Decision Report 201304151

Summary

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.

Recommendations

We recommended that the practice:

• ensure that the GP considers the available national guidelines and includes his reflection on these in his next annual appraisal;
• ensure that the GP considers how he completes his clinical notes and seeks advice to do so;
• make a formal apology for their delay in dealing with the complaint; and
• implement and adhere to NHS guidance on dealing with complaints.