Overview
The complainant (Ms C) raised concerns about the Medical Practice (the Practice) on behalf of her client (Mrs A). Mrs A's complaints relate to her son (Mr B) and attempts to register him at the Practice. Mr B was in prison but was due for liberation on 18 January 2013. Whilst Mr B was still a prisoner, Mrs A visited the Practice and completed registration forms for him. She also made an appointment for the day of his release so that he could obtain antipsychotic medication (medicines used to treat mental health conditions) to alleviate methadone (a drug used medically as a heroin substitute) withdrawal. Mrs A contacted the Practice on 16 January 2013 and confirmed that Mr B's appointment was booked for 18 January 2013. Also on 16 January 2013, the Practice Manager received a call from Greater Glasgow and Clyde Patient Registrations advising that Mr B was still registered as 'care of HMP' (care of Her Majesty's Prison) and that he could not be registered elsewhere until he was liberated. The Practice Manager thereafter cancelled the registration on the system and advised two members of staff to update Mrs A and Mr B. Neither of the staff members provided the update. Mr B was released as planned on 18 January 2013. He attended at the Practice for his appointment and was advised that there was none on the system. The Practice Manager gave him contact details for the community mental health team, community addictions team and NHS 24. Mr B left the Practice without seeing a GP. He died from pneumonia (an infection of the lungs) three days later on 21 January 2013.
Specific complaints and conclusions
The complaints which have been investigated are that:
- Mr B was unreasonably refused access to a GP (upheld); and
- the Practice unreasonably did not respond to further letters related to the complaint (upheld).
Redress and recommendations
The Ombudsman recommends that the Practice:
- apologise to Mrs A and acknowledge that they should have seen and assessed Mr B properly on 18 January 2013;
- provide us with copies of their Significant Event Analysis and Enhanced Significant Event Analysis with their reflections on what happened and why this occurred;
- provide us with their written policies on the registration of new patients and the provision of immediately necessary treatment;
- ensure that all staff within the Practice are fully trained on patient registration and provision of immediately necessary treatment;
- apologise to Ms C and Mrs A for their failure to deal with further complaint correspondence appropriately;
- work with the Board to create a new complaint handling procedure and provide a copy to us for review; and
- ensure that all staff are fully trained on the complaint handling procedure.
The Practice have accepted the recommendations and will act on them accordingly.