Decision Report 201606735

Summary

Mr C complained that the practice failed to appropriately manage pulmonary fibrosis (a lung condition) in his late mother (Mrs A). The condition was first identified in a scan carried out five years prior to Mrs A's death and she regularly attended the practice over the intervening years with symptoms that included breathlessness. We obtained independent medical advice and we identified that there were missed opportunities to appropriately refer Mrs A to respiratory medicine. In particular, we considered that a referral should have been made following the initial scan. We also considered that a referral should have been made a year before Mrs A's death, when an x-ray reported progression of the pulmonary fibrosis.

We found that all tests in between these times were not reported back to the practice in terms that would have prompted referrals. However, we noted that one GP expressed awareness of the condition during this period and made a referral to a geriatric clinic. While we considered it appropriate that further investigation was arranged, we noted that a respiratory referral would have been more appropriate.

We were assured that the limited available treatment options for pulmonary fibrosis meant an earlier referral was unlikely to have altered Mrs A's prognosis. However, we recognised that earlier specialist intervention would have afforded Mrs A and her family the opportunity to better understand the nature of her condition and be assured that her symptoms were being appropriately managed. We upheld the complaint.

Recommendations

We recommended that the practice:

• apologise to Mr C and his family for the missed opportunities to refer Mrs A to respiratory medicine; and
• reflect on the failings identified in this investigation and ensure that the GPs are familiar with the relevant guidelines and care pathways for patients with pulmonary fibrosis.