Decision Report 201407598

Summary

Miss C complained that her mother-in-law (Mrs A) had not been properly assessed by a GP following episodes of dizziness and elevated heart rate and blood pressure. Mrs A had suffered a fatal heart attack three days after visiting the GP.

The GP said that Mrs A had suffered from a number of health problems. At the consultation in question she had been extremely anxious and had been prescribed medicine to counteract this. Her pulse and blood pressure had also been taken.

We took independent advice on the care and treatment provided. Our adviser said the medical records did not show that a comprehensive examination of Mrs A had been carried out. Our adviser noted that Mrs A suffered from diabetes and that the appropriate Scottish guidance for management of patients with this condition had not been followed, which was unreasonable. We found that the GP had not carried out an adequate examination of Mrs A. However, our adviser also said that Mrs A's death had been impossible to predict and that even had a more thorough examination been carried out, it would not have been possible to prevent her fatal heart attack.

Recommendations

We recommended that the practice:

• apologise to the family for the failings identified;
• provide evidence that the GP has familiarised themselves with the Diabetes SIGN (Scottish Intercollegiate Guidelines Network) guidance by including this as a learning need in their yearly appraisal;
• provide evidence that this case and our adviser's comments have been discussed between the GP and their appraiser; and
• carry out a Significant Event Review and discuss this with the GP and the local clinical director to ensure learning from the case is appropriately identified.