Investigation Report 201200068

  • Report no:
  • Date:
    October 2012
  • Body:
    A Medical Practice in the Forth Valley NHS Board area
  • Sector:

The complainant (Mrs C) raised a number of concerns that her sister, Ms A, reported to her GP practice (the Practice) symptoms of increasing chest, neck and back pain which were not properly investigated. Strong analgesia had little or no effect but the practice continued to issue prescriptions for morphine without physically assessing Ms A. In late December 2011 Ms A was referred to hospital by a GP from NHS 24 where bone cancer was diagnosed. Shortly following the diagnosis, in early January 2012, one of Ms A's vertebra in her neck collapsed and she is now paralysed from the neck down. She has been told that her cancer is terminal and in May 2012 was told that she only has months to live.

Specific complaints and conclusions
The complaints which have been investigated are that the Practice:

  • (a) unreasonably failed to make timely and appropriate investigations to establish the cause of the symptoms reported by Ms A (upheld);
  • (b) unreasonably failed to make any referrals for specialist opinions in view of Ms A's symptoms (upheld); and
  • (c) inappropriately issued prescriptions for morphine without physically assessing Ms A (upheld).


Redress and recommendations
The Ombudsman recommends that the Practice:

  • (i) issues a written apology for the failings identified in this report;
  • (ii) carry out a Significant Event Audit (SEA) on this case;
  • (iii) carry out a review of a case note sample to assess the quality of examinations conducted and the information recorded; and
  • (iv) completes the review of how acute prescriptions are issued and put a robust monitoring system in place.


The Practice have accepted the recommendations and will act on them accordingly.

Updated: December 11, 2018