Decision Report 201304030

Summary

Mr C complained that the medical practice did not provide his late wife (Mrs C) with appropriate diagnosis, care and treatment over a four-year period. Mrs C suffered from haemochromatosis (a condition where the body absorbs an excessive amount of iron which is then deposited in organs, mainly the liver) and had cirrhosis of the liver as a result. She also had diabetes and other health conditions. Mr C said that the practice demonstrated a lack of personal interest and care, and had not communicated with his wife. Mr C said that they were never told about the seriousness of her state of health, and that she had a life threatening condition. Mrs C died in 2012, and Mr C also said that no-one from the practice contacted him after her death.

We took independent advice on the complaint from one of our advisers, who is a GP. The adviser said that most of Mrs C's care and treatment was reasonable and appropriate. However, the adviser identified a number of failings in relation to her care and treatment in 2011. The practice had not recorded Mrs C's diabetes diagnosis on her medical summary and so she was not entered on their diabetic recall register to attend for an annual review. The adviser said, however, that this failure was unlikely to have resulted in Mrs C coming to any significant harm. The practice told us that they had reviewed this and put measures in place to stop it happening again. The adviser also said that, given Mrs C's medical conditions, the practice should have asked her to come in for review during 2011, and should have reviewed and monitored her medication, particularly in relation to the prescribing of spironolactone (a water pill that helps shift the fluid that gathers in cases of liver disease). The practice had continued to issue prescriptions for over a year, without having seen a safe set of blood results or having discussed the medication with Mrs C, and our adviser said that this was poor medical practice. We were unable to reach a conclusion about what the GPs had said to Mr and Mrs C about the state of her health.

The practice confirmed that they had not contacted Mr C after his wife died, although they said that they usually did try to get in touch with close family members after a bereavement. They apologised for this and said they have now changed their procedures to make sure that they proactively contact the family of a patient who has died.

Having considered the evidence carefully, and taken into account the advice we received, we upheld Mr C's complaint because of the failings our investigation identified.

Recommendations

We recommended that the practice:

• issue a written apology to Mr C for the failings identified in this complaint;
• provide us with evidence of their policy of checking patients' summaries as a routine part of a patient's first diabetic review; and
• provide us with evidence that there is a process in place to ensure that patients' repeat medications are reviewed annually.

When it was originally published in September 2014, this case was wrongly categorised as 'some upheld'.  The correct category is 'fully upheld'.