Decision Report 202107634

Summary

C complained that their sibling (A) had not received appropriate care and treatment from their GP practice in relation to symptoms of an infection. C felt the on-call GP failed to arrange for A to be admitted to hospital and that the practice failed to see and examine A, who died the following day of sepsis (an infection of the blood stream).

C also complained that they were unable to access the practice, and that the practice failed to follow its emergency protocol. As such, C complained that the practice had failed to provide reasonable care and treatment to A. The practice considered the care and treatment provided to A had been reasonable.

We took independent advice from an experienced GP adviser. We found that it was reasonable for the on-call GP not to admit A to hospital as this was a decision for the Scottish Ambulance Service (SAS) to make and paramedics expressed no concerns. It was also reasonable for the practice to not examine A as they had already been assessed by the Out-of-Hours Service, the District Nurse and paramedics.

However, we fund that the practice failed to follow the emergency protocol and C and A were unable to access the practice. We also found that the practice's handling of C's complaint was unreasonable due to the quality of investigation carried out. Therefore, on balance, we upheld these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow the emergency protocol when they attended in person to seek an appointment for A. 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:

• For SAER's to be carried out within prescribed timescales.
• Patient Problem Lists should be appropriately summarised with major diagnoses and events to be included.

In relation to complaints handling, we recommended:

• For administrative staff to be reminded of their duty of candour.
• For all complaints to be dealt with empathetically and sincere apologies provided.

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.