Decision Report 202405245

Summary

C complained that their GP practice failed to provide them with reasonable care and treatment. C attended the practice with loss of appetite, vomiting, concentrated urine, poor fluid intake, a temperature of 38.7 degrees, and a high heart rate.

C was prescribed antibiotics and given advice on what to do if their condition worsened. C’s condition deteriorated and they attended the practice again. C was referred for a chest x-ray and diagnosed with empyema (pockets of pus that have collected inside a body cavity). C’s condition was life-threatening and they remain impacted by it.

In their response to the complaint, the practice arranged an independent review of C's treatment by a respiratory consultant. They noted that C had a significant tachycardia (heart rate exceeding 100 beats per minute at rest). The practice said that this could have been discussed with the Acute Medical Unit at the time. However, it was likely that they would have advised to treat C at home rather than to admit them.

We took independent advice from a GP. We found that C’s presentation and clinical examination findings were suggestive of pneumonia at least, and indicated that they were at high risk of sepsis. We found that C should have been admitted to hospital rather than sent home with antibiotics. Therefore, we upheld C's complaint.

During the course of our investigation the practice confirmed further reflection and learning. We were satisfied that in doing so they had appropriately addressed the failings in C’s care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in our investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.