Decision Report 202007590

Summary

C complained about the care and treatment provided to their late brother (A). A’s consultations with the practice took place when COVID-19 restrictions were in place and as such, a number of their appointments were held via phone.

A had been complaining of a persistent sore throat and tongue. A also said that they had been reporting a lump in their neck. A was referred to the Ear, Nose and Throat (ENT) department and was diagnosed with oropharyngeal cancer (a type of cancer that begins in the cells of the tonsils). C complained that there was a delay in referring A to ENT for further investigation.

We took independent advice from a GP. We found that there was a poor standard of record keeping by the practice. The records did not always demonstrate that an adequate medical history was obtained or that adequate safety netting and follow-up advice was provided. We also identified that the wrong antibiotics were prescribed on one occasion and that the wrong test for glandular fever was performed. We were concerned that the practice’s own investigation of the complaint did not identify any of these failings.

We considered that there was likely a delay of 15 days in referring A for further investigation. While this was not significant, in light of the other failings identified, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The medical centre should ensure that staff are confident and knowledgeable in carrying out physical examinations.
• The medical centre should ensure that the Significant Event Analysis addresses both clinical care and treatment and internal processes.
• The medical centre should ensure the standard of record-keeping meets General Medical Council Good Medical Practice standards.
• The medical centre should have a policy to review their cases or seek medical advice, especially when several consultations occur and the case is non-responsive or atypical.

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.