Decision report 201200309

Summary

Mrs C complained that the care and treatment provided to her sister (Ms A) was unreasonable. Ms A had a history of chronic obstructive pulmonary disease (a long-term lung condition), osteoporosis (thinning of the bones) and heart problems. A GP from the medical practice visited and, after examining her, prescribed antibiotics and steroids (drugs commonly used to fight infections) in tablet form. Ms A had trouble taking these as she was normally unable to swallow tablets and usually had medication in liquid or powder form. Her condition did not improve.

A second GP visited the next day and again examined Ms A but was unable to take her temperature as his thermometer was broken. The GP prescribed a different antibiotic, again in tablet form. Neither GP considered that Ms A's condition warranted emergency admission to hospital and the second GP said that Ms A had specifically told him that she did not want to go to hospital. Ms A's condition continued to deteriorate and Mrs C called NHS 24 (a national advice helpline) later that evening. Ms A was taken by ambulance to hospital where she was found to be suffering from sepsis (serious infection) and hypothermia (where the body temperature falls below the normal range). She was admitted, but died shortly afterwards.

We did not uphold any of Mrs C's complaints. Our investigation, which included taking independent advice from a medical adviser, concluded that the examinations and management plan for Ms A had been reasonable. In particular, the adviser said that in light of Ms A's reluctance to go to hospital it was appropriate to take her views into consideration and to manage her condition at home. The family disputed that Ms A did not want to go to hospital, but the records showed that the ambulance paramedics had recorded her reluctance to go there. The practice acknowledged that Ms A had medication in liquid form, but there was nothing specific in her notes to highlight that she had difficulty in swallowing tablets. In any event, the second GP did not have access to the notes on his visit as he had been passed the call while out of the practice doing other home visits. There was also no clear evidence that Ms A or the family specifically told either GP that Ms A could not swallow tablets.