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Decision Report 201508247

  • Case ref:
    201508247
  • Date:
    February 2017
  • Body:
    A Medical Practice in the Lothian NHS Board area
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mrs C complained about the care and treatment provided to her mother (Mrs A) when she attended her GP practice complaining of breathlessness and collapse. During this period, Mrs A also had three admissions to hospital. Shortly after her third admission to hospital, she suffered a heart attack and died. Mrs C said that the practice failed to take Mrs A's symptoms seriously and delayed in taking appropriate action. She also said that the practice should not have prescribed a certain medication in light of Mrs A's heart condition.

We took independent advice from an adviser who specialises in general practice. We found that while the standard of medical care in relation to Mrs A's symptoms was reasonable, there were shortcomings in relation to a referral to hospital and the prescription of medication. While these shortcomings did not contribute to Mrs A's death, we upheld the complaint because of the prescription of medication that should not be given to patients with heart conditions.

Recommendations

We recommended that the practice:

  • ensure the relevant GP reviews the issues relating to the medication prescribed, including its contraindications;
  • review their systems for sending urgent referrals to ensure there are no avoidable delays; and
  • apologise for the failings this investigation identified.

Updated: March 13, 2018