Decision Report 201809801

Summary

C raised numerous concerns and complaints about repeated errors with the issuing of Movelat (pain relieving gel). C maintained the gel should be issued to them weekly but when submitting requests to receive the gel, they experienced difficulties. C received mixed responses as to why the gel was not issued. Some of the replies issued indicated the gel should be issued monthly. Other replies acknowledged that the gel should be issued weekly and explanations were offered for the error.

The evidence available confirmed that the gel was to be prescribed weekly to C. Despite this, C had to continually raise concerns in relation to ongoing errors with the prescribing frequency of the medication. It took some time before preventative steps were taken, by way of a note that was added to C's record confirming that the frequency of the prescription for the gel should not be changed.

We accepted that any delay in issuing the gel will not have had serious consequence for C, and we recognised the actions taken to minimise errors with the prescribing frequency of the gel. However, we found the administrative handling of the matter was poor. C had to unnecessarily submit repeated feedback and complaints only to receive mixed replies and for the problem with the prescribing frequency to continue longer than it needed to. As such, we upheld this aspect of the complaint.

C also complained about the decision taken by the healthcare team to discontinue a prescription for Difflam spray (an anti-inflammatory spray used to treat many painful conditions of the mouth or throat). It was explained to C that the throat spray was a short-term treatment for symptomatic relief of painful conditions of the mouth. It was noted that C had been taking the spray for several months, but there was no record to confirm the reason for that. C was reviewed by the dentist, who found no evidence of ulcers. The dentist had initially agreed to reinstate the spray but it was discontinued following a further discussion with an advanced nurse practitioner due to lack of mouth ulcers.

We took independent advice from an appropriately qualified clinical adviser, We found that the decision to stop the mouth spray had been taken in line with good practice as set out by the General Medical Council. As such, we did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to issue the pain relieving gel weekly, as per their prescription. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the unnecessary time and trouble they had to go to in an effort to get clear explanations and replies in relation to the prescribing errors with the pain relieving gel, and to get the issue resolved.

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.