SPSO Individual Decisions

Mrs C contacted the practice about appointments for her sons. She was unhappy with the way in which the practice handled her contact. She felt that the practice manager had breached confidentiality by referring to a previous conversation she had had with a GP at the practice about one son when she was calling about her other son. She also felt that the practice had not acted correctly in relation to allegations that she was abusive and that she was told to go elsewhere. She was also unhappy that they had noted on her medical records that she was more interested in her sons' rights than taking them to review appointments. Following consideration of Mrs C's complaint to the practice and to us, the practice's response to her complaints as well as the information the practice provided to us following our enquiry (which included records of the conversations Mrs C had had with the practice), we did not uphold Mrs C's complaints. We felt it was reasonable for the practice manager to refer to previous conversations between Mrs C and the practice in so far as it related to her own actions and behaviour, rather than the specific medical conditions of her sons. The notes of the conversations did not indicate that Mrs C was abusive, rather that she was upset and excessively angry. Given the circumstances, we considered that the practice's handling of Mrs C's contact, which was to put a note on her record that any future issues are fed back to the practice manager, was a reasonable way to proactively manage internally any potential issues with future contact. There was no record in the practice's notes of the conversation that Mrs C was told to go elsewhere and the practice and Mrs C had differing recollections of what was said. It was not possible, therefore, for us to determine exactly what was said. Although we understood that Mrs C was unhappy about what was written in the record about not taking her sons to review appointments, we considered that the practice's ex

Mrs C, an advocacy worker, submitted a complaint on behalf of her client (Ms A) regarding the care and treatment received by Ms A's late brother (Mr A) from his medical practice. Ms A complained about the time taken for the practice to diagnose her brother's cancer and about a failure to involve her in his care and listen to her concerns about his deteriorating condition. Mr A had a history of mental and physical health problems and had been diagnosed with renal cancer several months after being discharged from hospital, where he had been an in-patient for over 15 years. After being diagnosed with cancer, Mr A died the following month. We took independent medical advice from a GP. The adviser did not consider that there were any unreasonable delays in investigating Mr A's symptoms and referring him to a hospital specialist. They noted that the practice took reasonable steps to try to have hospital investigations happen sooner and remained alert to the potential need for hospital admission. The adviser observed that Mr A had capacity and was entitled to decline investigation, as he did on occasion. However, they considered that the relevant investigations were carried out and that additional assessments, at the times these were declined, would not have changed Mr A's diagnosis or treatment plan. They also considered that, from the available evidence, Mr A's care appeared to have been appropriately discussed with Ms A and her concerns taken into account. We accepted the advice received and did not uphold the complaints. Related reading View Decision Report 201406036 as a PDF (11.38 KB) Updated: March 13, 2018

Miss C complained about the care and treatment her baby son received from the GPs at the practice. Miss C said she attended the practice a dozen times over a three-month period as her son was continually crying and was in great distress. Miss C raised a number of issues about her son’s care. She said that the GPs at the practice unreasonably failed to listen to her concerns about her son’s health. She said that they failed to ask relevant questions which might have helped get to the bottom of her son’s problems sooner. She also said that they did not recognise when they were out of their depth and needed to refer her son to more specialist medical staff. Miss C said that eventually a referral was made to the Royal Hospital for Sick Children, where severe reflux and colic was diagnosed as the cause of her son’s symptoms. We obtained independent medical advice on the complaint from a GP adviser. The adviser said that the GPs at the practice listened to Miss C’s concerns and tried reasonable medication options. The adviser said that, when there was no evidence of consistent improvement, they arranged specialist referral to a dietician and a paediatrician (a doctor dealing with the medical care of infants, children and young people). The adviser said that the practice’s response was reasonable, referral occurred early on in the consultation history and there was no evidence of delay in referral. The adviser found no evidence that the GPs failed to ask relevant questions which might have helped diagnose Miss C’s son’s medical problems sooner, or that the GPs treated him beyond their competencies. The adviser also indicated that the GPs acted in accordance with relevant national guidelines and Lothian NHS board’s policy. Related reading View Decision Report 201500502 as a PDF (11.41 KB) Updated: March 13, 2018

Mrs C complained that GPs at the practice failed to provide her late husband (Mr C) with appropriate treatment over an eight month period. Mr C had reported symptoms of stomach pains and cramps and, despite changes to his diet and medication, the symptoms persisted. Eventually Mr C asked to be referred to a gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) where it was diagnosed that he had a bowel blockage which turned out to be cancerous. The practice said that Mr C had shown signs of severe diverticulitis (a disease of the digestive system) for many years but had refused to give permission for investigations during that time. It was only recently that he had given permission for a referral to be made to hospital specialists who confirmed the diagnosis. Mrs C did not believe that the practice had sent reminder letters to Mr C and said that the practice should have followed this up. We took independent advice from one of our GP advisers. We found that the practice had acted appropriately in that they had documented that they had advised Mr C of the risks should he fail to have further investigations carried out. They also explained what further investigations were required and that it was his decision whether or not to agree to the further investigations and that he should reconsider the options at regular intervals. The practice were not responsible for arranging the further investigations but would have referred Mr C to hospital specialists who would decide which further investigations were appropriate. Related reading View Decision Report 201500087 as a PDF (11.37 KB) Updated: March 13, 2018

Mr C complained about the care and treatment given to his son (Mr A) in the month before he died. Mr A had two consultations at the practice during this period. During the consultations he expressed concern about his mental health. At his second appointment he saw a locum GP, who noted that his mood was lower. They discussed whether he should be off work, and he was prescribed anti-depressants. He also completed two questionnaires in a public place within the practice. He later reported to Mr C that he had found it difficult to complete these in such a public place. Nine days later Mr A took his own life. The GPs involved both met with Mr C and his family in the weeks after his death, and a significant event analysis (SEA) was conducted four months later. Mr C complained that Mr A was not given enough support when he needed it, that he should have been signed off work, and that the locum GP should have had greater involvement in the SEA. We sought independent advice from one of our GP advisers, who reviewed Mr A's notes. She said that, on the basis of these notes, the discussions at both appointments had been reasonable, that due consideration had been given to Mr A's symptoms, and that his subsequent death could not have been predicted. The adviser was also satisfied that the SEA was in line with NHS guidance. We considered that, while Mr A's death was tragic and a sad loss for his family, the care and treatment he had from the practice was reasonable, and the GPs involved could not have predicted that his mental health would decline as it did. We were satisfied that the SEA had been conducted in a reasonable manner, and appropriately took into consideration a report provided by the locum GP. Related reading View Decision Report 201502006 as a PDF (11.44 KB) Updated: March 13, 2018

Mr C complained to us that the medical practice had failed to provide appropriate care and treatment to his daughter (Miss A). He said that the practice had failed to act on Miss A's symptoms despite a history of abnormal smears and his view was that there was a delay in diagnosing cancer. Mr C also complained that during her treatment Miss A was asked to re-register with another practice as she had moved home and had therefore moved out of the practice catchment area. The practice had reasoned that Miss A may have needed access to district nurses which they would not have been able to provide if Miss A was outwith their area. Mr C felt this was insensitive. The practice provided records that showed that they had issued an urgent referral and their view was that they had taken appropriate action. We took independent advice from an adviser in general practice medicine and concluded that the practice had provided a reasonable level of care. The complaint about treatment was not upheld. The adviser also said that although under the General Medical Services contract the practice had the right to ask Miss A to re-register with another GP as she had moved out of their catchment area, it was inappropriate to ask her to do so given that she was undergoing treatment and that she would be unlikely to need the services of district nurses. Therefore, we upheld the complaint about the timing of the practice’s request to re-register.

Mr C underwent an x-ray to investigate back pain he was experiencing. The report of this x-ray also recorded the possible presence of an aortic aneurysm (swelling of the main blood vessel that leads away from the heart and down the body). The report recommended that Mr C's GP arrange for him to be sent for a further ultrasound to assess it further. Mr C was not informed of the presence of the aortic aneurysm and no ultrasound was arranged. Mr C complained that this was unreasonable. We found that the practice had recognised the error, which occurred because the GP who recalled Mr C for an appointment was not the GP who saw Mr C. In order to prevent this happening again the practice had altered their report handling procedures. The practice apologised to Mr C. We took independent advice from one of our GP advisers. The adviser confirmed that the practice should have arranged for an ultrasound to be carried out. The adviser was satisfied that the action taken by the practice since the error was brought to their attention was reasonable and sufficient. We upheld this complaint. However, in light of the action already taken by the practice we had no further recommendations to make in that regard. As their complaints handling procedure was not in line with government guidance, we made a recommendation to address this.

Miss C complained about three consultations with three of the GPs at her medical practice as she did not feel the questions asked by the GPs had been appropriate. We took independent advice from one of our GP advisers, who considered that the questions and actions of Miss C's GPs had been thorough and appropriate. For example, when Miss C reported an episode of self-harm, the GP appropriately asked, amongst other things, about her support network at home. Related reading View Decision Report 201405489 as a PDF (10.8 KB) Updated: March 13, 2018

Ms C complained that her mother (Mrs A) had not been provided with a reasonable standard of treatment by her medical practice. She felt the practice had unreasonably handled much of Mrs A's contact over the phone and, following hospital investigations and tests, that the practice had failed to take the appropriate steps. We considered whether Mrs A's treatment was reasonable in the circumstances at the time. We took independent advice from one of our medical adviers, who explained that managing contact over the phone is common practice, and that there was nothing to indicate it had been done unreasonably in this case. Our adviser also said that it was the hospital doctor's responsibility to explain hospital test results and, in any event, the practice had not misinterpreted hospital correspondence as Ms C felt they had. Although we took Ms C's concerns into account and recognised her strength of feeling, the medical advice we received was that the records did not indicate that Mrs A's treatment had been unreasonable. We did not consider the evidence indicated that Mrs A's practice had failed to provide her with a reasonable standard of medical treatment, and so we did not uphold this complaint. Related reading View Decision Report 201404869 as a PDF (11.16 KB) Updated: March 13, 2018

Miss A had provided a urine sample at the practice which was to be sent away for testing. Mrs C, who complained on behalf of Miss A, said that when a colleague called to check on the results for Miss A, the practice said that they could not trace the sample. Mrs C complained to the practice in August 2014 and received a response in October 2014. Mrs C complained to us that the practice had failed to properly process Miss A's urine sample and failed to properly handle her complaint. We took independent medical advice from our GP adviser, who said that there was no recognised system to check that samples had left the practice and arrived at the laboratory, and that the sample going missing was likely due to an administrative difficulty which would be difficult to trace the origin of. In addition our adviser said that the response from the practice was reasonable and Miss A had come to no harm. Therefore, we did not uphold Mrs C's complaint about the loss of Miss A's urine sample. We upheld Mrs C's complaint about the practice's handling of her complaint. We found that the practice had failed to observe their own policy in terms of timescales for responding to complaints, and had not made any apology for the delay in their response.

Mrs A had fallen at home and sustained a head injury and suspected fractured hip. She had contacted the medical practice and a GP attended and decided that she required to be taken to hospital. The GP arranged that an ambulance should attend within an hour and left Mrs A with a neighbour to wait for the ambulance. Mrs A's daughter (Mrs C) complained that the GP should have arranged an emergency ambulance and should have waited with Mrs A, who is elderly, until its arrival. The practice maintained that Mrs A was stable and the situation was not life-threatening and the GP was satisfied that she did not need to wait for the arrival of the ambulance. We took independent medical advice from one of our GP advisers, who said that given the situation, Mrs A required an immediate ambulance and the GP should have remained with her in case she deteriorated. The adviser noted that Mrs A was immobile; had symptoms of a hip fracture; had a significant head injury which was bleeding; was unable to recall how the fall occurred; and had a complex medical history. Our adviser was also concerned that the GP had noted the possibility that Mrs A may have required a brain scan to rule out any possible bleed to the brain. In light of this advice, we upheld Mrs C's complaint that the GP failed to provide Mrs A with appropriate medical treatment when she attended the home visit.

Ms C complained about the care and treatment she received from her medical practice. She was unhappy they had not given her a clear diagnosis for her symptoms over an extended period of time, and felt they had delayed in telling her about the diagnoses they actually had made in this time. As part of our investigation we took independent advice from one of our medical advisers, an experienced GP, who reviewed Ms C's medical records. He said the paperwork indicated that the practice had tried to address her concerns and their steps had been reasonable. Although he acknowledged they may not have explained Ms C's symptoms to her satisfaction, the evidence did not indicate they acted unreasonably. In addition, as most diagnoses were actually made by hospital doctors following referrals by the practice, our adviser explained that it would mainly have been for the hospital doctors to tell Ms C about her diagnoses. Our adviser said the records indicated that the practice had been reasonable in communicating any diagnoses they had actually made to Ms C. Our role was to make a decision about the reasonableness of Ms C's care and treatment based on the available evidence. Some conditions are particularly difficult to diagnose and treat, and the absence of a clear diagnosis would not necessarily mean that the practice had acted unreasonably. Although we recognised how significant this matter was for Ms C, we did not uphold her complaints as we received clear advice that her care and treatment was of a reasonable standard. Related reading View Decision Report 201305181 as a PDF (11.31 KB) Updated: March 13, 2018

Mrs C took her young daughter (Miss A) to her medical practice as Miss A had a high temperature that would not come down, despite being given paracetamol. Mrs C said her daughter was shivering and was having difficulty catching her breath. Mrs C said that at the appointment the GP described Miss A's condition as a chest infection and prescribed antibiotics. Miss A was later admitted to hospital suffering from pneumonia (a lung infection). Mrs C said that the GP should have told her that he suspected pneumonia, rather than describing her daughter's condition as a chest infection. She thought that her daughter should have been referred for further tests and investigations at the appointment, rather than being sent home with a prescription for antibiotics. Mrs C also said that the practice had failed to handle her complaint appropriately. She said that, at a meeting, the GP seemed more upset about her complaint than about Miss A's experience, which had left her traumatised with a fear of hospitals and doctors. We took independent advice from one of our medical advisers. The adviser said that the evidence showed that the GP recorded a diagnosis of suspected pneumonia in his notes, and prescribed antibiotics for treatment at home, in line with national guidelines. He also said that there was no evidence that Miss A had not received an acceptable standard of care. Our investigation also found that the practice carried out a thorough investigation into Mrs C's complaint. They provided an explanation for the remarks made by the GP at the meeting with Mrs C and where they identified learning points they took action to address them. We found that the practice had responded appropriately to Mrs C's complaint. Related reading View Decision Report 201304451 as a PDF (11.43 KB) Updated: March 13, 2018

Case ref: 201305859 Date: November 2014 Body: A Medical Practice in the Lothian NHS Board area Sector: Health Outcome: Not upheld, no recommendations Subject: clinical treatment / diagnosis ummary Mr C complained to us about the care and treatment given to his late wife (Mrs …

Mr C complained that his former medical practice did not keep correct medical records and failed to give him the correct care and treatment. He also complained that the practice dealt inappropriately with urine samples presented for testing. We obtained independent advice on the complaint from one of our medical advisers, who is a GP, and considered all the relevant information, including Mr C's medical records and the complaints correspondence. Our investigation found no evidence to suggest that the practice had failed to keep correct records and the records showed that Mr C had been appropriately treated for his symptoms. We also found that five urine samples were taken, all of which were presented for results which were also recorded. Related reading View Decision Report 201305386 as a PDF (10.92 KB) Updated: March 13, 2018

Mr C complained that he was prescribed medication that caused an unpleasant side effect. He said he had not been fully informed of the possibility of experiencing this side effect. We took independent advice from one of our medical advisers, who said that GPs are only required to mention the most common side effects. The adviser said that the patient information leaflet provided with the medication details all the other possible side effects and advises patients to report to their GP immediately if they experience any of these. The adviser also said that it was not certain that the medication Mr C complained about was what was causing the side effect. In light of the advice received we did not uphold the complaint. Related reading View Decision Report 201402507 as a PDF (10.92 KB) Updated: March 13, 2018

Mrs C complained about the medical care and treatment the medical practice gave to her late husband (Mr C). In particular, she was unhappy that he was not referred to hospital earlier. During our investigation, we obtained independent advice from one of our medical advisers, who is a GP. We found that for the most part the treatment provided to Mr C was reasonable and appropriate. The adviser said that, although some GPs might have considered referring him to hospital earlier, the practice had acted within national guidelines and it was not unreasonable that Mr C was not referred earlier than he was. The medical records showed that the practice had been attentive and had managed Mr C's care as best they could. We were, however, concerned that there was no evidence in the records that the practice had recognised and considered Mr and Mrs C's distress when deciding how best to progress his care. We were also concerned that there was no evidence to support the practice's position that Mr C was involved in the decision-making process. As a result we made a number of recommendations to further improve practice.

Ms C complained that a consultation that her late husband (Mr A) had at his medical practice was unreasonable, and was unhappy with their handling of her subsequent complaint. Mr A had been suffering from a cough and loss of appetite, and was due to see his GP but as his condition had worsened he arranged an earlier emergency appointment. The GP examined him and diagnosed pneumonia. He prescribed an antibiotic (a drug used to fight bacterial infections), took blood samples for testing, completed a referral form for Mr A to take to his local hospital for a chest x-ray later that day and planned to review Mr A again in one week, or earlier if his condition deteriorated. Mr A returned home, and, sadly, his teenage son found him dead there some three hours later. Ms C complained to the practice in July and September 2013 and the GP responded in July and October 2013. Ms C was dissatisfied with the responses and asked us to look at her complaint. Our investigation, which included taking independent advice from one of our medical advisers, found that there were some failings in the GP's actions and his recording of the consultation and we upheld this part of Ms C's complaint. The adviser said that although the GP had noted some observations, other key observations (such as blood pressure, temperature, and respiratory rate) were not recorded. The adviser said that, although there was no indication that Mr A needed to be immediately admitted to hospital, the lack of these recordings were of concern where a patient had been diagnosed with pneumonia. The adviser also noted that guidance on the management of lower respiratory tract infections (SIGN 59), issued by the Scottish Intercollegiate Guidance Network (SIGN) recommended that two different, but complementary, types of antibiotic should be prescribed for patients with suspected pneumonia. SIGN 59 also recommended review in 48 hours rather than the one week planned by the GP. Overall, the adviser was of the view

Mrs C went to her medical practice because she had been having headaches for a few months. She was given migraine medication to try, and an appointment was made for her to come back a week later. Mrs C did not go to the appointment but had called NHS 24, where the on-call doctor thought she might have acute sinusitis (inflammation causing facial pain). Later that month, Mrs C went back to the practice with her sister. She said the medication had not worked. She also had other problems, including being increasingly unable to socialise or attend to her personal hygiene. She was treated for sinusitis, but her symptoms became even worse, and she went back to the practice at the end of the month. She described increasing withdrawal, problems with her eyesight and that she had been off work for a number of weeks. The day after this appointment, NHS 24 were called again, and Mrs C was immediately admitted to hospital for a scan. She was diagnosed with a brain tumour and had an operation to remove it. Mrs C complained that the GP at the practice failed to pick up on her serious illness and refer her to hospital. She said that as a consequence her life had been put at risk. We obtained all the complaints correspondence and Mrs C's relevant clinical records and took independent advice from one of our medical advisers, who is a GP. Our investigation found that the GP missed a number of classic features associated with brain tumours. The adviser said that on her second visit to the practice Mrs C was demonstrating enough of these to merit urgent referral. He said that although some of the changes could be interpreted as being associated with depression, in his opinion that would be a secondary consideration in a patient with persistent headache and such a significant change in personality. The symptoms should have alerted the GP to a possible serious diagnosis and she should have made a comprehensive assessment including a detailed clinical examination, then refer

Mr C complained that his GP practice failed to properly diagnose his symptoms for several years, and did not undertake a simple blood test that finally revealed the cause of his illness. However, as he did not then respond to our correspondence, we were unable to investigate his complaint, and closed his case. Related reading View Decision Report 201305207 as a PDF (10.73 KB) Updated: March 13, 2018

Mr A had been suffering from a number of serious medical conditions including lupus (an autoimmune condition that affects the body's defences against illnesses and infections). Mr A was discharged from hospital into the care of his medical practice. He was readmitted several days later, after a visit from an out-of-hours doctor, and died the day after readmission. Mr A's son (Mr C) complained that after Mr A was discharged from hospital there was a lack of reasonable care by the practice. Mr C was concerned that no doctor from the practice visited his father at home, despite both Mr A and Mr C speaking to different doctors there. In response to the complaint, the practice said that they would not routinely visit a patient after they were discharged from a hospital unless there were special circumstances. They took the view that there were no urgent concerns about Mr A at that time. They had received Mr A's discharge summary from the hospital after he had already been at home for several days. Doctors in the practice had spoken with both Mr C and Mr A by phone, and with the district nurse who had been visiting Mr A at home, and the practice had arranged for a doctor to visit Mr A at home in the coming days for review. We took independent advice about the complaint from one of our medical advisers. The adviser was of the view that the practice had not failed in their care of Mr A, and that the hospital discharge letter, received several days after Mr A's discharge, did not indicate any issue that needed a doctor to visit. In addition, the adviser said that the information that Mr A, Mr C and the district nurse gave the practice did not highlight anything suggesting that Mr A needed to be reviewed sooner than planned. We accepted the adviser's view that, from the information presented to the practice at the time, the care and treatment they gave Mr A after he was discharged from hospital was reasonable and appropriate. Related reading View Decision Report 201

After Mr C suffered blackouts and dizziness in 2009, a GP at his medical practice diagnosed hypertension (high blood pressure). Mr C said he made many visits to the practice after that with symptoms that including falling asleep involuntarily during the day. In August 2010, he told them that he was suffering numerous headaches, he felt dizzy and faint and felt he was going to collapse. In 2012, the GP prescribed an anti-depressant, saying that Mr C's problems were related to his mental health and that an appointment would be made with a psychiatrist. When abroad later that year, Mr C saw an ear, nose and throat surgeon, who diagnosed a number of problems, including hypertension and problems with his nose and airways linked to breathing difficulties. The surgeon referred Mr C to hospital there, where he was diagnosed with obstructive sleep apnoea (OSA – a sleep disorder). He said he was given medical advice, including that he should stop taking the anti-depressant as it was dangerous, given his condition. When he returned to Scotland and went to the practice, they stopped the anti-depressant medication. He told them about the diagnosis of OSA and was referred to a sleep clinic the following month. Mr C complained that GPs at the medical practice failed to diagnose OSA in 2009. He said that they then continued to maintain that his condition was psychological, and unreasonably failed to accept the diagnosis of sleep apnoea. He said his life was put at risk because of the misdiagnosis. We took independent advice on this case from one of our medical advisers, who is a GP. Their advice, which we accepted, was that the GPs at the practice acted reasonably in the way they approached Mr C's multiple symptoms. The diagnosis was, however, potentially delayed by the lack of good communication at all consultations, and the adviser noted some issues regarding Mr C's compliance with appointments and medication. This might have partly arisen through a lack of understan

Mrs C complained on behalf of her late brother-in-law (Mr A) that the medical practice delayed twice in referring him to hospital. Mr A visited his GP nine times between September 2011 and November 2012, with various symptoms, including a sore throat. He was finally referred to the ear, nose and throat (ENT) department in November 2012, and was diagnosed with throat cancer, for which he had surgery and radiotherapy. When he then reported ear pain to the ENT surgeons he was told that this was likely nerve damage following his treatment. He continued to experience pain and in May 2013 went to his GP. The GP found evidence of inflammation, prescribed various drops, and told Mr A to come back if the pain did not resolve. Mr A went back to the practice the next week and saw a locum (temporary) GP who diagnosed nerve damage and prescribed a drug for nerve pain. He also advised Mr A to come back if the pain did not stop. Mr A contacted the practice by phone a week later and told another GP that he was still in pain. The GP made an urgent referral to ENT that day, and Mr A was seen by an ENT consultant some four days later. After further investigations he was diagnosed with inoperable throat cancer in July 2013 and he died in January 2014. Our investigation included taking independent advice from one of our medical advisers, who is a GP. We did not uphold the first complaint as the adviser said that there was no unavoidable delay in making the first referral to ENT. The clinical records showed that although Mr A reported throat pain on some occasions, this was not a constant feature and there was evidence that at times certain treatments resolved or improved this. When, however, Mr A reported a 'red flag' symptom (a symptom especially likely to indicate a particular serious illness) in November 2012, the GP had spoken to an ENT specialist and urgently referred Mr A that day. On the second complaint, the adviser found that there was a delay of one week between Mr

Mrs C's late father (Mr A) saw a GP at his medical practice about, amongst other things, a cough. He had a chest x-ray, the results of which were normal. Some seven months later, in June 2012, he had three further consultations at the practice about chest problems and a persistent cough, and a further chest x-ray, taken after the third appointment showed an abnormality in the lung. After collapsing and being admitted to hospital, Mr A went to the practice again in July and was referred urgently to the respiratory clinic because of his persistent cough. Mr A also attended a cardiology (heart) clinic where a scan was arranged. The clinic told the practice that the scan showed that Mr A might have a pulmonary (lung) tumour. The respiratory clinic then found that the scan showed metastatic malignancy (cancer that had spread) in his lung. They wrote to the practice about this and said they had not discussed the potential diagnosis with Mr A but had told him that there was a shadow on the lung that needed investigation. Several weeks later Mr A saw a GP, who did not explain the result of the scan but wrote in the medical notes that Mr A was aware that cancer was a possibility. Mr A was then referred to oncology (cancer specialism) and at the end of October a cancer nurse told the practice that Mr A had now been told his diagnosis. After this Mr A asked the practice for an appointment but they told him they could no longer treat him because he had moved out of their area. Mr A died shortly afterwards. Mrs C complained that the practice did not provide reasonable care and treatment to her late father. She said that they did not carry out appropriate investigations and/or tests within a reasonable time and failed to communicate with him and his family about his diagnosis. Mrs C was also concerned that the practice refused to treat him after he moved house, although he had been a patient there for over 25 years and they were well aware of his medical history. We

Mrs C's late father (Mr A) had moved house just as he had been given a diagnosis of terminal lung cancer. Because of this, he had de-registered from his previous medical practice, and registered as a new patient at the medical practice about which the complaint was made. The GP there noted the cancer diagnosis, and compiled a full summary of Mr A's medical history. The GP also referred him to hospital that day as he was acutely unwell. After his discharge, he was seen twice by GPs at the practice, and in the following month he was again admitted to hospital. He was discharged shortly after to the care of his GP and district nurses. The next month, Mr A was admitted again, by emergency ambulance. This time, when he was discharged his consultant advised the practice that any future admission should be to a hospice. Shortly after this, a GP visited him at home and noted how Mr A and his family were struggling and that the situation was difficult and stressful. The GP arranged a hospice bed for the following day and noted in the records that Mr A's wife (Mrs A) and family were happy with this plan. A specialist nurse also visited and, with the GP, provided specialised pain relief equipment. Mr A was admitted to the hospice the next day, and passed away during the early hours of the following morning. Mrs C complained about the end of life care provided to Mr A and that GPs showed a lack of care and empathy. She was unhappy that, after hospice care had been arranged, Mr A could not be admitted until the next day. She also told us that Mrs A was very distressed that during the time with the practice she had to explain her husband's medical history to a number of GPs. Mrs A had said that several of them appeared to have failed to read his clinical notes before visiting. We took independent advice on this case from one of our medical advisers. The adviser said that the practice provided a reasonable standard of care to Mr A in relation to pain relief and supp