Decision Report 201700042

Summary

Mrs C complained that the practice failed to carry out appropriate checks for allergies before prescribing penicillin. Mrs C was visited by a GP at home and prescribed an antibiotic containing penicillin which she is allergic to. Mrs C did not suffer any ill-effects as she read the information on the packet and therefore did not take the medication. The practice said that the GP asked Mrs C if she was allergic to penicillin before prescribing, which Mrs C denies. They also noted that doctors do not have sight of patients' medical records when on house calls but that the GP looked at the patient's medical summary before the appointment.

We took independent advice from a GP. They considered that it was reasonable for the surgery to check a patient's records before leaving the practice and to ask the patient if they were allergic to any medications. We found that Mrs C's penicillin allergy was noted on the medical summary the GP said that they had referred to. We considered that if the GP had checked this first they ought to have been alert to prescribing penicillin in a patient with allergies. Although the practice acted reasonably in checking the medical records before the home visit, we considered the allergy should have been picked up then. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to take sufficient steps to establish that she was allergic to penicillin, and prescribing her an antibiotic that contained penicillin. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• All GPs should be reminded of the importance of carefully checking records before house calls (or if that is not possible, checking for allergies by phoning the surgery), in addition to asking patients about allergies, before prescribing penicillin.

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.