Decision Report 202203433

Summary

C complained about the care and treatment their spouse (A) received from the practice. A had contacted the practice on several occasions with worsening symptoms including headaches, and problems with vision and mobility. C complained that the practice unreasonably failed to undertake tests or act on results, such as when a discrepancy was found in the power of A's legs. C considered the practice unreasonably treated A for anxiety and failed to recognise there was a serious underlying reason for A's symptoms. A was ultimately found to have a brain tumour and died within a few days of receiving this diagnosis.

In responding to C's complaint, the practice provided a letter each from two of the GPs involved in A's care which explained their decision making in respect of the presenting symptoms at the time. The practice also explained they had undertaken a Significant Adverse Event Review (SAER) of A's case for learning and improvement.

We took independent advice on the complaint from a GP. We found that A had initially been treated for labyrinthitis (an inner ear infection) and urinary tract infection which was reasonable and in keeping with the symptoms reported by A at the time. We also found that after A was given a new prescription for glasses, it was appropriate to trial the glasses for improvement of the symptoms of headache and light headedness on standing. In relation to A's upper leg weakness, we found that this can occur for many reasons and, in isolation, would not suggest a more serious underlying cause. Referring to the working diagnosis of anxiety, we considered that this was not unreasonable in the circumstances.

However, the complaint presents a significant learning opportunity, highlighting the need for recognition that symptoms can deteriorate within a short time, and consideration that confused or difficult reporting of symptoms by the patient could in itself be an indicator of an underlying cause. We considered that the practice had provided a reasonable standard of care to A. Therefore, we did not uphold C's complaint but provided the practice with feedback on guidance on conducting adverse event reviews.