SPSO Individual Decisions

C complained on behalf of their spouse (A) about the treatment provided to them. A had a history of cancer and attended the practice with urinary symptoms. A was later diagnosed with bowel cancer which had metastasised (spread to other parts of the body). C complained that the practice's response to A's symptoms, and the length of time it took for A's cancer to be diagnosed, were unreasonable. We took independent advice from a GP. We considered that A's symptoms were reasonably investigated, with appropriately prioritised referrals being actioned in a timely manner. A's history of cancer was considered when assessing their symptoms. A's symptoms initially aligned with a benign (non-cancerous) condition. When A's presentation changed, appropriate steps were taken, with further investigation and referrals to secondary care. A's pain was reasonably managed. Therefore, we did not uphold the complaint. Related reading View Decision Report 202002090 as a PDF (24.18 KB) Updated: January 20, 2021

Mrs C complained about the care and treatment given to her late husband (Mr A) by the practice before his death. In particular, she said that he was given a specific medication in tablet form althought it was known that he had swallowing problems, that communication from the practice had been poor and that Mr A had had sepsis (a blood infection) which had gone undiagnosed. We took independent advice from a GP. We found that Mr A was taking many different medications all in tablet form and there was no information in his medical records to indicate that he had a problem swallowing medication. We also found that the records showed appropriate communication and no evidence that Mr A had sepsis. We did not uphold the complaint. Related reading View Decision Report 201803700 as a PDF (23.7 KB) Updated: May 22, 2019

Mrs C complained about the care provided to her late husband (Mr A) by the practice. Mr A who suffered from chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed) attended the practice on a number of occasions reporting breathing problems but felt that the doctors did not listen to him. Mr A was later admitted to hospital with pneumonia (an infection of the lungs) where he suffered a heart attack and died. Mrs C complained that the practice failed to provide Mr A with appropriate treatment in view of his symptoms. We took independent medical advice from a GP. We found that the practice had carried out thorough investigations into the symptoms reported by Mr A and that his COPD did result in him having breathing issues. We also found that the practice prescribed appropriate antibiotics but that Mr A's condition and symptoms were drastically different between his final two consultations and it was only at that time that a hospital admission was required. Therefore, we did not uphold the complaint. Related reading View Decision Report 201804677 as a PDF (23.89 KB) Updated: April 17, 2019

Mr C attended his GP practice with symptoms of fatigue, reduced appetite and night sweats. Tests indicated an infection and Mr C was prescribed antibiotics and referred to hospital. Several weeks later, after discussing the matter with the GP, Mr C decided to cancel the hospital appointment offered. However, Mr C was unaware that the referral to hospital mentioned the possibility of serious pathology (red flag symptoms). When Mr C had the same symptoms a year later, an x-ray showed suspected cancer in his right lung and further tests showed stomach cancer. Mr C complained that failings by the practice meant that he had been unable to make an informed decision about the initial referral the year before and that his life had been shortened considerably. Mr C complained that the practice failed to provide him with a reasonable standard of medical care. We took independent advice from a GP. Overall, we found that the standard of medical care and treatment provided was reasonable. We were satisfied that Mr C had been investigated appropriately and that the tests taken were thorough. Therefore, we did not uphold the complaint. Related reading View Decision Report 201700272 as a PDF (11.19 KB) Updated: December 2, 2018

Mr C complained that a GP practice did not properly maintain the medical records of his wife (Mrs A) and as a consequence, when she was admitted to hospital she was given medication which led to serious side effects. He further complained that a member of staff spoke to him inappropriately and told him that by stopping his wife's medication he could cause Mrs A's death. We took independent general practice advice and noted that while Mrs A's medical records showed that a conversation with Mr C had taken place where he said that he was stopping her medication due to his belief that it caused side effects, they did not record a change to her medication. This was because Mrs A had the capacity to make decisions about her treatment and any changes could only be made after discussion with her. Whilst the records noted a terse conversation with Mr C about his wife's medication, there was no evidence that he had been spoken to inappropriately. It was clear that the repercussions of Mrs A stopping taking her medication had been clearly explained to Mr C. We did not uphold the complaint. Related reading View Decision Report 201508145 as a PDF (11.11 KB) Updated: March 13, 2018

Mr A's mother and partner complained about the care that Mr A received from the medical practice after he visited them with a number of different symptoms including tiredness, sweating and backache. Mr A was later diagnosed with testicular cancer and they felt that doctors has incorrectly attributed his symptoms to his existing long-term condition. They were concerned that there had been a failure to conduct appropriate investigations as a result and that an emergency hospital referral should have been made when Mr A's condition deteriorated. After taking independent advice from a GP, we did not uphold these complaints. We received advice that there was no evidence that doctors had attributed Mr A's symptoms to his existing condition and we found that they had arranged appropriate investigations to determine the cause of his illness. The adviser also considered that the practice had made appropriate timely referrals for Mr A. Related reading View Decision Report 201508808 as a PDF (11.07 KB) Updated: March 13, 2018

Ms C complained to us about the system that the medical practice used for reporting on warfarin (a drug used to prevent blood clots) blood tests. Her mother (Mrs A) had been discharged from hospital and a blood test was taken on a Friday. Ms C was told to phone the practice later that day for the result. Ms C did so and was told by a receptionist that the results would not be ready until Monday and that her mother should continue on the same dosage of medication (one tablet daily) in the meantime. On the Monday, the practice phoned Ms C and advised her that her mother's medication should be reduced to one tablet every other day. In the meantime, Mrs A had developed speech problems and had difficulties swallowing, eating and drinking. Ms C felt that the dosage of medication that her mother was taking over the weekend had caused Mrs A's deterioration. We took independent advice from a GP adviser and concluded that whilst the dosage of medication taken over the weekend had not harmed Mrs A (and was not the cause of her deterioration), the system of reporting warfarin blood test results was not entirely in accordance with local guidelines and that it was not clear whether the receptionist had spoken to Ms C on the instructions of a clinician. We upheld the complaint.

Over a period of time, Ms C began to experience constant bloating, was unable to lose weight and was concerned about other symptoms. She attended her GP, who examined her stomach and said there was excess fluid but he was not concerned. The GP's note of this consultation said that Ms C was doing well with her diet, had lost three stone, but felt she was putting weight on despite not changing anything. He arranged routine blood tests which came back normal. Ms C's symptoms got worse. A few weeks later she attended a different GP. The GP found what she thought was a cyst on Ms C's left ovary and a scan confirmed this. Surgery removed a very large (30 centimetres by 24 centimetres) cyst. Ms C complained that the care and treatment she received from the first GP was inadequate. We sought independent advice from a GP adviser. The adviser considered the relevant General Medical Council (GMC), Scottish Intercollegiate Guidelines Network (SIGN) and National Institute for Health and Care Excellence (NICE) guidance. They concluded that the note of the appointment was not of a reasonable standard as it was sparse in detail, showed evidence of only a very limited recorded history, and no evidence of a medical examination. The adviser explained that Ms C's symptoms required examination and follow-up, neither of which was recorded. They also considered that the note did not show evidence of good communication or working in partnership with patients so it was not of a reasonable standard. The adviser explained that, in line with SIGN and NICE guidance on the investigations needed to exclude ovarian cancer, Ms C should have had a particular blood test and a scan. Therefore, we found that reasonable investigations were not carried out. We upheld Ms C's complaint and made several recommendations.

Mrs C complained about one of her mother (Mrs A)'s GPs. Mrs C said the GP should have sent Mrs A to hospital after seeing her at a home visit. Several days later another GP admitted Mrs A to hospital, where she died. We looked at Mrs A's medical notes and the GP's file on Mrs C's complaint. We also took independent advice from one of our GP advisers. We found that the GP provided appropriate treatment to Mrs A at the home visit, and there were no indications at the visit that Mrs A should have been admitted to hospital as an emergency. We also found that, in the circumstances, Mrs A's deterioration several days later could not have been foreseen at the home visit. We concluded that the care provided to Mrs A at the home visit was reasonable in the circumstances, and that the GP did not unreasonably fail to send Mrs A to hospital on that day. We did not uphold Mrs C's complaint. Related reading View Decision Report 201407551 as a PDF (10.99 KB) Updated: March 13, 2018

Mr C complained to us that his medical practice had failed to diagnose his heart condition. We took independent advice on this complaint from one of our medical advisers and found that there was no evidence in the medical notes that indicated that the practice had failed to follow up on the symptoms Mr C had reported. There were no recorded symptoms of possible heart problems and so we did not uphold the complaint. Mr C then wrote to us to complain that some of his consultations with the practice had not been recorded accurately. In view of this, we decided to reopen the case to investigate his complaint that his medical records were inaccurate. We obtained a full historical print out of Mr C's computer record from the practice and considered this along with the information he provided to us. However, there was no evidence that the practice had altered or deleted any of the records of the consultations that he had referred to. Our adviser also considered that the GPs had acted reasonably in summarising the consultations in the computer records. In view of all of this, we did not uphold this complaint. Related reading View Decision Report 201402052 as a PDF (11.07 KB) Updated: March 13, 2018

Mrs C's father (Mr A) had suffered from a painful degenerative condition that caused his spinal cord to become compressed. An operation was carried out and, after a difficult recovery, Mr A was pain free for a number of months. He then began to have new pain in his shoulder and went to his GP as he was worried that this could have been a recurrence of the condition. Mr A's GP considered that he did not have any new symptoms that indicated his spinal cord was compressed. Mr A had a number of consultations over the following months where the GP adjusted his pain relief medication. He also attended hospital appointments which clinicians reported to the GP; none of them considered that he was suffering from spinal cord compression. Mr A was subsequently seen at home by the GP as he was in too much pain to visit the surgery. The GP made a referral for a scan which was carried out a few days later. The scan showed a narrowing of the spinal canal and an urgent referral was made. Mrs C complained that the GP repeatedly failed to diagnose her father's condition, delayed referring him for a scan and had not assisted him in obtaining medical equipment to help him manage at home. The practice responded saying that the GP had acted appropriately. After taking independent advice from one of our medical advisers, we found that the GP had provided Mr A with reasonable care and treatment. Our adviser explained that there was no evidence that Mr A was suffering from new spinal cord compression and so there was nothing to suggest that a scan should have been carried out earlier. In relation to obtaining medical equipment for use at home, our adviser said that the occupational therapy department would deal with this rather than the GP. As the GP had advised Mrs C's family to contact the occupational therapy department, we considered that this had been handled reasonably. Related reading View Decision Report 201305012 as a PDF (11.52 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment provided to her daughter (Miss A) by a medical practice. Miss A has a long-term health condition and needs multivitamins daily. Mrs C said that, on more than one occasion, GPs at the practice wrongly prescribed a multivitamin containing a high dose of vitamin A, which was potentially toxic to Miss A. Mrs C said that she and the dietician noticed the error, not the GPs, and she complained to the board, who responded on behalf of the practice. Mrs C was not satisfied with the board's response. After taking independent advice from one of our medical advisers, we were satisfied that the practice took Mrs C's complaint seriously, conducted a full and honest investigation, including a significant event analysis, and proposed reasonable actions to prevent a similar situation in the future. There had clearly been a mis-prescription of Miss A's multivitamins which affected a period of roughly six months, which the practice accepted. We found that this was caused by poor communication between the practice and other healthcare staff involved in Miss A's care. We also found that the practice operated two different methods of prescription, which meant that a GP dealing with Miss A for the first time could easily miss details of previous prescriptions which had not been entered on the practice system. We were also critical that, when it was established early on that Miss A's prescribed multivitamin was not listed on that system, no action was taken to have the system updated or to forewarn other GPs in the practice. We upheld Mrs C's complaint and made recommendations to address the failings identified. Mrs C also complained about the handling of her complaint, but we found that it was investigated thoroughly and that the board’s response was reasonable.

Mr C complained that when he attended his medical practice the GP who saw him did not tell him that he could stop his diabetic medication. As a result, he had continued to take it for a year, and he wondered whether this was detrimental to his health. The practice apologised and explained that the GP recalled discussing the matter with Mr C at the time but forgot to amend the repeat prescription list. They said that by continuing with the medication, Mr C did not come to any harm. After taking independent advice from one of our medical advisers we found that, although we could not establish exactly what the GP and Mr C discussed, it was the GP's intention to stop the medication at that time. However, human error prevented the medication from being removed from the repeat prescription list. Because of this, we upheld Mr C's complaint. However, as the practice had already apologised to Mr C and reminded staff about properly documenting conversations with patients, we did not make any recommendations. Related reading View Decision Report 201402836 as a PDF (11.1 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment she received from her medical practice when she attended with clearly visible changes in her left breast. The GP told Mrs C that there was nothing wrong other than a blockage and suggested that she buy starflower oil. Mrs C's health deteriorated over the next few months and nine months later, she was diagnosed with breast cancer. After taking independent advice from our GP medical adviser and considering the records and Mrs C's comments, we found that the GP had failed to adequately examine her breast. In view of the visible changes, Mrs C's age and the fact that she had a family history of breast cancer, we also found it unreasonable that the GP did not immediately refer her to the breast clinic. Our adviser said that the delay in referring Mrs C there was likely to have had a significant impact on the extent of the tumour and the level of treatment Mrs C required. However, the practice had carried out a significant event review, had demonstrated that they had learned lessons from the complaint and had apologised to Mrs C. In view of this, we did not need to make any recommendations. Related reading View Decision Report 201305253 as a PDF (11.17 KB) Updated: March 13, 2018

Mr C complained that when he made a request to the practice for a copy of his late mother's GP clinical records he was not provided with a full copy of her records for the previous ten years. He also had concerns that since 2005 his mother had visited the practice with recurrent ear infections, but it was not until late 2010 that she was referred to an ear nose and throat consultant, who diagnosed a tumour in her ear. We did not uphold Mr C's complaints. Our investigation found that the practice had provided a full copy of his late mother's records and had explained that they initially kept paper records before moving to electronic records. We also found that although Mr C's mother had reported ear infections intermittently since 2005, these had cleared with treatment. By 2010 the ear problem with which she presented to the practice was different. Related reading View Decision Report 201204261 as a PDF (11.08 KB) Updated: March 13, 2018

Mr C's wife (Mrs C) visited a medical practice on a number of occasions complaining of stomach pain. Mr C complained that the practice unreasonably delayed in diagnosing his wife's illness. The practice initially gave Mrs C painkillers. When the pain did not go away the practice took blood tests to rule out cancer. Mrs C then started to complain of weight loss as well as pain. When these symptoms occurred together the doctor referred her to general surgeons at the local hospital, where Mrs C was diagnosed with mesenteric ischemia (a condition that reduces blood flow to the bowel). To investigate the complaint we took independent advice from one of our medical advisers. He explained that this diagnosis was difficult to make, and would need to be made at a hospital as it required detailed investigations to confirm it. The adviser was satisfied that the practice had referred Mrs C appropriately when she started to have increasing pain and weight loss. The adviser confirmed that there was no evidence of an unreasonable delay in diagnosis. Related reading View Decision Report 201203049 as a PDF (11.21 KB) Updated: March 13, 2018

Mr C complained about the care and treatment that his late wife (Mrs C) received at the medical practice over a three month period. Mr C was unhappy that the practice did not carry out relevant investigations of Mrs C's persistent and severe abdominal pain. He told us that he felt that doctors at the practice did not listen to their concerns, and that there was a lack of support. After Mrs C was admitted to hospital, further investigations showed that she had pancreatic cancer, and Mrs C died a few weeks later. We did not, however, uphold Mr C's complaint. Our investigation found clear evidence to show that the practice had carried out appropriate and reasonable investigations to try to diagnose the cause of Mrs C's ongoing pain. They had also referred Mrs C to a specialist for further investigation. We noted that a CT scan (a special scan using a computer to produce an image of the body) had been carried out two months before her diagnosis, but had not shown any abnormalities. Our independent medical adviser also explained that pancreatic cancer tends to present late, often with non-specific symptoms, and has some of the lowest survival rates of all cancers. Related reading View Decision Report 201201552 as a PDF (11.26 KB) Updated: March 13, 2018