SPSO Individual Decisions

C suffered with lower back and right hip pain. C complained about the care and treatment provided by the practice in relation to their diagnosis of Hip Osteoarthritis. C said that despite raising concerns with the practice, they failed to take appropriate action to ensure C’s symptoms were further investigated. We took independent advice from a qualified GP. We found that the management of C’s symptoms was reasonable and appropriate steps were taken to investigate C’s symptoms. We did not uphold this aspect of the complaint. With respect to the handling of C’s complaints, we found that the practice’s complaints handling procedure was not compliant with current requirements. We also found that, whilst their complaints response demonstrated that they had investigated the complaint, the practice unreasonably failed to provide further response to C’s subsequent communications or the communications from our office. We therefore upheld this aspect of the complaint.

C complained about the care and treatment provided to their relative (A) by the practice. A attended the practice frequently within a year and was later diagnosed with an aggressive form of cancer. A died shortly after. C believed that A's concerns were not properly taken into account when they attended the practice and that A should have been referred sooner for investigations. The practice provided a detailed reply to C, stating their view that A's concerns had been investigated appropriately, and that there had been no indication for a cancer referral. We took independent advice from a GP. We found that there was no reason to suspect cancer as a possible cause of A's symptoms. However, as symptoms persisted, an urgent cancer referral should have been considered. We found that it was highly unlikely, given the aggressive nature of A's cancer, that the delay in A's diagnosis had any impact on the outcome of A's disease. Although A's initial treatment was reasonable, we found that there were failings in care in that the practice should have made an urgent referral for A sooner. We therefore upheld this complaint.

C complained about the end of life care their late spouse (A) had received from the practice. A had Lewy body dementia (a progressive dementia that results from protein deposits in nerve cells of the brain which affects movement, thinking skills, mood, memory, and behaviour) and was cared for at home by C. When A’s condition deteriorated, C complained that the GP had not visited them at home to assess their decline. C also complained that there had been a delay in initiating their end of life care plan allowing access to appropriate pain relieving medication and to the community palliative care team for support. In response, the practice said that although a GP had not visited A at home in their final weeks, a number of GPs had been in constant liaison with the district nursing team about their care and prescribing appropriate medications. They noted that their duty doctor had not been aware of, or could refer into, the palliative care team but following liaison with the district nursing team, this was progressed and A had received assistance thereafter. We took independent advice from a GP. We found that the practice had not provided a reasonable standard of end of life care to A. We considered they should have carried out an earlier assessment of A’s palliative and end of life needs to inform better care planning, that there was an unreasonable delay in providing A with appropriate pain relieving medication, and noted that staff lacked awareness of the community palliative care team and the referral process. Therefore, we upheld C's complaint.

C complained on behalf of their parent (A) for whom they hold power of attorney. C complained that the practice had incorrectly diagnosed and treated A with chronic back pain. C stated that A was later admitted to hospital with a fractured back and pneumonia. The practice advised that there was nothing to clinically suggest a fracture at the time and it would not have altered treatment. They noted that A did not have pneumonia as per hospital discharge. We took independent advice from a GP. We found that a thorough physical examination was undertaken which did not raise concerns of a fracture. We also found that appropriate pain relief is the only immediate treatment for vertebral fractures. There were no symptoms of pneumonia when the patient was seen by the GP and no suggestion of pneumonia in the medical records. We did find one mention of pneumonia in a letter between two third party medical professionals, who were not involved in A’s hospital care. Therefore, we did not accept this as evidence of a pneumonia diagnosis. In light of this, we found that the overall care and treatment provided to C was reasonable and did not uphold C’s complaint. Related reading View Decision Report 202111152 as a PDF (24.31 KB) Updated: November 23, 2022

C complained about the care and treatment provided to their late child (A) by their GP practice. A had attended the practice on several occasions over a five month period with persisting chest symptoms. C complained that the practice failed to recognise the severity of A's symptoms or recognise that symptoms were indicative of a serious cardiac condition until A's health had significantly deteriorated. A subsequently suffered a cardiac arrest resulting in them being transferred to another health board for surgery, where they later died. We took independent advice from a GP adviser. Although we noted that there had been a delay of a few days in responding to A's x-ray report, we found that the practice's care of A was reasonable, with referrals and tests being timeously arranged and in keeping with A's presenting symptoms at the time. Therefore, we did not uphold the complaint. Related reading View Decision Report 202101690 as a PDF (24.18 KB) Updated: August 24, 2022

C complained about a delay in diagnosis of cancer due to insufficient investigations undertaken by a number of GP's at the practice. C was later diagnosed with stage 4 lung cancer. C said the signs of cancer were missed, which was likely due to seeing different GP's at each consultation. In addition to this, C had a history of kidney cancer and considered their history was not adequately taken into account. C attended the practice on several occasions, reporting a number of concerns. C said that considering their history of cancer, the early signs of lung cancer were evident. It was only following a CT scan for C's kidney cancer that the oncology team found evidence of stage 4 lung cancer. The practice agreed that some of C's symptoms during this time could explain developing cancer. However, they also considered that the symptoms reported could be caused by a wide range of diagnoses. The practice evidenced that multiple x-rays were taken along with blood tests and vital sign checks, and there was nothing to indicate that cancer was developing. Due to these findings, the practice say that they had no medical reason to request a CT scan or refer C to a specialist team. We took independent advice from a GP adviser and reviewed the relevant medical records. We found that C did not present with any symptoms suggestive of lung cancer but a variety of unrelated problems, some of which were long standing. It was noted there was a lack of red flag symptoms of lung cancer, and as such, there was no requirement for a CT scan or to be referred to a specialist team during this period. In light of this, we found that the overall care and treatment provided to C was reasonable. We therefore did not uphold this complaint. Related reading View Decision Report 202107375 as a PDF (24.6 KB) Updated: July 20, 2022

C complained to the practice about the lack of care provided to their late parent (A). C said that A had reported breathing and sleeping problems in a telephone consultation to the GP but the GP had only provided medication and A died from a suspected heart attack a week later. The practice believed that appropriate treatment had been provided. We took independent advice from a GP. We found that there was no evidence that A had reported breathing problems to the GP and that there were no recorded symptoms which would have indicated that A required a face-to-face GP consultation, a hospital admission, or that A would suffer a sudden event a week after the telephone consultation. Therefore, we did not uphold the complaint. Related reading View Decision Report 202103401 as a PDF (24.06 KB) Updated: December 22, 2021

C complained that the practice refused to provide their late parent (A) with an in-person GP appointment. A had a history of lung cancer which had been treated with radiotherapy (a treatment of disease, especially cancer, using high-energy radiation) previously. A contacted the practice by phone to report pain in their right leg and buttock. A was not seen in-person due to COVID-19 guidance, however a telephone consultation was arranged. The consulting GP considered that A’s symptoms likely resulted from sciatica (back and leg pain caused by irritation or compression of the sciatic nerve) and prescribed treatment for this. Further phone consultations followed with the GP and others at the practice on four other occasions. The consultations consisted of a mixture of planned contacts by the GP and unplanned contacts by A. C later contacted the practice and expressed concern that A’s condition had not improved. C asked for A to be seen in person. A was seen by a GP that day. A’s case was discussed with an oncology (cancer) nurse specialist. It was agreed that A’s condition required further investigation. A was subsequently referred to an oncology clinic and was diagnosed with metastatic lung cancer. A died the following year. We took independent advice from a GP. We found insufficient evidence to suggest that the practice had refused any request from A for an in-person appointment. However, we did find that there had been a unreasonable delay in providing A with an in-person appointment. On consideration of relevant guidance, the clinical record and specialist advice we found that A should have been seen in-person on the third contact they had with the practice. We considered that the delay in providing A with an in-person appointment was brief and were unable to conclude that the delay had a material impact on A’s prognosis. In the circumstances, we upheld the complaint.

C complained that their partner (A) was inappropriately prescribed a strong opiate painkiller by their GP, that they developed severe mental and physical health problems as a result of being kept on this medication for too long, that A was not appropriately reviewed while on this medication, and that their requests for help were not acted upon. We took independent advice from a GP, who considered whether the prescribing to A was reasonable in the circumstances. They found no evidence to support that the long-term prescribing of the medication contributed to the deterioration in A's mental and physical health. They noted there was evidence of regular review and discussion of A's pain and pain relief. We accepted this advice and did not uphold this complaint. However, we noted some complaint handling issues. The practice did not initially request consent from A to enable them to take C's complaint forward. Additionally, there were subsequent delays in preparing their response and they did not keep C updated or agree an extension to the target timeframe. We advised the practice to review their handling of C's complaint and ensure mechanisms are in place to ensure compliance with the NHS Scotland Complaints Handling Procedure. Related reading View Decision Report 201902396 as a PDF (24.36 KB) Updated: May 19, 2021

C complained that the practice failed to provide them with effective treatment for a skin complaint and that they waited an unreasonable length of time before they saw a doctor. We took independent advice from a nurse adviser and a GP adviser. C had first attended two nurse consultations, a week apart, as they had developed an itchy rash on their back. We noted that the initial working diagnoses (insect bites/fungal infection) and the care and treatment provided at this point was reasonable. Ten days after C's first consultation, they contacted the practice again. As the triage telephone call mentioned 'shingles' as another possible diagnosis, a referral to see a GP should have been made at this time. However, C was given an appointment with an advanced nurse practitioner. Although C was being treated with an allergy tablet, there was no documented working diagnosis of what was causing the itch. We found that the management of C at this time was not reasonable. C contacted the practice again the following day and requested to be seen by a GP. This was the fourth time C had contact with the practice in eleven days since the onset of the rash, which was getting worse and becoming painful. Although the advanced paramedic practitioner who saw C on this occasion sought advice of a GP regarding treatment, we considered that it was unreasonable that C was not referred to be seen by a GP at this time. C made a further request for a GP appointment two weeks later and again was given an appointment with an advanced paramedic practitioner. We found that this was unreasonable given that this was C's second request for a GP appointment, they had seen nurse and paramedic practitioners four times over a period of several weeks and had attended the out-of-hours service, during which time their rash was getting worse/not responding to prescribed treatment and was painful. Due to their ongoing symptoms, C attended again at the out-of-hours service when they were prescribed

C complained about matters relating to their previous GP practice. C had been removed from the practice list as in the practice's view there had been a complete breakdown in the doctor/patient relationship due to the way C was using a prescribed antibiotic medication. The practice wrote to C to inform them of their decision. C had concerns about the practice's decision to remove them from the list. We found that the practice had failed to provide C with a warning before removing them from the practice list. Therefore, we upheld this aspect of the complaint. C was also unhappy with the factual accuracy of a letter sent by the practice regarding the removal decision. We did not find that the practice's letter contained inaccuracies and we were unable to conclude that it was unreasonable. We did not uphold this aspect of the complaint.

C complained to the practice about a consultation they had. They said that they reported symptoms of severe pain and swelling of the abdomen and that they were grey in colour and had difficulty standing up. C said the practice prescribed them with laxatives (medication to help increase bowel movements). C continued to deteriorate and days later was admitted to hospital as an emergency, where it was found they had perforated diverticular (diverticula are small bulges or pockets that can develop in the lining of the intestine as you get older) disease. C said they had to undergo emergency surgery and were an inpatient for a month. C felt that the practice should have diagnosed their serious condition and arranged an urgent hospital admission. We took independent advice from a medical practitioner. We found that the GP involved had carried out an appropriate examination based on C’s presenting symptoms and that a diagnosis of constipation was reasonable. There was no clinical indication that C’s health was going to suddenly deteriorate with severe diverticular disease and that they would require a hospital admission. We did not uphold the complaint. Related reading View Decision Report 202001802 as a PDF (24.32 KB) Updated: December 16, 2020

C complained to the practice about their failure to diagnose that they were at risk of suffering a heart attack when they attended the practice on two occasions. The GPs had diagnosed a chest infection; however, C’s condition deteriorated and they were admitted to hospital where it was discovered they had suffered a heart attack. C felt that the GPs should have diagnosed their heart condition sooner and that if they had then their heart would not have been so damaged. We took independent advice from a GP. We found that the GPs involved in C’s care carried out appropriate assessments and that the symptoms which C presented with were not indicative of cardiac problems. We did not uphold the complaint. Related reading View Decision Report 201911284 as a PDF (24.07 KB) Updated: November 18, 2020

C’s sibling (A) attended the practice with constipation and blood in their urine. C was referred to the local health board’s urology department (specialists in the male and female urinary tract, and the male reproductive organs) where they were diagnosed with pedunculated fibroids (benign (non-cancerous) growths in the uterus). This diagnosis was later found to be inaccurate and the growths were found to be cancerous. C complained that the practice failed to provide reasonable treatment to A when they attended the practice in response to their symptoms. We took independent advice from a GP. We considered that the actions and investigations carried out by the practice were reasonable at each appointment, based on the information available at the time. A was referred to appropriate specialities and prescribed reasonable medication in response to their symptoms and the diagnosis made by urology. We did not uphold the complaint. Related reading View Decision Report 202000410 as a PDF (24.17 KB) Updated: November 18, 2020

C attended the practice a number of times over several years with recurring urinary tract infections (UTIs). C said that in that period, the practice had failed to undertake a test for a prostate specific antigen (PSA test) despite C's repeated requests. When the practice did agree to undertake a PSA test the result for this was high and caused the practice to urgently refer C to the local NHS board's urology department for further investigation. Subsequently, C was informed that they had prostate cancer. C complained that the treatment provided by the practice was unreasonable. We took independent advice from a GP. We found that the practice provided reasonable treatment to C. We considered that C's condition of recurrent UTIs had been identified by the practice, who appropriately noted that this should be managed by the urology department. The referral to this department was in line with General Medical Council's Good Medical Practice as the ongoing symptom management of the patient lay outwith the practice's professional expertise. We concluded that the care provided by the practice was reasonable. We did not uphold this complaint. Related reading View Decision Report 201905840 as a PDF (24.3 KB) Updated: July 22, 2020

C complained about the care and treatment provided to their late spouse (A) by the practice. A had reported symptoms of excessive wind, bloating, nausea and loss of appetite. A was later diagnosed with metastatic melanoma (skin cancer that has spread). C complained that the practice delayed in carrying out an appropriate assessment of A's symptoms and that they failed to follow up on A's treatment and referrals. The practice considered that A was seen promptly following triage and that according to the Scottish Referral Guidelines, A did not warrant an urgent referral based on their symptoms at the time. We took independent advice from a GP. We found that the assessment of A's symptoms was appropriate and the relevant guidelines for suspected cancer were followed appropriately by the practice. We also found that the referral for an urgent endoscopy (a procedure whereby a flexible tube with a camera is used to view the organs inside the body) was timely and appropriate. We did not uphold the complaint. Related reading View Decision Report 201900587 as a PDF (24.21 KB) Updated: July 22, 2020

Ms C, an advocate, complained on behalf of her client (Ms A) about the treatment which Ms A received at the practice. Ms A had reported concerns about hip pain on a number of consultations, but the GPs wrongly diagnosed a soft tissue injury when Ms A had actually suffered a fracture of the hip. We took independent advice from a GP. We found that Ms A had an extensive medical history of hip problems and was under the care of the orthopaedic (conditions involving the musculoskeletal system) team. When Ms A reported hip pain following a fall it was not unreasonable for the GPs to conclude that Ms A had suffered a soft tissue injury as she was able to weight bear. Although it would appear that the fracture had occurred by the time Ms A was seen by the GPs, this was not an indication that the care and treatment was unreasonable. We did not uphold the complaint. Related reading View Decision Report 201811067 as a PDF (23.77 KB) Updated: September 18, 2019

Mr C complained about the treatment the practice provided to his mother (Mrs A). Mrs A was attended by a GP at home after it was reported she was having problems with her leg. At this time Mrs A was also receiving nursing care from district nurses. Mr C complained that the practice did not respond to a request from a district nurse for a further home visit the following day. Mrs A's condition worsened and she was admitted to hospital where she later died. We took independent medical advice from a GP. We found that Mrs A's treatment by the practice was reasonable and found no failings in the treatment offered. We saw no evidence a district nurse requested a home visit by the practice. Therefore, we did not uphold Mr C's complaint. Related reading View Decision Report 201806748 as a PDF (23.67 KB) Updated: June 19, 2019

Mrs C complained about the treatment she had received from the practice. She had reported in consultations that her right big toe was cold, blue and painful. The pain continued and she received additional painkillers. Blood tests revealed a low iron count and iron tablets were prescribed. The pain continued and Mrs C also reported pain in her leg at the groin which was diagnosed as a groin strain. Mrs C continued to report problems and a referral was made to the vascular (circulatory) service where it was found she had blood clots in her leg and groin which resulted in her requiring an amputation of a foot. We took independent medical advice from a GP. We found that initially it was felt Mrs C had chilblains (a painful, itch/swelling on a hand or foot, caused by poor circulation in the skin when exposed to cold) which was not unreasonable given the presenting symptoms. However, when the symptoms persisted the practice should have considered an alternative diagnosis of critical ischaemia (limb threat due to peripheral artery disease) rather than continue with chilblains. We also found that the diagnosis of tendonitis (groin strain) was unreasonable as Mrs C had not sustained an injury and that safety netting advice should have been given to Mrs C when she was prescribed painkillers. We upheld the complaints.

Mrs C complained about the care and treatment provided to her mother (Mrs A) by the practice. She complained that Mrs A's symptoms and medical and dental history were largely ignored. Mrs C felt that Mrs A's life was cut short as a result of poor care and treatment by the practice. We took independent advice from a GP. We found that the care and treatment provided to Mrs A by the practice was of a reasonable standard. We found no evidence that the practice had failed to act on abnormal results or that the practice failed to arrange appropriate investigations and referral to secondary care. We did not uphold the complaint. Related reading View Decision Report 201706114 as a PDF (23.6 KB) Updated: January 23, 2019

Miss C complained on behalf of her late mother (Mrs A) that the practice unreasonably admitted Mrs A to hospital when it was her wish to remain at home. Mrs A had terminal cancer and was being cared for at home. A GP from the practice visited her at home and was concerned about the ability to meet her care needs there. Therefore, the GP arranged for Mrs A to be admitted to hospital where she died two days later. Miss C was concerned that this was against Mrs A's wishes as she had wanted to remain at home. We took independent advice from a GP. The adviser considered that the initial decision to have Mrs A admitted to hospital was reasonable. However, by the time that the ambulance crew had arrived, she had lost consciousness. We found that, at that point, the GP should have consulted the family about having Mrs A admitted to hospital. We considered that Mrs A should have been allowed to remain at home if that was what her family wanted. Therefore, we upheld Miss C's complaint.

Mr C transferred to the practice from another practice and, on first attendance at the new practice, was prescribed Sertraline (an anti-depressant medication used to treat anxiety). However, he suffered side effects as a result of this prescription. He was of the opinion that this would have been immediately obvious to the doctor he saw, had they checked with his previous GP, as Mr C had previously been prescribed this medication and had suffered side effects. He was also unhappy with the manner and tone adopted by the doctor. He complained about these matters to the practice and was further concerned by the tone and content of the response he received, which he considered to be confrontational and unprofessional. Mr C brought his complaints to us. He complained that the practice unreasonably failed to consider his medical history before prescribing Sertraline and that the prescription of Sertraline was inappropriate due to the potential side effects. We took independent advice from a GP. We found that, in order to justify immediately prescribing Sertraline, rather than first trying therapies that did not require medication, the doctor should have documented a pressing clinical need or sought further evidence from Mr C's previous practice to ensure that this was appropriate. However, we found no evidence that this took place. Therefore, we upheld these two aspects of Mr C's complaint. We also considered that the tone and content of both the clinical records and the practice's complaints responses, both to Mr C and to us, was inappropriate. We upheld this aspect of Mr C's complaint.

Mrs C complained to us that the practice had failed to appropriately monitor her for any side effects of taking nitrofurantoin medication (antibiotic to treat urinary tract infections) for a number of years. She subsequently went on to develop pulmonary fibrosis (lung disease) and liver disease and she felt that these conditions were a direct result of the practice's failure to monitor her medication. We took independent advice from a GP adviser and concluded that the practice had failed to appropriately monitor Mrs C's liver function and respiratory status over a number of years. The British National Formulary, which is the gold standard reference and guidance regarding medicines, has over the years highlighted advice and more recently issued safety alerts that patients on long term nitrofurantoin medication should be regularly monitored for liver function and respiratory function, although it does not state the frequency. In addition, Mrs C was exhibiting symptoms which are recognised complications of nitrofurantoin medication. We upheld the complaint.

Mr C complained about the practice regarding the handling and communication of decisions to reduce or remove three medications he was prescribed for chronic pain. The practice had taken steps to reduce these medications, as they considered a continued consumption of a high dosage of opiate medication was placing Mr C at risk of further health problems and addiction. However, Mr C was concerned that his pain was no longer being suitably managed and also that he was not adequately involved in the decision making process. We took independent advice from a GP adviser. We found that the clinical decision to reduce the medications was correct, and in line with relevant guidelines. We were also satisfied that the decision to remove the prescription for one of the medications was reasonably handled and communicated. For this reason, we did not uphold the complaint about this prescription. However, we considered that the practice had failed to appropriately discuss the decisions to reduce the dosage of the other two medications with Mr C in advance of the reduction. As such, we upheld these two complaints. Although we upheld the complaints we found that, in response to Mr C's initial complaints, it was clear that the practice had accepted the failings in question, apologised for them, and taken steps to ensure these mistakes would not be repeated. As such, we did not make any recommendations. Related reading View Decision Report 201705806 as a PDF (11.25 KB) Updated: December 2, 2018

Ms C complained to us about the care and treatment that her late father (Mr A) had received from the practice. Mr A had attended the practice as he was feeling some discomfort in his chest after exertion and increasing fatigue. He was referred to hospital urgently for a chest x-ray. The GP also increased the dose of Verapamil (a medication used for high blood pressure and angina) Mr A was receiving. Mr A had a scan of his heart at the hospital approximately ten days later This showed valve disease in Mr A's heart, which can lead to heart failure. An appointment was made for him to see a consultant cardiologist (a doctor who specialises in finding, treating and preventing diseases of the heart and blood vessels) and the Verapamil was stopped and his medication changed. Mr A's condition deteriorated and he returned to the practice several days after the hospital appointment. He complained of chest pain radiating to his back and said that he was no better with the new heart medication. The GP thought that this might be caused by gastric irritation and increased his medication for stomach acid. Mr A died from heart failure the following morning. Ms C complained about the practice's decision to increase her father's Verapamil. We took independent advice from a GP adviser. We found that Mr A had been referred to hospital because it was considered that he had worsening angina. The GP had consequently increased Mr A's Verapamil, which is a recognised and common treatment for angina. The GP could not have foreseen the echocardiogram result at that time and, therefore, could not have foreseen that increasing the Verapamil was not the best treatment. Mr A's valve disease had not been caused by Verapamil, but is a condition that deteriorates over many years. We did not uphold this aspect of Ms C's complaint. Ms C also complained that the GP did not examine Mr A's chest at the appointment after his hospital visit. We found that the GP should have examined Mr A, a