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Case ref:201303935
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Date:January 2015
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Body:A Medical Practice in the Dumfries and Galloway NHS Board area
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Sector:Health
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Outcome:Some upheld, action taken by body to remedy, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C complained about the care and treatment provided to her daughter (Miss A) by a medical practice. Miss A has a long-term health condition and needs multivitamins daily. Mrs C said that, on more than one occasion, GPs at the practice wrongly prescribed a multivitamin containing a high dose of vitamin A, which was potentially toxic to Miss A. Mrs C said that she and the dietician noticed the error, not the GPs, and she complained to the board, who responded on behalf of the practice. Mrs C was not satisfied with the board's response.
After taking independent advice from one of our medical advisers, we were satisfied that the practice took Mrs C's complaint seriously, conducted a full and honest investigation, including a significant event analysis, and proposed reasonable actions to prevent a similar situation in the future. There had clearly been a mis-prescription of Miss A's multivitamins which affected a period of roughly six months, which the practice accepted. We found that this was caused by poor communication between the practice and other healthcare staff involved in Miss A's care. We also found that the practice operated two different methods of prescription, which meant that a GP dealing with Miss A for the first time could easily miss details of previous prescriptions which had not been entered on the practice system. We were also critical that, when it was established early on that Miss A's prescribed multivitamin was not listed on that system, no action was taken to have the system updated or to forewarn other GPs in the practice. We upheld Mrs C's complaint and made recommendations to address the failings identified.
Mrs C also complained about the handling of her complaint, but we found that it was investigated thoroughly and that the board’s response was reasonable.
Recommendations
We recommended that the practice:
- apologise to Mr and Mrs C for the poor handling of Miss A's multivitamin prescription; and
- provide us with evidence of the procedural changes that have been implemented following the significant event analysis.