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Decision Report 201800557

  • Case ref:
  • Date:
    May 2019
  • Body:
    A Medical Practice in the Tayside NHS Board area
  • Sector:
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis


Ms C complained about the care provided to her late mother (Mrs A) by the practice. Mrs A had attended the practice on a number of occasions with chest pains, confusion, arm weakness and sight problems. Mrs A also had a history of high cholesterol (a fatty substance found in the body that can increase risk of health conditions) and a family history of heart problems. Mrs A later died at home and Ms C felt that the GPs involved in her care should have made earlier referrals to hospital specialists.

We took independent medical advice from a GP. We found that although Mrs A had attended the practice on a number of occasions before her death, she had not reported chest pain for a period of six months and it was felt reasonable that the staff had assumed her previously reported symptoms had resolved. During previous consultations with GPs they had considered a number of diagnoses and prescribed appropriate medication for the symptoms which were reported. There were also attendances at hospital where scan results were reported as being normal. Therefore, we did not uphold Ms C's complaint. However, we provided feedback to the practice that on one occasion, there was a need to make a referral to cardiology for further investigation and to provide Mrs A with safety netting advice. While there was no evidence that this would have prevented Mrs A's death, it may have led to an earlier diagnosis of heart problems and allowed treatment options if required.

Updated: May 22, 2019