Decision Report 201608304

Summary

Miss C complained that the medical practice had failed to carry out an appropriate assessment or refer her late father (Mr A) to hospital when he attended a consultation. Mr A was very breathless and suffered from pulmonary fibrosis (scarring of the lungs). The GP did not take Mr A's temperature or provide medication, as they felt that no further treatment was required at that time. Mr A was told to wait until his next scheduled respiratory clinic at the hospital, which was in nine days time. When Mr A attended the clinic, a clinician arranged an immediate hospital admission. Mr A deteriorated and died a few days later. Miss C felt that the GP should have referred Mr A to hospital sooner.

We took independent advice from an adviser in general practice medicine. We concluded that, although the GP had arranged for an ECG (electrocardiogram - test to check the rhythm of the heart), the GP failed to record Mr A's oxygen saturation, temperature and blood pressure. We found that the GP had failed to carry out an examination of the heart, which would have been appropriate for a patient who had presented with increased breathlessness and chest pains. We also concluded that, while it was possible that the GP's decision for Mr A to wait until his clinic appointment may have been reasonable, we were unable to establish this as the standard of record-keeping for the consultation was inadequate. We upheld Miss C's complaint that the GP failed to provide Mr A with appropriate treatment in view of his reported symptoms. However, in view of the inadequate record-keeping, we could make no finding on the complaint that the GP should have referred Mr A for a hospital assessment.

Recommendations

What we asked the organisation to do in this case:

• Send Miss C a written apology for the failure to carry out a thorough assessment in view of Mr A's reported symptoms.
• Send a written apology to Miss C for the inadequacies in record-keeping which meant we could not determine whether a hospital referral was required.

What we said should change to put things right in future:

• The GP involved should ensure that a thorough assessment is carried out in view of a patient's reported symptoms.
• The GP involved should ensure that their record-keeping meets the standard of what would be expected under the General Medical Council's Good Medical Practice guidance, in terms of clinical assessment, record-keeping and safety netting.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.