Decision Report 202104785

Summary

C complained about the care and treatment provided to their late child (A) by the medical practice. C was concerned that A had been misdiagnosed by their GP during a telephone appointment. During the appointment, A reported shortness of breath, experiencing breathlessness, and feeling faint when walking upstairs and putting on their shoes. A was diagnosed with anxiety and prescribed a beta blocker (drug that blocks the action of hormones like adrenaline). Later that week, A died suddenly due to pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung). C raised concerns that there was a delay in A receiving treatment, the treatment that A received was inappropriate, and that harm was caused as a result of A being given the wrong treatment.

We took independent advice from a GP adviser and subsequently from another GP adviser with a specialism in sexual and reproductive health. We found that there are numerous risk factors for pulmonary embolus and, in this case, the main risk factors were BMI, family medical history and prescription of combined oral contraceptive. Neither risk alone would preclude prescribing combined oral contraceptive, but consideration would be made for two risks, as in this case. We found that the health centre failed to provide A with reasonable medical care and treatment. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Patients presenting with similar symptoms should be carefully considered and where appropriate face-to-face appointments offered.
• Prior to prescribing the combined oral contraceptive pill for patients who have two or more risk factors for pulmonary embolus, careful consideration should be given to the risk factors, and a shared discussion should take place with the patient on the additional risks, ensuring that they understand that there may well be additional risk. This should be documented.

In relation to complaints handling, we recommended:

• The health centre should ensure that all complaints are handled in line with the NHS Model Complaints Handling Procedure (MCHP), particularly in terms of the requirement to respond in a timely manner. In particular, where a response to a complaint cannot be provided within the MCHP timescales, complainants should be provided with an updated timescale as to when they can expect to receive a response. Significant Adverse Event reviews should be accurate and reflect and record the available evidence and information, which should be reflected in the investigation report (and where appropriate, complaint responses).

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.