SPSO Individual Decisions

C complained that the practice failed to properly investigate their hip pain symptoms, resulting in a delayed cancer diagnosis. C raised concerns that questions were not asked, or tests carried out, that might have led to an earlier diagnosis. The practice responded to the complaint and carried out a Significant Event Analysis (SEA). They noted that a muscular injury was suspected at the initial consultation. At the time of the second consultation, an x-ray had been incorrectly reported as normal by the hospital. Therefore, the practice were not alerted to any need for further tests at that time. We took independent medical advice from a GP. We found the practice's management of C reasonable at the initial presentation. However, when C re-presented a month later with worsening bone pain despite a normal x-ray, further investigation (blood tests) should have been carried out. C was then diagnosed after orthopaedic (specialists in the treatment of diseases and injuries of the musculoskeletal system) review the following month. We upheld C's complaint. However, given the extensive nature of the disease identified, we did not consider that further investigation by the practice at the second consultation would have altered the overall outcome. We also found that the SEA should have reflected the further investigation that should have been considered at the second consultation. We gave some feedback to the practice on learning from adverse events, with reference to Healthcare Improvement Scotland's relevant guidance.

Mr C suffers from post-traumatic stress disorder and has a longstanding difficulty leaving his house as a consequence. Mr C complained that the practice unreasonably decided that he was not housebound. Mr C's psychiatrist wrote to the practice noting their view that his longstanding mental health difficulties effectively rendered him housebound. The practice had previously refused a request from Mr C for a home visit on the basis that he had managed to attend the surgery in the preceding months. Mr C contacted the practice to ask them to clarify their position in light of his psychiatrist's letter, and they maintained that he is not housebound. We took independent advice from a GP, who considered that the practice's home visit policy was overly rigid in that it appeared to require a purely physical inability to travel and did not give due regard to Mr C's mental disability. Therefore, we upheld this complaint. Mr C also complained that the practice failed to disclose relevant information to his psychiatrist when discussing his situation over the phone. This pre-dated the psychiatrist's letter and the psychiatrist appeared to agree with the practice at that time that Mr C was not housebound. Mr C considered that the conclusions drawn by his psychiatrist would have been altered if the long standing nature of his condition and its symptoms had been discussed. However, we noted that the psychiatrist was already aware of Mr C's long term symptoms and medical history from previous assessments by them. The purpose of the call was to find out if there were any current issues that they needed to be aware of. We found that it was reasonable for the practice not to refer to more details of Mr C's past medical history during the phone call. Therefore, we did not uphold this complaint. In addition, Mr C complained that the practice did not advise him of his right to approach us on completion of their complaints process. The practice complaints policy and NHS complain

Mr C complained about the care and treatment provided by the medical practice to his late wife (Mrs A), who suffered from diabetes. In particular, he complained about the treatment of Mrs A's ulcers, decisions made by the practice during home visits and the practice's initial decision to refuse a home visit. Mr C also complained about the practice's response to his complaint. During our investigation we took independent GP and nursing advice. The advice we received from the GP adviser was that the care and treatment given to Mrs A was in line with NHS guidance on the management of diabetes, and the decisions taken by the practice during home visits were reasonable. The advice we received from the nursing adviser was that the nursing care provided by the practice was reasonable. We found no evidence that a home visit had been refused by the practice, but that the practice had been hesitant to visit given that a home visit had been carried out within 24 hours prior and the complaint remained the same. The advice we received and accepted from the GP adviser was that in these circumstances it had been reasonable to question the necessity for another home visit. The practice had accepted that there were inaccuracies in their response to Mr C and in their clinical records. We therefore upheld this aspect of Mr C's response.

Mr C complained to us about the care and treatment provided to his wife (Mrs A) by the medical practice. He complained that the practice failed to provide Mrs A with appropriate treatment when she presented with lower back pain, and that they failed to appropriately examine her at her consultations. Mr C felt that the back pain was a symptom of the cancer Mrs A was later found to have and which led to her death. Mr C further complained that Mrs A had been provided with inappropriate inhalers for a number of years. In investigating this complaint, we took independent advice from a GP adviser. We found that whilst Mrs A had presented with lower back pain for a number of months, there were no symptoms at that time which would have alerted her GP to the possibility of her having cancer. When Mrs A reported new symptoms, these were found to be due to abdominal cancer. We found that the management of Mrs A's original symptoms, which was primarily with painkillers, was reasonable. We also found that Mrs A was reasonably examined by GPs at the practice based on her reported symptoms. We therefore did not uphold this aspect of Mr C's complaint. With regard to the inhalers Mrs A had been prescribed, we found that as Mrs A had never been formally diagnosed with an illness that would require regular use of inhalers, it was not reasonable that she had been prescribed these on a long-term basis. Whilst we did not find there to have been adverse effects as a result of this failing, we upheld Mr C's complaint. The practice acknowledged that the monitoring of Mrs A's inhaler use could have been better and told us they had undertaken a review of their system regarding this.

Mrs C complained that the medical practice failed to identify that her father (Mr A) had cancer. Mr A had multiple health issues and regularly attended the practice but it was not until the family eventually took him to hospital that he was diagnosed with an aggressive tumour. He died nine days later. The practice noted that there had been no change to Mr A's longstanding symptoms other than some worsening in the weeks before he died, and they did not consider that his cancer could have been detected much earlier or would have responded to treatment. We took independent medical advice from a GP who noted that the practice had arranged relevant investigations including chest x-rays, scans and blood tests. Although Mr A's liver function test results were noted to have been abnormal in the month prior to diagnosis, the practice had already arranged a colonoscopy and the adviser did not consider that further tests were indicated at that stage. When the tests were repeated two days prior to diagnosis, they showed a significant deterioration and the practice took appropriate steps to upgrade an existing ultrasound scan referral to urgent. The adviser noted that the hospital may have separately arranged investigations themselves around this time when Mr A self-presented with his family. However, we found that the practice had by then already taken reasonable and prompt action when they identified the deterioration in Mr A's liver function results. We therefore concluded that the practice did not unreasonably delay taking steps to have Mr A's cancer diagnosed and we did not uphold the complaint. Related reading View Decision Report 201508703 as a PDF (11.38 KB) Updated: March 13, 2018

Mr C has a diagnosed personality disorder and post-traumatic stress disorder (PTSD). He complained that the practice had refused to come to his home for a house call in relation to physical symptoms he was experiencing including a cough. When the practice initially declined the house call request, Mr C said that his PTSD had rendered him housebound. He later asked for a mental health referral. The practice advised that they needed to see him at a consultation at the surgery before this could be made and Mr C also complained about this decision. In addition, Mr C complained that his complaint to the practice had not been handled properly. After taking independent advice from a GP, we did not uphold either of Mr C's complaints about his care. We found that Mr C had been seen recently at the practice and that it was reasonable to ask him to attend for an assessment of his physical symptoms. The GP adviser also considered that it was reasonable to require a face-to-face consultation before making a mental health referral. We also took independent advice from a mental health adviser. The mental health adviser said that the practice's approach was reasonable but highlighted the fluctuating symptoms of PTSD and considered that their approach may need to change in future. These comments were drawn to the practice's attention. However, we found no evidence that Mr C had been provided with information about the Patient Advice and Support Service and the final response to Mr C's complaint did not include information on how to progress his concerns if he remained dissatisfied. We upheld this aspect of Mr C's complaint.

Mr C complained about a GP during a home visit deciding not to refer his wife (Mrs C) to hospital. Mr C was particularly concerned that Mrs C had been treated with steroids during a recent hospital admission for a chest infection, and this was likely to affect her diabetes. The GP said that, during the home visit, they considered Mrs C was suffering from diabetes and a flare-up of her chronic obstructive pulmonary disease (COPD - a disease of the lungs in which the airways become narrowed). However, they said there was no evidence of a chest infection. The GP said the steroid treatment was important for Mrs C’s COPD (although it had a negative impact on her diabetes control) and they encouraged Mr C to continue this treatment. The GP considered their actions were appropriate. After taking independent medical advice from a GP adviser, we upheld Mr C’s complaint. In relation to Mr C’s concerns about the steroid treatment, we found that the GP acted appropriately by advising Mr C to continue this (as the benefit to Mrs C’s COPD outweighed the impact on her diabetes). However, the adviser explained that Mrs C had lower oxygen saturation levels than when tested 11 days earlier, and the GP should have arranged further investigation of this (which would usually be done in a hospital setting).

Mr C complained to the practice that he was concerned that his daughter (Miss A) had been inappropriately prescribed medication for bladder problems. He felt that this was not clinically indicated and was for convenience only, and that Miss A was at risk of side effects from the medication. The practice believed that the medication was appropriate for the symptoms Miss A presented with. We took independent advice from one of our medical advisers, an experienced GP. Our adviser was satisfied from the medical records that, given Miss A's reported symptoms of urinary frequency and medical history, the medication was appropriate. We found that the practice's actions in prescribing the medication was appropriate and we did not uphold Mr C's complaint. Related reading View Decision Report 201404149 as a PDF (10.96 KB) Updated: March 13, 2018

Mrs C was concerned by the care and treatment provided to her late mother (Mrs A) by a GP at the medical practice. Mrs C was unhappy that although Mrs A was complaining of pain and discomfort in her leg, the GP failed to consider the possibility of deep vein thrombosis (DVT - a blood clot in a vein). A month later, Mrs A died of a bilateral pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs). To investigate the complaint, we carefully considered all the relevant information (including the complaints correspondence and Mrs A's relevant clinical records) and obtained independent advice about Mrs A's care and treatment from one of our medical advisers, who is a GP. We found that the GP's treatment of Mrs A was reasonable and that the records showed why he had not suspected DVT, given the symptoms that Mrs A had at the time. The adviser said that a clinical picture may at the time not be as clear cut as when looking back and considering a matter with hindsight. In the circumstances, the adviser thought that it was reasonable for the GP not to consider DVT. We noted that, since Mrs C's complaint, the GP had clearly reflected on what had happened, and had reviewed local guidelines in attempt to prevent this happening again. Although we did not uphold the complaint, we made recommendations that the GP takes further steps to ensure good clinical practice. We upheld Mrs C's complaint about complaints handling, as we found that timescales were not met when responding to her letters.