Decision Report 201508145

Summary

Mr C complained that a GP practice did not properly maintain the medical records of his wife (Mrs A) and as a consequence, when she was admitted to hospital she was given medication which led to serious side effects. He further complained that a member of staff spoke to him inappropriately and told him that by stopping his wife's medication he could cause Mrs A's death.

We took independent general practice advice and noted that while Mrs A's medical records showed that a conversation with Mr C had taken place where he said that he was stopping her medication due to his belief that it caused side effects, they did not record a change to her medication. This was because Mrs A had the capacity to make decisions about her treatment and any changes could only be made after discussion with her. Whilst the records noted a terse conversation with Mr C about his wife's medication, there was no evidence that he had been spoken to inappropriately. It was clear that the repercussions of Mrs A stopping taking her medication had been clearly explained to Mr C. We did not uphold the complaint.