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Case ref:201606388
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Date:January 2018
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Body:A Medical Practice in the Grampian NHS Board area
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Sector:Health
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Outcome:Not upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C complained about the care and treatment of her late mother (Mrs A). Mrs A became unwell and was seen initially by an out-of-hours doctor, who diagnosed infection and prescribed antibiotics. Mrs C called the practice and spoke to a GP the following day as Mrs A was still unwell, and a home visit was arranged for the following day. When a GP reviewed Mrs A at home the next day, arrangements were made to admit her to the GP unit in a local care home. From there, she was transferred to hospital in the early hours of the following morning, where she deteriorated and died five days later.
Mrs C complained that, when she called the practice, they did not arrange for Mrs A to be reviewed that day. We took independent advice from a GP adviser, who considered that the GP carried out an appropriate assessment and, based on the information gathered, took steps to arrange for Mrs A to be reviewed within a reasonable timescale. We accepted the advice and did not uphold the complaint.
Mrs C also complained that the GP who reviewed Mrs A at home should have arranged to admit her directly to hospital. She also raised concerns that the GP retrospectively altered Mrs A's recorded oxygen saturation level. The practice indicated that this was to rectify a typing error. We were advised that the originally recorded level should have led to a direct hospital admission, whereas the amended level was in keeping with the actions taken. We were unable to establish the true picture and, therefore, could not conclude that there was an unreasonable failure to admit Mrs A to hospital. As such, we did not uphold the complaint however we made a recommendation in relation to record-keeping.
Recommendations
What we said should change to put things right in future:
- The practice should take steps to clarify whether the entry in the clinical records accurately reflects the date that it was retrospectively amended. If it does not this should be rectified to ensure complete clarity.
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.