Overview
The complainant (Mrs C) raised a number of concerns that her mother (Mrs A) had not been reasonably cared for or treated by medical staff at St John's Hospital (the Hospital) or her GP practice (the Practice) in the months before her death, and that the responses to Mrs C's enquiries and complaints by Lothian NHS Board (the Board) and the Practice had not been appropriate and had been unnecessarily distressing to her.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the Board did not provide reasonable care and treatment to Mrs A between May 2007 and February 2008 (partially upheld to the extent that the investigation, diagnosis, care and treatment of Mrs A from November 2007 to February 2008 was not reasonable);
- (b) the actions taken by the Board in response to Mrs C's complaints about the care and treatment of Mrs A were not reasonable (upheld);
- (c) Mrs A did not receive adequate care and treatment from the Practice between November 2007 and February 2008 (partially upheld to the extent that the Practice did not reasonably address or follow-up the symptoms that Mrs A displayed which can be linked to cancer, that the Practice's prescription of pills rather than other forms of treatment to Mrs A was not reasonable, that the Practice did not reasonably take into account changes in Mrs A's condition and that the level of information recorded in Mrs A's notes was not comprehensive); and
- (d) the Practice's responses to Mrs C's enquiries and complaints were inappropriate and unnecessarily distressing (partially upheld to the extent that, although the Practice appropriately responded to some of Mrs C's enquiries and complaints, some of the Practice's responses, or lack of responses, to Mrs C's enquiries and complaints were inappropriate and unnecessarily distressing).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) apologise to Mrs A's family that the chest x-ray of 26 November 2007 was mis-reported and that this led to a delay in the diagnosis of Mrs A's cancer;
- (ii) remind medical staff that letters to GPs should be dictated immediately after consultations with patients;
- (iii) encourage the practice of discussing patients with atypical clinical features at multi-disciplinary meetings;
- (iv) take steps to assure themselves of the quality of their chest x-ray reporting service;
- (v) apologise to Mrs C that the investigation of her complaints did not uncover the mis-reporting of the chest x-ray of 26 November 2007; and
- (vi) ensure that investigations of similar complaints in the future consider the possibility that x-rays, scans, test results or similar may have been mis-reported.
The Ombudsman recommends that the Practice:
- (i) apologise to Mrs A's family for those aspects of her care and treatment that were not reasonable;
- (ii) produce a plan for reviewing their adherence to national guidelines. This plan should be minuted and form part of the Practice's clinical governance meetings. The minutes should be inspected by the Board's clinical governance lead to ensure that the Practice have identified areas for improvement and taken action to address these issues;
- (iii) ensure that national guidelines are readily available to all practitioners;
- (iv) undertake a review of clinical record-keeping using the Royal College of General Practitioners (Scotland) template on section 3D (2) of the Revalidation Toolkit. The review should be discussed with the Board's clinical governance lead to ensure that the Practice have identified areas for improvement and taken action to address these areas;
- (v) apologise to Mrs C that their responses to her enquiries and complaints were inappropriate and unnecessarily distressing; and
- (vi) review their complaints handling procedure to ensure that complainants are given direct answers to reasonable direct questions, that individual circumstances, distress and stated preferences are reasonably taken into account when suggesting meetings with correspondents and complainants, that it is made clear to correspondents how to set in motion the Practice's complaints procedure and that avoidable errors are reasonably eliminated, taking into account the individual circumstances of a complaint.
The Board and the Practice have accepted the recommendations and will act on them accordingly.