Decision Report 201204750

Summary

Mr C complained about the care and treatment that a medical practice provided to his late mother (Mrs A) before her death. He said that GPs had not taken reasonable steps to assess and monitor Mrs A's pain when making changes to her medication. He also said that they had unreasonably put Mrs A on the Liverpool Care Pathway (a framework used by healthcare professionals in the last hours or days of life when a death is expected).

We obtained independent advice on this complaint from our GP adviser. We found that in general, the practice had taken reasonable steps to assess and monitor Mrs A's pain when making changes to her medication. However, we upheld this complaint as they should have ensured that arrangements were in place to review Mrs A and that this was noted in the medical records, after her medication was increased on one occasion and it was identified that she had a chest infection. At the very least, they should have phoned to find out if the medication was effective or was causing problems. There was no evidence that they did so.

Our investigation also found that the practice had considered admitting Mrs A to hospital or to a hospice when her condition deteriorated. They discussed this with the family and with the nursing staff caring for Mrs A. They decided that she should not be admitted and that they would start the Liverpool Care Pathway. We did not uphold this complaint as, although we considered that the GP should have recorded more detail about the decision we found that, based on the information available at the time, the decisions not to admit Mrs A to hospital and to start the Liverpool Care Pathway were, on balance, reasonable. That said, we found that the practice's responses to Mr C about the matter had not been satisfactory and that they had failed to respond in detail and we made a recommendation to address this.

Recommendations

We recommended that the practice:

• make the staff involved in Mrs A's care and treatment aware of our findings;
• issue a written apology to Mr C for the failure to satisfactorily respond to his complaints;
• take steps to ensure that in the future complaints are investigated and responded to appropriately; and
• remind the GPs of the need to maintain clear and thorough medical notes.