Decision report 201202056

Summary

Mr C's late wife (Mrs C) was diagnosed with cancer in June 2011. He complained that staff at the practice failed to take account of the seriousness of her condition and to take follow-up action. Mr C raised concerns about the way in which his wife's medication was given; a failure to document phone conversations; a failure to admit Mrs C to hospital when a provisional diagnosis of gastroenteritis (inflammation of the stomach and intestines) was made; and a failure to monitor her calcium levels. Mr C complained that, by the time Mrs C was admitted to hospital in October 2011, she was hallucinating. He believed that his wife had suffered more than she needed to as a consequence of the practice's failures or inaction.

In considering Mr C's complaint, we obtained independent advice from one of our medical advisers. Our investigation found that once Mrs C was diagnosed with cancer, her care was primarily the responsibility of the hospital and hospital staff. It was clear from hospital records that the practice was kept up to date with Mrs C's condition, and it was also clear that when requested, the practice took appropriate action. Our adviser confirmed that, in his experience, not all patients wanted to hear further from their GP, or to discuss matters with them, at what can be a busy and difficult time.

On the matter of administration of medication, we found that although Mr C was unhappy that his wife was given her medication in tablet rather than liquid form, the adviser said that there was no record on file confirming that this was required.

On the issue of Mrs C's non-admission to hospital when gastroenteritis was suspected, the adviser said that the records confirmed that this was discussed with Mr and Mrs C and it was noted that she was 'OK' to stay at home. Mr and Mrs C were given advice that if her condition worsened, they should phone NHS 24.

We found that Mrs C's calcium levels were not taken, and as she was vomiting, the adviser was of the view that when completing blood tests, this test should also have been carried out. He said that if her calcium levels were high, it might then have been possible to reduce them, and in turn this might have led to a reduction in Mrs C's sickness.

Recommendations

We recommended that the practice:

• apologise to Mr C for the failure to monitor Mrs C's calcium levels.