SPSO Individual Decisions

C complained about the care and treatment provided to their late child (A) by the medical practice. C was concerned that A had been misdiagnosed by their GP during a telephone appointment. During the appointment, A reported shortness of breath, experiencing breathlessness, and feeling faint when walking upstairs and putting on their shoes. A was diagnosed with anxiety and prescribed a beta blocker (drug that blocks the action of hormones like adrenaline). Later that week, A died suddenly due to pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung). C raised concerns that there was a delay in A receiving treatment, the treatment that A received was inappropriate, and that harm was caused as a result of A being given the wrong treatment. We took independent advice from a GP adviser and subsequently from another GP adviser with a specialism in sexual and reproductive health. We found that there are numerous risk factors for pulmonary embolus and, in this case, the main risk factors were BMI, family medical history and prescription of combined oral contraceptive. Neither risk alone would preclude prescribing combined oral contraceptive, but consideration would be made for two risks, as in this case. We found that the health centre failed to provide A with reasonable medical care and treatment. We upheld C’s complaint.

C complained about the care provided to their late parent (A). The practice visited in the morning and found them to be coherent and capable of declining a full examination. A's carers left around midday and did not have any specific concerns about A. By the evening, A's condition had deteriorated and they were taken to hospital. A died two days later. We took independent advice from a GP adviser. We found that there was evidence of appropriate communication between the GPs and other professionals and agencies involved in A’s care. Therefore, we did not uphold the complaint. Related reading View Decision Report 202007688 as a PDF (24.11 KB) Updated: February 15, 2023

C is an advocate who complains on behalf of A. A has a brain injury which impacts on their daily living tasks and functioning. C complained that A received poor treatment from their GP practice and that there were delays in making referrals for specialist input following a fall down stairs which made A’s existing health conditions worse. We took independent advice from a GP adviser. We found that A's treatment had been reasonable. We noted that A had come to the practice with a number of previous unresolved problems. We considered that A's new GPs were right to be mindful that A's neurological symptoms had already been assessed as 'functional', meaning they had no known physical cause. C also complained about repeated prescription of antibiotics. We found that this did not seem excessive given the poor general state of A's health and that referrals for specialist input had been appropriate. Therefore, we did not uphold C's complaints. Related reading View Decision Report 202008029 as a PDF (24.23 KB) Updated: July 20, 2022

Ms C complained on behalf of her father (Mr A) that it was unreasonable for the practice to refuse Mr A a home visit. Mr A had been seen by the practice the day before and the next day a home visit was requested for him. The practice did not consider that a home visit was required and asked Mr A to attend, which he agreed to. Ms C said that Mr A required urgent medical attention and should have been seen at home. We took independent medical advice and found that whilst there were differing accounts of what was discussed during the call requesting a home visit, there was no evidence in the medical records of clinical symptoms which were described during the call, nor in the notes from Mr A's appointment the previous day, which would have suggested a house call was required. We found that the practice's policy on home visits was reasonable and was applied appropriately in the circumstances. Therefore, we did not uphold this aspect of the complaint. Ms C also complained that the practice's response to her complaint was unreasonable. We found that the practice failed to communicate with Ms C in line with their complaints handling procedure. Therefore, we upheld this aspect of the complaint. We noted that the practice had apologised for this but made a further recommendation for learning and improvement.