The complainant (C) complained to my office about the care and treatment provided to their late parent (A) by their GP practice (the Practice) after A presented at the Practice in August 2019, with shortness of breath and chest pain. A was subsequently diagnosed with severe Chronic Obstructive Pulmonary Disease (COPD, a lung condition that causes breathing difficulties) and lung cancer. A very sadly died in late 2020.
C complained that the Practice failed to provide reasonable care and treatment to A when they presented with chest pain. In particular that the Practice did not perceive A’s condition as being serious and urgent and the significant deterioration in A’s health was not investigated.
In responding to the complaint, the Practice considered that A’s symptoms were taken seriously and that appropriate investigations were undertaken including excluding cardiac causes for their symptoms.
I sought independent advice on this complaint from a GP (the Adviser). I found that:
- The Scottish Referral Guidelines for Suspected Cancer (the Guidelines), in particular, the section relating to lung cancer, should have been taken into account by the clinicians at the Practice from the outset when treating A.
- There was a failure by the Practice to recognise the seriousness of the symptoms A presented and to refer them urgently as required under the Guidelines. I considered this was a significant failing in care.
- While a referral was made to the respiratory physicians, I was extremely critical that this was not made on an urgent basis.
- While the Practice subsequently conducted a Significant Event Analysis (SEA), it was limited and did not fully address what had occurred in A’s case. There was no mention of the Guidelines in the SEA report. I was particularly critical of this.
Taking account of the evidence and the advice received, I upheld the complaint. I also considered there was a failure by the Practice to provide C with a full and informed response in relation to certain aspects of their complaint and in particular to take into account the Guidelines.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Practice to do for C:
| Complaint number |
What we found |
What the organisation should do |
What we need to see |
|---|---|---|---|
|
(a) |
Under (a) we found:
|
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.
|
A copy or record of the apology. By: 26 June 2023 |
We are asking the Practice to improve the way they do things:
| Complaint number |
What we found |
What should change |
What we need to see |
|---|---|---|---|
|
(a) |
Under complaint (a) we found:
|
Patient symptoms should be appropriately identified and managed. Symptoms or features suggestive of cancer should result in the appropriate referral being made in line with relevant guidance. |
Evidence that this decision has been shared and discussed with relevant staff in a supportive manner. This could include minutes of discussions at a staff meeting or copies of internal memos/emails. Evidence that training needs in relation to the application of relevant guidance have been identified and addressed. Evidence of how the findings of this case have been used as a reflective training tool for relevant staff. By: 24 July 2023 |
| (a) | The SEA conducted by the Practice was limited and did not fully address what occurred in A’s case or take account of the relevant Scottish Referral Guidelines for Suspected Cancer. |
Local and Significant adverse event reviews should be reflective and learning processes that considers events against relevant standards and guidelines, to ensure failings are identified and any appropriate learning and practice improvements are made. |
Evidence that the Practice have reviewed their systems and processes for reviewing significant events to ensure it is a fully reflective and learning process that supports the staff involved to identify learning and improvement. By: 24 August 2023 |
We are asking the Practice to improve their complaints handling:
| Complaint number |
What we found |
Outcome needed |
What we need to see |
|---|---|---|---|
|
(a) |
Under complaint (a) we found:
|
Complaint responses should consider and respond fully to the issues raised in accordance with The Model Complaints Handling Procedures | SPSO. They should take into account any relevant national or local guidance in both the investigation and response, and identify and action learning. Learning from complaints and the learning should be shared throughout the organisation so that actions and improvements can be implemented to prevent the same issues happening again. |
Evidence that these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (e.g., a record of a meeting with staff; or feedback given at one-to-one sessions). Evidence that the Practice’s complaint handling process is clearly signposted on its website and that information, including documentation (e.g., complaint leaflet and/ or template complaint response letter have been updated) in accordance with the model complaints handling procedure. Evidence that the website and documents properly signpost to the SPSO, including the current SPSO contact details. Evidence that relevant staff have or are scheduled to have appropriate complaint handling training. By: 24 July 2023 |
Feedback
Points to note
The Practice, when making an urgent cancer suspected referral, could have requested consideration of a CT scan. This would have allowed for A to be considered for a CT scan after their first chest x-ray was carried out. I encourage the Practice to share this and reflect on it for the future.