Decision Report 202108741

Summary

C complained that their late sibling (A) should have been given a telephone or face-to-face consultation with a GP following increasing contact with the practice and an escalation of symptoms relating to chest pain that resulted in A's death from acute myocardial infarction (heart attack). C also complained that the practice's handling of the resulting Significant Adverse Event Review (SAER) was unreasonable.

The practice considered the care and treatment of A to be reasonable. The GP was shielding at home during the COVID-19 pandemic and could not see patients face-to-face. The practice stated it was subject to restrictions imposed by the Scottish Government at the time. The practice also said that A was appropriately triaged and their care managed by a range of healthcare professionals.

We took independent clinical advice from a GP. We found that A should have been offered a telephone consultation with the GP and a face-to-face appointment with the locum GP. We found that A's care was delegated to nursing staff when GP input was required and there was a lack of review between the GP and nursing team when A's symptoms failed to resolve.

We also found that the SAER failed to identify learning points, failings and reflection and did not include the health care professionals involved in A's care.

Therefore, we upheld C's complaints.

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:

• Patients should receive appropriate treatment in relation to their presenting symptoms and potential causes considered as appropriate.
• Significant Adverse Event Reviews should be a reflective and learning process that appropriately considers events in sufficient detail, to ensure failings are identified and any appropriate learning and practice improvements.
• When appropriate, patients should be reviewed by a GP either by phone or in person dependant on their symptoms.
• When necessary and required, patients receiving treatment from the nursing team should have their care appropriately reviewed and discussed with a GP.

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.