Decision Report 201102334

Summary

Mr C complained to the medical practice about the treatment that his late wife (Mrs C) received for gout. A GP had prescribed tranquilisers instead of painkillers. After two weeks Mrs C started losing skin on her hands and the GP reduced the medication. Mrs C was later admitted to hospital, where she died, with the cause of death stated as kidney failure and diabetes. Mr C said that his wife should have been admitted to hospital sooner, as she was passing blood.

Although we noted that this was a complex medical case, we upheld Mr C's complaint. After taking independent advice from one of our medical advisers, our investigation found that there was a lack of documentation in the GP records about Mrs C's deterioration in the weeks before she was admitted to hospital. There was also a failure to check her kidney function in view of medication that had been prescribed, and the practice should have referred Mrs C for a specialist opinion or hospital admission sooner.

Recommendations

We recommended that :

• conduct a significant event audit to see if lessons can be learned from this complaint;
• apologise to Mr C for the failings identified in our report; and
• ensure that the GP concerned revises the presentation of acute renal failure and management of hypertension and discusses the case at his next appraisal.