her medication was serving a dual purpose, such as controlling her blood pressure and fluid overload. The adviser considered that the practice took appropriate steps to monitor Mrs A, including active assessment of her hypertension and regular blood tests. They explained that the number of underlying conditions made it difficult to control Mrs A's blood pressure, but were satisfied that the difficulties were not due to a lack of care on the part of the practice. We accepted this advice and did not uphold the complaint. Related reading View Decision Report 201604171 as a PDF (11.14 KB) Updated: March 13, 2018

Ms C, who works for an advocacy and support agency, complained on behalf of Miss A that a locum GP working at her GP practice inappropriately prescribed her antibiotic medication which she was allergic to. Miss A suffered a severe allergic reaction to the medication, resulting in an emergency hospital attendance that evening. Ms C also complained that, when Miss A returned to the practice the following day, the GP failed to appropriately examine her allergy rash. We took independent medical advice and found that the medical records noted that Miss A had previously had a reaction to the medication. As it should not, therefore, have been prescribed, we upheld the complaint. However, it was noted that the GP had already acknowledged and apologised for the prescribing error, which we were assured was down to human error and not systemic in nature. We did not, therefore, make any recommendations in this regard. In relation to the subsequent attendance, the adviser noted that Miss A had already been examined and treated at the hospital the previous night and that a detailed examination was not required. We did not uphold this aspect of the complaint. Ms C also complained that the practice had not responded appropriately to the complaint. We noted that the practice passed the correspondence to the GP (who was by then working at another practice) to respond to directly. This resulted in delays. We concluded that the practice should have retained ownership of the complaint and managed it in line with their complaints process. We upheld this aspect of the complaint.

Miss C complained that her medical practice unreasonably removed her from the practice patient list because of comments which had been made on her social media site. The practice said that they would not tolerate such comments and that there had been a breakdown in the doctor/patient relationship which meant that it was not possible for them to treat Miss C. They considered the tone of the comments to be both threatening and bereft of any respect for the practice. We took independent advice from an adviser in general practice and concluded that the comments which were made could be reasonably interpreted as threatening to the practice and as such it was not unreasonable that Miss C was removed without a preceding warning. We found the practice had adhered to their contractual specifications in this regard and their actions were reasonable. We did not uphold Miss C's complaint. Related reading View Decision Report 201604142 as a PDF (11.04 KB) Updated: March 13, 2018

Mr C complained on behalf of his constituent (Mrs B). Mrs B was concerned about the care her mother (Mrs A) received from her medical practice. Mrs A was receiving palliative care in the home from Mrs B and the district nursing service. Mrs B was concerned that the GPs at the practice did not undertake home visits to provide medical and emotional palliative care support for her and her mother. In particular, Mrs B felt that a GP should have visited in the days prior to her mother's death. We took independent advice from a GP adviser. The adviser was satisfied that the GPs visited Mrs A on a reasonable number of occasions. Similarly, they did not find evidence that the GPs unreasonably failed to visit in the days before Mrs A's death and noted that the medical records did not indicate that an urgent home visit was clinically required at this time. Furthermore, the adviser did not consider that the practice had unreasonably failed to provide a reasonable level of support and guidance to Mrs B. We therefore did not uphold this aspect of Mr C's complaint. Mrs B also expressed concern that the practice had not responded to her complaint in a compassionate manner. We found that the practice had not followed their own complaints procedure in this instance in that they had not adopted as conciliatory and sympathetic a tone as possible when responding to the complaint. We further considered that the practice had failed to respond to the complaint in a person-centred way as required by the Scottish Government's 'Can I help you?' guidance for handling healthcare complaints. For these reasons, we upheld this aspect of Mr C's complaint.

Mr C, who works for an advocacy service, complained on behalf of Mrs B. Mrs B's husband, Mr A, was a patient at the medical practice. He initially attended with left-sided chest pain that he reported had been present on and off for months. An x-ray was arranged but this was normal. He went on to report neck pain and urinary symptoms. Mr A was later diagnosed with lung cancer which had spread to the vertebrae in his neck. His urinary symptoms were found to be unconnected to this diagnosis. Mrs B was concerned that the practice had not provided an appropriate level of care to Mr A. She said that his condition could have been diagnosed earlier and made particular reference to a scan which she felt should have been arranged. After taking independent advice from a GP, we found that Mr A had not been provided with appropriate medical treatment. While we found that a scan could not have been arranged for Mr A by the practice, he should have been referred to the local NHS board's respiratory team after he reported chest pain being present on and off for months, even though the x-ray was normal. The adviser highlighted that this action was supported by the Scottish Referral Guidelines for Suspected Cancer. We found that the other aspects of Mr A's care were reasonable.

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mr A) that there had been an unreasonable delay in the GP practice referring Mr A for further assessment and advice when he attended with on-going abdominal pain and diarrhoea. Mr A had undergone a colonoscopy (an examination of the bowel with a camera on a flexible tube) in hospital several months earlier and had been diagnosed with diverticulosis (small pouches that stick out from the wall of the gut). He had then had a bowel screening test, which showed blood in his bowel motion and his health board had written to him to say that they would arrange another colonoscopy. Mr A then attended the practice with abdominal pains and diarrhoea. He was prescribed medication and it was recorded that he was hoping to have a repeat colonoscopy from the board. He attended the practice again four weeks later and they sent a routine referral to the board asking for advice about whether he needed further investigation. Mr A was subsequently diagnosed with bowel cancer, which had spread to his liver and lungs. We took independent advice from a GP. We found that the practice had provided a reasonable standard of care to Mr A when he attended with abdominal pains and diarrhoea. The on-going investigation by the board into Mr A's bowel problems fell outwith the practice's remit. It was also reasonable for the practice to send a routine referral to the board asking for advice. We did not uphold Ms C's complaint. Related reading View Decision Report 201602908 as a PDF (11.35 KB) Updated: March 13, 2018

Mr C complained about care he and his wife (Mrs C) received from their medical practice. This related to the prescribing of medication to Mr C and a repeat blood test, the investigation and treatment of symptoms suffered by Mrs C and invitations sent regarding appointments. We sought independent medical advice on the complaint. The adviser had no concerns about the medical care provided by the practice and we did not uphold Mr C's complaints. However, during the investigation concerns were raised about the practice's complaints handling and a particular doctor's approach to complaints. For that reason we made a number of recommendations to address these concerns.

Ms C, who works for an advocacy and support agency, complained on behalf of her clients (Mr and Ms B) about care their daughter (Miss A) received from her medical practice. They also complained about the response to their complaint. Miss A attended her medical practice on three occasions over two months. On the third attendance she was seen by a locum doctor who urgently referred her to hospital where she was diagnosed with a brain tumour. Miss A died later that month. We sought independent medical advice. The adviser's view was that no symptoms were recorded at Miss A's earlier appointments that would have indicated a serious neurological problem and that the treatment given was reasonable. The adviser said the only significant symptom appeared in the last consultation, where Miss A was appropriately referred to hospital. For these reasons, we did not uphold this complaint. However, we did uphold Ms C's complaint about the practice's response to the complaint as there were unreasonable delays in responding and third-party information was included in the response when it should not have been.

Miss C complained to us that the practice had failed to provide her with appropriate care and treatment when she developed problems following back surgery. In particular, she felt that her GP should have taken a urine sample as she was having difficulty urinating and that as she was suffering from pain and swelling at the surgery wound site, a referral should have been made to a specialist consultant. Miss C continued to be in pain for a number of days before contacting the out-of-hours service where she was admitted to hospital for further surgery. The practice said that it was not appropriate to take a urine sample as the urinary symptoms which Miss C reported were consistent with a diagnosis of a urine infection and that appropriate antibiotics were prescribed. In regards to the wound site, it was felt that the problem was a build-up of fluid which would resolve naturally over time. We took independent advice from a GP and concluded that there was no requirement for her GP to take a urine sample as the diagnosis of a urine infection was reasonable. However, we found that the GP should have referred Miss C for an urgent specialist orthopaedic opinion as she had developed an acute complication following the surgery. Miss C's symptoms of swelling and pain at the wound site had only been present for three days but it had been three weeks since Miss C's original back surgery. We therefore upheld this complaint.

Mrs C complained to us about the care and treatment that her mother (Mrs A) had received from her medical practice before her death. Mrs C considered that Mrs A should have been admitted to hospital earlier and that her death could have been prevented. We took independent advice from a GP adviser. We found that the examinations carried out by the GPs and the treatment plan put in place for Mrs A had been reasonable. A urine infection had been treated appropriately with antibiotics and it had been reasonable to delay a blood test until she finished the antibiotics. The clinical entries in her records were of a reasonable standard and were in line with guidance from the General Medical Council. We also found that on the final occasion Mrs A was seen by the GPs, the treatment given to her in relation to her chest symptoms had been reasonable and in line with the relevant guidance. However, her condition deteriorated later that day. She was admitted to hospital and died on the following day. There was no evidence that Mrs A's death was caused by or hastened by the GPs' actions or that it could have been prevented. When Mrs A saw the GPs, there had been no indication that she should be admitted to hospital. We found that the care and treatment provided to Mrs A had been of a reasonable standard and we did not uphold Mrs C's complaint. Related reading View Decision Report 201507788 as a PDF (11.24 KB) Updated: March 13, 2018

Ms C complained about the care her mother (Mrs A) received from her medical practice. Mrs A had been experiencing diarrhoea for a number of weeks. The practice had prescribed medication, requested a stool sample and offered referral for a colonoscopy (imaging of the bowel). Mrs A later died in hospital. We sought independent medical advice. The adviser was satisfied the practice had provided a reasonable standard of care. We therefore did not uphold Ms C's complaint. Related reading View Decision Report 201602314 as a PDF (10.85 KB) Updated: March 13, 2018

Mrs C complained about a GP's consultation with her husband (Mr A). In particular she felt that that the GP had not taken into account that Mr A had cancer, had unreasonably missed the fact that Mr A had a deep venous thrombosis (DVT) and had inappropriately prescribed quinine. We took independent advice from a medical adviser and concluded that the GP had acted reasonably. In particular, they had taken account of Mr A's cancer, the DVT which Mr A had could not have been detected at the time and the prescription was appropriate. Related reading View Decision Report 201600866 as a PDF (10.85 KB) Updated: March 13, 2018

Ms C, an advice agency worker, complained on behalf of the family of Mrs A. Two GPs at the practice had visited Mrs A's home on request and diagnosed that she had a urinary tract infection, for which they prescribed medication. After the GPs left, the family tried to move Mrs A upstairs to her bedroom, but in the process she suffered a leg injury. An ambulance was called and she was admitted to hospital for that injury. The family complained that Mrs A was not very mobile and that the GPs should have admitted her to hospital, rather than simply leave them on their own to manage an elderly, immobile patient in a home with steep stairs. We took independent advice on this case from a GP. Our investigation established that the GPs had acted in line with guidance on hospitalisation in the SIGN guideline, 'The Management of Urinary Tract Infection in Adults'. (SIGN is the Scottish Intercollegiate Guidelines Network, which is an organisation that develops clinical guidelines for the NHS in Scotland.) In other words, they had appropriately identified that, in her case, Mrs A should be treated at home but that hospitalisation might become appropriate. The GPs had also appropriately arranged urgent referral to a multi-disciplinary team, who would be able to help Mrs A with self-care and mobilisation. The GPs considered that they had advised the family that Mrs A might need to remain downstairs initially. In the absence of independent evidence, the facts around this could not be established either way. The lead GP felt on reflection that he could have checked more whether the family had understood his advice and information, and said he would check this more in future cases. Related reading View Decision Report 201508443 as a PDF (11.49 KB) Updated: March 13, 2018

Mrs C complained on behalf of her late husband (Mr A) about care he received from his GP practice. Mr A attended the practice having been diagnosed with oedema (where fluid collects in the legs and abdomen). He had been prescribed medication to combat the oedema. Mr A was referred to his GP to investigate the cause of the oedema and the GP took blood tests, which were normal. The GP also noted that, apart from the oedema, there were no signs of heart failure. As Mr A was obese, and therefore at greater risk of heart problems, the GP referred him for an echocardiogram (a heart scan that uses sound waves to create images) to investigate any potential heart problems. Mr A passed away before he was seen for a heart scan. The cause of death was an enlarged heart. We took independent advice from a medical adviser. The adviser was satisfied that the practice had made appropriate investigations into Mr A's symptoms and made an appropriate referral. For this reason, we did not uphold the complaint. Related reading View Decision Report 201502987 as a PDF (11.12 KB) Updated: March 13, 2018

Mr C complained that his former GP practice unfairly refused a repeat prescription and removed him from their practice list after he complained about the matter. We took independent advice from a GP adviser and found evidence to show that the repeat prescription had been lost or mislaid by the practice and this had not been explained by the reception staff to the GP who had been asked to reissue it. It was only at Mr C's persistence that he managed to receive his medication a few days later after attending the practice on several occasions. We also considered that the practice had not investigated and responded appropriately to this aspect of Mr C's complaint. We identified that the practice had not followed General Medical Services (GMS) contractual guidance, nor their own policy, when they removed Mr C from the practice list without issuing a warning. We concluded that the practice failed to address Mr C's concerns in a professional manner and that they resorted to unreasonably removing him from the practice list causing him unnecessary distress and inconvenience.

Ms C attended an appointment at her GP practice with a three-week history of constipation, vaginal bleeding and abdominal pain. Ms C was asked by her GP if she could be pregnant and Ms C said she was not. Ms C carried out a pregnancy test that same evening, and it showed that she was in the early stages of pregnancy. Ms C subsequently had three phone consultations with the practice over the following days. Ms C was advised to contact the Early Pregnancy Assessment Service who informed her that, given her symptoms, she may be having a miscarriage. An appointment was made for her to have a scan the following week. When Ms C attended her appointment, the scan revealed she had an ectopic pregnancy and required emergency surgery. Ms C was unhappy with the care and treatment she received at the practice. She complained about the attitude of one of the doctors who she felt did not listen to her and treat her with sensitivity. Ms C also said that she was not prescribed antibiotics for a urinary tract infection until she insisted and she was not offered an examination even though she was pregnant. We took independent advice from a GP. They considered that the care and treatment provided to Ms C at her appointment and during the first phone consultation was appropriate and reasonable. In relation to the second phone consultation which involved the doctor Ms C was unhappy with, there were different versions of what had occurred which we were unable to reconcile. The advice we received was that based on the information provided in the medical records, the doctor's actions in relation to Ms C's clinical treatment were reasonable. However, it appeared that the doctor had not meaningfully engaged with Ms C. We also found that during the third phone consultation with another doctor, that doctor had failed to take into account the relevant guidance on the management of bacterial urinary tract infections in pregnant women and had failed to follow appropriate prescribing g

Mr C was suffering from hoarseness and was referred to hospital by the medical practice for an out-patient appointment at the ear, nose and throat (ENT) department. He was seen by a consultant who identified no suspicious findings and he was discharged back into the care of the practice. Mr C continued to have the same symptoms and was re-referred some time later. He was later seen by a speech and language therapist who identified possible malignancy in the voice box and thereafter, Mr C was diagnosed with cancer. Mr C complained that there had been unreasonable delays in referring him for a further ENT appointment and that the practice's communication with the hospital had not been adequate. After taking independent advice on this case from an adviser, who is a general practitioner, we did not uphold Mr C's complaint about delay in referral. We found no evidence that there had been unreasonable delay in making referrals and the adviser explained that it was reasonable for doctors at the practice to have been reassured when the initial ENT consultation revealed no sinister findings. Although the adviser considered the majority of the practice's communication with the hospital to have been reasonable, we upheld Mr C's complaint about communication as we found that the initial referral to ENT was categorised as routine, rather than urgent in line with the relevant guidance. The advice we received, however, was that this had no impact on Mr C as the subsequent ENT consultation had not identified any sinister findings. We made a recommendation to the practice to ensure they are aware of the issue.

Miss C attended the practice on a number of occasions for acute stomach pain, and was treated with omeprazole (medication for an acid-related stomach disorder or ulcer). Miss C then visited a private GP, who suggested she try esomeprazole (another stomach medication). Miss C told the practice this gave her some relief from her symptoms, and they gave her a repeat prescription. The practice also referred Miss C to a gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) when she requested this (about six weeks after she first reported symptoms). Miss C later arranged a private endoscopy overseas, which showed that she had probably had a stomach ulcer which had now healed. Miss C complained that the practice failed to diagnose a stomach ulcer and delayed in referring her to gastroenterology. She was also unhappy that the practice did not prescribe esomeprazole until she had received this from a private GP, and she raised concerns that her ulcer could have been caused by the practice prescribing ibuprofen in the past. After taking independent advice from a GP, we did not uphold Miss C's complaints. We found that the practice's treatment was reasonable, and in line with national guidance on dyspepsia (indigestion) at the time. The adviser explained that Miss C did not have any 'alarm features' to warrant referral to gastroenterology, and omeprazole was an appropriate medication to treat both ulcers and gastritis (inflammation of the stomach). The adviser said Miss C did not take this medication for a long enough period to know whether or not it was effective (before switching to esomeprazole). The adviser also considered that it was reasonable that the practice previously prescribed ibuprofen (while this can cause either ulcers or gastritis, this is rare in patients under 60). Related reading View Decision Report 201501702 as a PDF (11.52 KB) Updated: March 13, 2018

Miss C complained about care her late mother (Mrs A) received from the medical practice. Mrs A had experienced chest pains and called an ambulance. Paramedics came to Mrs A's home and carried out an echocardiogram (a way of monitoring the heart). The paramedics did not believe Mrs A was suffering angina (chest pain caused by a problem in the blood supply to the heart) or a heart attack. They offered to take her to hospital. Mrs A, however, declined and said she would attend her GP the next morning. Mrs A attended the practice the following morning, where she was seen by a GP. She was diagnosed with acid reflux and was prescribed medication for this. Mrs A passed away at home later that day. We took independent advice from one our medical advisers who is a GP. They considered the evidence and found that the GP who treated Mrs A had made a reasonable diagnosis based on the symptoms at the time, and the previous advice of the paramedics. Therefore, we did not uphold the complaint. Related reading View Decision Report 201504465 as a PDF (11.13 KB) Updated: March 13, 2018