Decision Report 201302944

Summary

Mr C complained about a number of aspects of the care and treatment the practice provided for his late mother (Mrs A). This included that there was a delay of six weeks in the practice referring Mrs A to a specialist, after a doctor at the practice told Mr C at a home visit that this would be done. Mr C also complained that when another doctor at the practice saw Mrs A at home on a later date, he failed to arrange for her to be admitted to hospital and made an inappropriate reference to her condition. Mr C said the practice failed to take his mother's deteriorating condition seriously and provide her with appropriate care and treatment.

After obtaining independent advice on this case from one of our medical advisers, who is a GP, we upheld Mr C's complaints. Our adviser said that he would have expected the first GP to have set a time to see Mrs A to go over blood test results and to review her condition. This did not happen. The referral, which was eventually made more than six weeks after the home visit, appeared to have been prompted by Mr C and was made to a psychiatrist for the elderly, rather than a consultant geriatrician. It appeared that the practice might have taken some reassurance from tests that had suggested there was no sinister cause for Mrs A's long-term problems. The adviser said, however, that as Mrs A had red flag (warning) symptoms that could suggest underlying cancer and as some time had passed since the tests were carried out, a referral to a consultant geriatrician should have been made.

The second doctor accepted that, at the later home visit, he had referred to Mrs A inappropriately. In our view, the term he used was insensitive and would likely have added to the distress Mr C was experiencing at that time. Having correctly decided not to admit Mrs A to hospital, it then appeared that this doctor failed to assess Mrs A's social situation at the visit, although we accepted that, overall, the practice acted reasonably in trying to get social work involved in her case.

Recommendations

We recommended that the practice:

• feed back the failings identified to the staff involved to ensure that a similar situation does not happen in future; and
• provide Mr C with a written apology for the failings identified.