SPSO Individual Decisions

C, an independent advocate, complained on behalf of their client (B). B’s adult child (A) died from an overdose of dihydrocodeine (opioid prescribed for pain or severe shortness of breath). A had been prescribed a number of different medicines by their GP practice including painkillers and benzodiazepines (depressants). B complained that the practice did not appropriately manage the risks of prescribing A such medication. B questioned why prescriptions were issued to A on a monthly basis, rather than weekly or even daily. B also complained that the practice had insufficient regard to A’s history of overdoses and that A should not have been given additional prescriptions on request, as had happened on multiple occasions. Lastly, B was concerned that A had remained with the practice despite having moved a significant distance away. In their response to the complaint, the practice stated that weekly or dispensing does not necessarily prevent the hoarding of medication, and that A had been maintained as patient due to their local GP being staffed primarily by locum doctors lacking a familiarity with A’s situation. They said that while they were aware of A’s overdoses these were often also due to alcohol or illegal drugs. The practice said that they felt A’s requests for additional medication had been genuine and that they needed to balance the risk that A would seek illicit drugs or street medication if suffering from withdrawal. The practice also stated that following this incident they had reviewed their approach to such patients and had recently refused a number of requests to keep on patients living remotely. We took independent advice from a GP. We found that the kinds of medication prescribed to A are implicated in many drug related deaths, often in combination with other substances such as alcohol. Taking into consideration A’s history, their mental health, alcohol misuse and history of multiple drug overdoses, early prescriptions should not have been given to A

C complained on behalf of B about the care and treatment provided to B's spouse (A) by the practice. A attended the practice on a number of occasions over a few years with ongoing and worsening abdominal and lower back pain. C complained that the practice assumed A was suffering from a musculoskeletal problem and failed to consider other diagnoses sooner. A was later diagnosed with lymphoma and died at the time of diagnosis. In responding to C's complaint, the practice undertook a Significant Adverse Event Review (SAER) and noted it was not clear when the lymphoma started. The practice also found that A had several normal or reassuring examinations and tests, and that several of A's presentations and tests pointed towards other diagnoses including liver disease and prostate disease. The SAER ultimately concluded that it seemed very unlikely that A had lymphoma for a long period of time given the very aggressive nature of their disease. We took independent advice from a GP. We found that a number of tests and investigations were reported as normal and therefore there was no cause to refer A to specialists on suspicion of cancer. However, when concerns were raised about a possible missed renal cause for A's pain, we found that further investigations should have been undertaken at this time. These did not occur until almost a month later. A was suffering from an aggressive and difficult to diagnose cancer and, while the care and treatment provided by the practice was generally considered to be reasonable, the review should have triggered further tests at the time. On balance, we upheld C's complaint.

C's parent (A) developed breathing difficulties and underwent investigations and treatment, including hospital admission, for bilateral pneumonia (inflammation of both lungs). As they had ongoing symptoms, the possibility of a cardiac (heart) cause was raised by A's GP. A CT scan of the chest was undertaken and confirmed pneumonia. An electrocardiogram (a test that records the electrical activity of the heart) identified an abnormality with A's heart so an echocardiogram (a heart scan that uses sound waves to create images) was requested. Shortly after this, A attended their GP with ankle swelling and was prescribed diuretic tablets. They also had a follow-up appointment with respiratory. Communication sent to the GP following this appointment referred to A's echocardiogram report as showing 'impaired left ventricle' and that cardiology opinion was awaited. A died suddenly before being seen in the cardiology out-patient clinic. C complained that the practice failed to provide appropriate treatment for A's heart condition, that they failed to communicate properly to A about their heart condition, and that they failed to ensure relevant information about A's family history was shared with hospital consultants. Related reading View Decision Report 201909321 as a PDF (24.38 KB) Updated: August 18, 2021

C complained on behalf of their parent (A) about the care and treatment A received from their GP practice; in particular, that there was a delay in referring A for further investigations which led to a delay in A being diagnosed with colon cancer. We took independent advice from a GP. We found that all appropriate investigative tests were carried out at A's first attendance at the practice. On their second attendance, we found that the care and treatment A received was reasonable and that tests were undertaken with appropriate follow-up to a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) who A chose to see at a private hospital. Following receipt of the consultant gastroenterologist's report, we considered that there was no unreasonable delay by the practice in making an urgent referral to the gastroenterology out-patient clinic at an NHS hospital. We considered that a rectal examination should have been performed when A attended the practice, however, this was a minor criticism and had not impacted on A's future treatment. We noted that this had been addressed in the Significant Event Analysis (SEA) carried out by the practice. On balance, we considered that the practice provided A with reasonable care and treatment. Therefore, we did not uphold the complaint. Related reading View Decision Report 201910988 as a PDF (24.4 KB) Updated: August 18, 2021

C complained about the care they received from their GP practice when they presented with problems with their sight and a headache. Whilst in the waiting room, C became more unwell. Following an examination, an emergency ambulance was called and C was taken to hospital where they were later diagnosed with a stroke. C complained that more immediate action should have been taken when they initially contacted and then attended the practice. The practice did not identify significant failings during their complaint investigation, but noted that some aspects could have been handled better. We took independent advice from a GP. We found that the practice’s initial handling of C’s call to the practice was reasonable, and it was appropriate that C was signposted to contact an optician. Furthermore, we found that, once C attended the practice, the care provided was reasonable and consistent with clinical guidance on assessment, history taking and examination. We did not uphold C’s complaint. Related reading View Decision Report 201907395 as a PDF (24.22 KB) Updated: November 18, 2020

Mr C complained that the practice failed to provide his late wife (Mrs A) with reasonable care and treatment. Mrs A had presented to the practice several times with severe back pain over a ten month period. Mrs A was told to self refer for physiotherapy. Mrs A subsequently went to A&E due to the pain she was suffering in her back. Mrs A was diagnosed with renal cancer which had spread to her spinal column and brain. Mrs A died from her illness. We took independent advice from a GP and a nurse. We found that although the practice doctors had been involved in prescribing painkillers and muscle relaxants to Mrs A, her back pain management and treatment plan was effectively being managed by the physiotherapy service who are independent practitioners. It was reasonable for a GP to expect that if a physiotherapist was concerned about deteriorating or urgent clinical signs in a patient that they would arrange appropriate hospital assessment or a scan. Mrs A had at no stage when she saw the practice doctors presented with red flag signs (indicators that a more serious problem may be developing/underlying) to suggest cancer. As such, the care provided by the practice doctors was reasonable. We found that with regard to Mrs A’s consultations with the advanced nurse practitioner, she had presented with potential red flag signs including unexplained weight loss. While Mrs A’s presenting symptoms were very atypical of renal cancer, it had not appeared that cancer had been considered given Mrs A had shown potential red flag symptoms and signs. We found that these red flag symptoms and signs had not been acted upon. Therefore, we upheld the complaint. We acknowledged that the practice in their complaint response to Mrs A and to this office accepted there were failings by the practice. They said they had learnt from Mrs A's case and we acknowledged the action the practice had taken to address this.

Mr and Mrs C complained on behalf of their daughter (Ms A) that the care and treatment Ms A received from practice was unreasonable. Mr and Mrs C said that the practice sought to reduce Ms A's prescriptions for morphine and diazepam when she joined as a new patient. Mr and Mrs C further complained that the doctor who saw Ms A did not give adequate reasons for why the medications were being reduced. We took independent advice from a GP. We found that it was reasonable for the practice to seek to reduce Ms A's medications. We also found that the doctor provided a clear explanation to Ms A, and Ms A's clinical records showed that she had received the same explanation on multiple occasions from other medical professionals involved in her care who had sought to reduce her medication doses. Therefore, we did not uphold this complaint. Mr and Mrs C further complained that Ms A was unreasonably removed from the practice list. We found that it was reasonable for Ms A to be removed from the practice list as the doctor/patient relationship had broken down with all the partners in the practice, and while the relevant legislation states that a warning should be given within 12 months, that a warning does not need to be given if the GP does not feel that it is reasonable or practical to do so, which was the case here. Therefore, we did not uphold this complaint. Mr and Mrs C also complained that the practice's handling of her complaint was unreasonable. We found that the practice's complaint responses did not adequately address the issues raised and the practice failed to signpost to this office. Therefore, we upheld this aspect of the complaint.

Mrs C complained about the treatment she received at the practice to have a leg wound dressed. Mrs C said that she attended on a number of occasions and told nursing staff that the wound was sore and infected but that they ignored her concerns. Subsequently, one of the nurses arranged for a swab to be taken and this identified that the wound had become infected. Mrs C felt that the nursing staff should have acted on her concerns earlier and that it would have saved her the additional pain and distress. We took independent advice from a nurse. We found that the nurses involved provided appropriate wound care and that there were no recorded signs of infection. A swab was taken because of slight inflammation of the wound which subsequently identified an infection which was treated with antibiotics. We did not uphold the complaint. Related reading View Decision Report 201905688 as a PDF (24.12 KB) Updated: June 17, 2020

Ms C complained about the care and treatment provided to her by the practice for a number of symptoms over period of several months. We took independent advice from a GP. We found that the assessments, investigations, referrals and treatment provided to Ms C were reasonable. We did not uphold the complaint. Related reading View Decision Report 201807532 as a PDF (23.82 KB) Updated: March 18, 2020

Mrs C's complaint concerned the care and treatment given to her late husband (Mr A) by his GP practice. Mr A first attended the practice with lower back pain but later attended with testicular pain. After an examination he was informed that there was suspicion of prostate cancer. An urgent referral was subsequently made by his GP and he was advised that there was a high risk that he had prostate cancer which had spread. Mr A later died. Mrs C complained that the practice had failed to properly investigate Mr A's testicular and back pain, and that their referral letter misrepresented the situation. Mrs C also complained that Mr A had been prescribed morphine which caused hallucinations and that no palliative care plan had been made for him. We took independent advice from a GP. We found that Mr A was treated reasonably and appropriately; there had been no delay in his diagnosis and an urgent referral had been made in a timely way. There was no evidence of misleading information in the referral letter and it was in line with General Medical Council Good Medical Practice. We also found that morphine could cause side-effects, particularly towards the end of life and that Mr A had been referred to the community palliative care team. We did not uphold the complaint. Related reading View Decision Report 201806794 as a PDF (23.95 KB) Updated: August 21, 2019

Ms C, an advice and support worker, complained on behalf of her client (Mr A) regarding the treatment which he had received from the practice, prior to him being diagnosed with prostate cancer. Mr A had attended frequent consultations with right hip pain and had been referred to physiotherapy (treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) on a number of occasions. He was also sent for an orthopaedic (treatment of diseases and injuries of the musculoskeletal system) referral which had not helped. Mr A stopped attending physiotherapy as he received no benefit from the exercises or the painkillers which the practice had prescribed. We took independent medical advice from a GP. We found that initially it was felt that Mr A had a musculoskeletal problem (injuries or pain in the joints, ligaments, muscles, nerves, tendons, and structures that support limbs, neck and back) which was reasonable in view of the presenting symptoms. The practice provided appropriate pain relief and made appropriate referrals for specialist opinions in orthopaedics and physiotherapy. It was only when Mr A presented with pain in his upper spine, which triggered a red flag sign, that blood tests were arranged which indicated possible prostatic cancer. This resulted in an urgent referral to the cancer specialists. We had no concerns about the way the GPs at the practice managed Mr A's reported symptoms over the period and there was no delay in making a specialist referral when he reported a new symptom of spine pain. We did not uphold the complaint. Related reading View Decision Report 201808175 as a PDF (24.2 KB) Updated: May 22, 2019

Mr C complained about the care he received from the practice prior to his diagnosis of hereditary haemochromatosis (a medical condition caused by an overload of iron in the body). Mr C experienced various symptoms that he said increased in number and severity over six years until his diagnosis. Mr C raised concerns that the practice should have carried out relevant tests, referred him to relevant specialists and reviewed his ongoing symptoms. We took independent advice from a GP. We found that appropriate tests were arranged and appropriate and timely referrals were made to various specialities. We considered that a slightly raised blood test result was not diagnostic of haemochromatosis and relates to different conditions. We concluded that the care provided by the practice was of a reasonable standard. We did not uphold Mr C's complaint. Related reading View Decision Report 201800379 as a PDF (23.76 KB) Updated: May 22, 2019

Miss C complained about the care and treatment provided to her by the GP practice. Ms C has complex medical conditions and was concerned about a medication being stopped, a decision to refer her to a specialist and the way in which a blood sample was taken. We took independent advice from a GP. In relation to the medication being stopped, we found that it was reasonable and safe for the practice to do this whilst waiting for a referral to a specialist. The GP had also asked Miss C to arrange an appointment with them if she wanted to discuss this. In relation to the referral to a specialist, Miss C felt that this was unnecessary. We considered the referral to be reasonable in order to establish the medical reason for Miss C's symptoms. Miss C was concerned about her vein being 'blown' when blood was taken, however, she did not raise this with the practice at the time. The GP subsequently apologised and said they were unaware of this as they were able to continue to draw blood. Miss C also raised concerns about communication from the practice regarding her medication being stopped. The practice accepted that this was the case, apologised and altered the way in which this would be communicated in future. We considered that the care and treatment Miss C received was reasonable and we did not uphold this complaint. Related reading View Decision Report 201709163 as a PDF (23.93 KB) Updated: May 22, 2019

Mr C complained about the practice's management of his son (Mr A)'s medication. We took independent advice from a GP. We found that Mr A's medication was managed in a reasonable manner and did not uphold Mr C's complaint. Related reading View Decision Report 201801819 as a PDF (23.41 KB) Updated: January 23, 2019

Mrs C made a complaint on behalf of Mrs B about the care and treatment her late husband (Mr A) received at his GP practice. Mr A had a number of health issues including epilepsy for which he had been prescribed medication for many years. Mr A had attended the surgery for worsening upper abdominal pain following a two day history of vomiting. Mr A was admitted to hospital where he died several days later. Pancreatitis (inflammation of the pancreas) was recorded as one of the causes of Mr A's death. Mrs C complained that the practice had failed to provide Mr A with reasonable care and treatment. In particular, that Mr A's GP had failed to recognise that Mr A's epilepsy medication could cause pancreatitis. We took independent advice from a GP. We found that the care and treatment provided to Mr A by the practice was reasonable. Mr A's health concerns were appropriately investigated and blood tests and referrals were made as appropriate and in a timely manner. We also noted that pancreatitis is a very rare side effect of the medication Mr A was taking for his epilepsy. We considered that the care provided to Mr A by the practice was of a reasonable standard and in line with good medical practice. Therefore, we did not uphold Mrs C's complaint. Related reading View Decision Report 201704771 as a PDF (23.96 KB) Updated: December 19, 2018

Mrs C complained about the care which she received from the practice. She said that the practice unreasonably refused to prescribe her pethidine (painkiller) medication and removed it from her list of repeat medications. Mrs C said that she had been on the medication for a number of years and that no alternative painkillers were prescribed and she was at risk of withdrawal symptoms. We took independent advice from a GP. We found that the clinical records indicated that Mrs C had agreed to stop pethidine, she had also said it was her intention to try ibuprofen (anti-inflammatory pain relief medication) and that she still had a stock of pethidine at home. We found that the GP correctly did not prescribe additional painkilling medication in the meantime and also that Mrs C had not been taking pethidine on a regular basis and as such it was unlikely she would have suffered from withdrawal symptoms. Therefore, we did not uphold Mrs C's complaint. Related reading View Decision Report 201803565 as a PDF (23.81 KB) Updated: December 19, 2018

We closed this complaint before concluding our investigation. The complainant had asked for the investigation to be put on hold while she made a subject access request, but more than six months later had not asked for our investigation to be continued. At the time of closing, more than a year had passed since she brought her complaint to us and her circumstances had changed, meaning the outcome she was seeking was no longer achievable. Related reading View Decision Report 201607509 as a PDF (10.8 KB) Updated: December 2, 2018

Ms C complained about the care and treatment provided to her late partner (Mr A) by GPs at the practice. Ms C complained that GPs incorrectly diagnosed a viral illness, and that they should have recommended hospital admission at an earlier point. We took independent advice from a GP. We found that, on the two occasions that GPs from the practice attended Mr A, they assessed and examined him reasonably and that, based on this, the diagnosis of viral illness was reasonable as there was no evidence of any more serious cause of Mr A's illness. We did not uphold this complaint. Related reading View Decision Report 201704913 as a PDF (10.87 KB) Updated: December 2, 2018

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Ms A). She said there had been a delay in Ms A's medical practice making a referral for her to attend the orthopaedic department when her back problems continued. She further said that the practice failed to follow up on the referral when it was eventually made. While the practice recognised that Ms A felt unsupported, they nevertheless said they had been appreciative of Ms A's difficulties and had tried to help her. We took independent medical advice from a GP. We found that while Ms A attended the practice prior to her referral, the medical records showed that she had been treated reasonably, that her condition had been monitored, that she had been appropriately examined, and that she had been prescribed medication in accordance with her symptoms and published guidance. There were no 'red flags' (signs to warrant urgent referral). Although we found that the practice did not issue the referral immediately, once the error was discovered it was issued and sent within the time-frame required by local guidance. An apology had been given to Ms A for the oversight. We did not uphold Ms C's complaint. Related reading View Decision Report 201603047 as a PDF (11.22 KB) Updated: March 13, 2018

Mr C, who received treatment for high blood pressure and kidney disease, complained that GPs at his medical practice had not monitored his blood pressure reasonably, and that this had caused damage to his kidneys. In response to Mr C's complaint, the practice said that his blood pressure had been monitored in accordance with the relevant guidelines. We took independent medical advice. The adviser was satisfied that it was appropriate for the practice to measure Mr C's blood pressure at whatever time he attended for an appointment and noted that there was no requirement in the guidelines stating that blood pressure cannot be taken in the morning, or after a patient's medication has been taken. The adviser considered that both Mr C's blood pressure and kidney function had been monitored with reasonable regularity and in accordance with the relevant requirements. Furthermore, the adviser did not have concerns about the medication prescribed to Mr C by the practice and concluded that there was no evidence that the practice had failed to adequately monitor Mr C's blood pressure or that their actions had contributed to reduced kidney function. We therefore did not uphold this aspect of Mr C's complaint. Mr C also complained that the practice did not respond reasonably to his complaint. In response to our enquiries, the practice identified that some of the complaint correspondence did not meet a number of the requirements of the Patients Rights (Scotland) Act 2011. The practice told us that the practice manager had undertaken to fully familiarise themselves with the requirements of the Act and that they would update the practice's complaints procedure to reflect the requirements. Although we found that many aspects of the practice's handling of the complaint were reasonable, we were critical that the practice had not followed the guidance in relation to acknowledging complaints and updating complainants after a delay. We therefore upheld this aspect of Mr C's comp

Mrs C complained to us that at numerous consultations over a nine-month period, the medical practice failed to provide her with appropriate treatment for her reported pain in her right arm. By the time she was referred for a specialist hospital opinion, a diagnosis of non-Hodgkin lymphoma (a cancer that develops in the lymphatic system) was made. Mrs C believed that the GPs at the practice should have referred her to hospital earlier and that as a result she has had to undergo courses of chemotherapy and radiotherapy. We obtained independent GP advice. We found that during the relevant period, in addition to the consultations at the practice, Mrs C attended the pain clinic and referrals to other departments. She also underwent an MRI scan and x-rays were taken. The symptoms which Mrs C reported to the practice were not in keeping with a diagnosis of non-Hodgkin lymphoma. We found that the practice arranged appropriate referrals and also closely monitored Mrs C's pain relief whilst communicating frequently with the pain clinic specialists. We therefore did not uphold Mrs C's complaint. Related reading View Decision Report 201604585 as a PDF (11.15 KB) Updated: March 13, 2018

Mrs C, who works for an advice agency, complained on behalf of her client (Miss A), who said she was suffering from Jarisch Herxheimer's reaction (a physical reaction to the death of microorganisms within the body during antibiotic treatment). Mrs C said Miss A believed that she had not received the appropriate care and treatment from her medical practice. Miss A believed that she had not been prescribed antibiotics appropriately and that the practice had inappropriately interfered with her consultations with hospital specialists. We took independent medical advice from a GP adviser. The adviser said, and we agreed, that Miss A had been treated appropriately. Jarisch Herxheimer's reaction was an unusual condition and would require diagnosis by a hospital specialist. Miss A had received the appropriate referrals, but the specialists in question had confirmed that Miss A did not have this condition. We found that there was no evidence that the practice had acted inappropriately or that they had attributed Miss A's problems to her mental health. We found that the care and treatment provided was of a reasonable standard and we did not uphold the complaint. Related reading View Decision Report 201508658 as a PDF (11.13 KB) Updated: March 13, 2018

Mrs C, who works for an advice and support agency, complained on behalf of her client (Ms A) that her medical practice had failed to investigate, diagnose and treat her symptoms. We took independent medical advice and found that Ms A had previously been referred to a number of specialists. She had no new symptoms that warranted further investigation and it was reasonable not to refer her back to the specialists. We found that the care provided by the practice had been of a reasonable standard and we did not uphold this aspect of Mrs C's complaint. Ms A considered that she was suffering from Jarisch Herxheimer's reaction (a physical reaction within the body during antibiotic treatment). Mrs C complained that the practice had unreasonably stated that this was not the cause of Ms A's symptoms. We found that this had already been investigated in hospital and there was no evidence that this was the diagnosis. We considered that the practice's comments in relation to this matter had been reasonable and we did not uphold the complaint. Mrs C also complained that it was unreasonable for the practice to suggest in their diagnosis that that there were psychological or psychiatric factors which were worsening Ms A's physical symptoms. We found that the practice's clinical assessment and opinion on this matter had been reasonable and we did not uphold this aspect of the complaint. Related reading View Decision Report 201600555 as a PDF (11.23 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment provided to her by her medical practice in relation to her ongoing ankle pain. During our investigation we took independent advice from a GP adviser. The advice we received was that the care and treatment provided by the practice in relation to the ongoing management of Mrs C's ankle injury was of a reasonable standard and no failings were identified. We did not uphold the complaint. Related reading View Decision Report 201508674 as a PDF (10.78 KB) Updated: March 13, 2018

Miss C complained that a GP with whom she had been discussing rape and sexual assault unreasonably referred her to a psychiatrist. In particular, Miss C raised concerns that the medical practice had been dismissive of her history and circumstances. She also raised concerns that the practice referred her unreasonably on the basis of previous psychiatric history. She said that the referral should have been to another specialist. The practice said that the GP referred her to the psychiatrist as it was clinically indicated to do so. They also said the referral was not based on Miss C's previous psychiatric history, but on the GP's concerns about Miss C. The practice also understood that Miss C was in contact with a rape counselling service. After receiving independent medical advice, we did not uphold Miss C's complaint. We found the referral was reasonable based on the clinical signs recorded in the medical records, which may have been consistent with certain mental health conditions. We also found that the GP considered appropriately the reported history of abuse in making the referral. Related reading View Decision Report 201508482 as a PDF (11.11 KB) Updated: March 13, 2018