Decision Report 201604419

  • Case ref:
    201604419
  • Date:
    February 2017
  • Body:
    A Medical Practice in the Western Isles NHS Board area
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained to us about the care and treatment provided to his wife (Mrs A) by the medical practice. He complained that the practice failed to provide Mrs A with appropriate treatment when she presented with lower back pain, and that they failed to appropriately examine her at her consultations. Mr C felt that the back pain was a symptom of the cancer Mrs A was later found to have and which led to her death. Mr C further complained that Mrs A had been provided with inappropriate inhalers for a number of years.

In investigating this complaint, we took independent advice from a GP adviser. We found that whilst Mrs A had presented with lower back pain for a number of months, there were no symptoms at that time which would have alerted her GP to the possibility of her having cancer. When Mrs A reported new symptoms, these were found to be due to abdominal cancer. We found that the management of Mrs A's original symptoms, which was primarily with painkillers, was reasonable. We also found that Mrs A was reasonably examined by GPs at the practice based on her reported symptoms. We therefore did not uphold this aspect of Mr C's complaint.

With regard to the inhalers Mrs A had been prescribed, we found that as Mrs A had never been formally diagnosed with an illness that would require regular use of inhalers, it was not reasonable that she had been prescribed these on a long-term basis. Whilst we did not find there to have been adverse effects as a result of this failing, we upheld Mr C's complaint. The practice acknowledged that the monitoring of Mrs A's inhaler use could have been better and told us they had undertaken a review of their system regarding this.

Recommendations

We recommended that the practice:

  • apologise for the failings identified in this investigation;
  • draw the comments of the adviser regarding prescription of inhalers to the attention of the relevant staff; and
  • update this office on the action taken following the practice's review of their systems for recalling patients who are on regular inhalers.

Updated: March 13, 2018