Decision Report 201501895

Summary

Mr C complained that the GP who examined his late father (Mr A) at a consultation had not provided a reasonable standard of care and treatment.  When Mr C visited Mr A later the same day, he was distressed by his father’s condition and called an ambulance.  When Mr A was admitted to hospital he was found to be dehydrated, with a chest infection.  He died four days later from aspiration pneumonia (caused by a poor swallowing mechanism whereby foreign matter enters the lungs).  Mr C also complained that his father’s medication had been unreasonably increased, despite previous knowledge that an increased dose previously reduced Mr A's appetite and he would therefore lose weight.

We took independent advice from a GP adviser.  They found the increase in the medication dosage to have been reasonable.  However, they noted that there was not a documented consultation for the day Mr A was admitted to hospital.  The adviser said this was not in line with General Medical Council (GMC) guidance.

On balance, we upheld the complaint as the practice were unable to demonstrate they had provided a reasonable standard of care and treatment.  We also noted they had failed to refer Mr C to us at the end of their complaints investigation.

Recommendations

We recommended that the practice:

• apologise to Mr C for the failings identified in our investigation;
• remind relevant staff of the importance of completing accurate documentation in line with the GMC guidance;
• ensure future complainants are referred to us at the end of the complaint response letter; and
• confirm the GP concerned will discuss this case at their next appraisal.