• Report no:
    202101928
  • Date:
    May 2023
  • Body:
    A Medical Practice in the Ayrshire and Arran NHS Board area
  • Sector:
    Health

The complainant (C) complained to my office about the care and treatment provided to their late parent (A) by their GP practice (the Practice) after A presented at the Practice in August 2019, with shortness of breath and chest pain. A was subsequently diagnosed with severe Chronic Obstructive Pulmonary Disease (COPD, a lung condition that causes breathing difficulties) and lung cancer. A very sadly died in late 2020.

C complained that the Practice failed to provide reasonable care and treatment to A when they presented with chest pain. In particular that the Practice did not perceive A’s condition as being serious and urgent and the significant deterioration in A’s health was not investigated.

In responding to the complaint, the Practice considered that A’s symptoms were taken seriously and that appropriate investigations were undertaken including excluding cardiac causes for their symptoms.

I sought independent advice on this complaint from a GP (the Adviser). I found that:

  • The Scottish Referral Guidelines for Suspected Cancer (the Guidelines), in particular, the section relating to lung cancer, should have been taken into account by the clinicians at the Practice from the outset when treating A.
  • There was a failure by the Practice to recognise the seriousness of the symptoms A presented and to refer them urgently as required under the Guidelines. I considered this was a significant failing in care.
  • While a referral was made to the respiratory physicians, I was extremely critical that this was not made on an urgent basis.
  • While the Practice subsequently conducted a Significant Event Analysis (SEA), it was limited and did not fully address what had occurred in A’s case. There was no mention of the Guidelines in the SEA report. I was particularly critical of this.

Taking account of the evidence and the advice received, I upheld the complaint. I also considered there was a failure by the Practice to provide C with a full and informed response in relation to certain aspects of their complaint and in particular to take into account the Guidelines.

 

Redress and Recommendations 

The Ombudsman's recommendations are set out below:

What we are asking the Practice to do for C:

Complaint number

What we found

What the organisation should do

What we need to see

(a)

Under (a) we found:

  • There was a failure to recognise the significance of A’s symptoms when they presented at the Practice between August 2019 and September 2020, to make an urgent referral.
  • The SEA conducted by the Practice was limited and did not fully address what occurred in A’s case or take account of the relevant Scottish Referral Guidelines for Suspected Cancer.
  • There was a failure by the Practice to fully address the issues raised when responding to C’s complaint and evidence of a lack of learning from the complaint by the Practice as a whole.

Apologise to C for the failings identified.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

 

A copy or record of the apology.

By: 26 June 2023

We are asking the Practice to improve the way they do things:

Complaint number

What we found

What should change

What we need to see

(a)

Under complaint (a) we found:

  • There was a failure to recognise the significance of A’s symptoms when they presented at the Practice between August 2019 and September 2020, to make an urgent referral.

Patient symptoms should be appropriately identified and managed.

Symptoms or features suggestive of cancer should result in the appropriate referral being made in line with relevant guidance.

Evidence that this decision has been shared and discussed with relevant staff in a supportive manner. This could include minutes of discussions at a staff meeting or copies of internal memos/emails.

Evidence that training needs in relation to the application of relevant guidance have been identified and addressed.

Evidence of how the findings of this case have been used as a reflective training tool for relevant staff.

By: 24 July 2023
(a) The SEA conducted by the Practice was limited and did not fully address what occurred in A’s case or take account of the relevant Scottish Referral Guidelines for Suspected Cancer.

Local and Significant adverse event reviews should be reflective and learning processes that considers events against relevant standards and guidelines, to ensure failings are identified and any appropriate learning and practice improvements are made.

Evidence that the Practice have reviewed their systems and processes for reviewing significant events to ensure it is a fully reflective and learning process that supports the staff involved to identify learning and improvement.

By: 24 August 2023

We are asking the Practice to improve their complaints handling:

Complaint number

What we found

Outcome needed

What we need to see

(a)

Under complaint (a) we found:

  • There was a failure by the Practice to fully address the issues raised when responding to C’s complaint and evidence of a lack of learning from the complaint by the Practice as a whole.
  • The complaint response contained out of date contact details for the SPSO, including the address.

Complaint responses should consider and respond fully to the issues raised in accordance with The Model Complaints Handling Procedures | SPSO. They should take into account any relevant national or local guidance in both the investigation and response, and identify and action learning.

Learning from complaints and the learning should be shared throughout the organisation so that actions and improvements can be implemented to prevent the same issues happening again.

Evidence that these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (e.g., a record of a meeting with staff; or feedback given at one-to-one sessions).

Evidence that the Practice’s complaint handling process is clearly signposted on its website and that information, including documentation (e.g., complaint leaflet and/ or template complaint response letter have been updated) in accordance with the model complaints handling procedure.

Evidence that the website and documents properly signpost to the SPSO, including the current SPSO contact details.

Evidence that relevant staff have or are scheduled to have appropriate complaint handling training.

By: 24 July 2023

 

Feedback

Points to note

The Practice, when making an urgent cancer suspected referral, could have requested consideration of a CT scan. This would have allowed for A to be considered for a CT scan after their first chest x-ray was carried out. I encourage the Practice to share this and reflect on it for the future.

Related reading

  • Report no:
    202100560
  • Date:
    May 2023
  • Body:
    A Medical Practice in the Lanarkshire NHS Board area
  • Sector:
    Health

The complainant (C), a representative of the Patient Advice and Support Service, complained to my office on behalf of A about the treatment A’s spouse (B) received from their GP practice (the Practice) between July and October 2020. B developed cellulitis (a bacterial infection of the skin) on one of their legs. Although B was treated with multiple courses of antibiotics, the infection did not improve. Following an allergic reaction to the antibiotics, B chose not to receive further treatment. Sadly, B’s condition deteriorated and B died.

C complained that the Practice prescribed five courses of antibiotics without seeing B and considered that a GP should have reviewed B face-to-face when the infection did not resolve. A complained that B was not told of the risks of refusing antibiotic treatment. A also considered that the Practice should have carried out blood and skin tests to ensure that an effective antibiotic was prescribed and that the Practice should have referred B to hospital for intravenous antibiotics when B’s condition did not improve.

The Practice detailed the contact they had with B and said that skin conditions such as cellulitis are treated by their Advanced Nurse Practitioners (ANPs) and that they considered the treatment offered to B had been appropriate. The Practice said that they would not recommend the referral of B to hospital due to the COVID-19 restrictions in place at the time.

I sought independent advice from a GP (the Adviser). The Adviser told me B should have been closely monitored and specialist advice should have been sought early on in B’s care pathway. The Adviser told me B should have been seen face-to-face at the first appointment and a doctor should have been involved after the first course of antibiotics failed to work and in line with NICE accredited guidelines, specialist input should have been sought after a second course of antibiotics failed to improve B’s condition and admission for intravenous antibiotics considered.

The Adviser also told me there were no restrictions in place preventing patients from being admitted to hospital should their condition require this between July and October 2020. The Adviser gave their view that the failings they had identified had contributed to B’s death.

In light of the evidence I have seen and the advice I received, I found that: the Practice did not provide reasonable care and treatment to B between July and October 2020. As such, I upheld C’s complaint.

 

Redress and Recommendations 

The Ombudsman's recommendations are set out below:

What we are asking the Practice to do for A:

Rec. number

What we found

Outcome needed

What we need to see
1.

Under (a) we found that the care and treatment provided by the Practice to B between July 2020 and October 2020 was unreasonable. In particular that:

  • B should have been seen face-to-face at their first appointment and by a GP after the first course of antibiotics failed to work.
  • Swabs should have been taken when there was no improvement.
  • Specialist input should have been sought after B’s condition failed to improve.
  • A Significant Event Analysis or similar reflective review should have been carried out.
  • The Practice’s complaint response was unreasonable.

Apologise to A for the failings identified.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

A copy or record of the apology.

By: 21 June 2023

We are asking the Practice to improve the way they do things:

Rec. number

What we found

Outcome needed

What we need to see
2. The care and treatment provided by the Practice to B between July 2020 and October 2020 was unreasonable.

Patients presenting with symptoms suggesting cellulitis should be appropriately assessed including a face-to-face assessment and being appropriately monitored.

If their condition does not improve treatment should be escalated in line with relevant guidance.

Evidence that the Practice have:

  1. Critically reviewed their guidance and training needs on the management of cellulitis for all relevant staff to ensure achievement of the outcomes needed.
  2. Ensured relevant guidelines are appropriately referred to and reflected.

Confirmation should be provided of the review and the changes implemented as a result of this review; how the guidance has been updated and disseminated, and how the training needs of staff have been addressed.

By: 16 August 2023, with a progress update by 5 July 2023.
3. A Significant Event Analysis or similar reflective review should have been held. Where there has been a significant adverse event a reflective review should be considered, and either a clear reason recorded as to why it was not carried out, or held, ensuring that events are considered against relevant standards and guidelines and that failings, and good practice, are identified and any appropriate learning and practice improvements made.

Evidence that the Practice have systems and processes in place for reflective review of significant adverse events that support staff involved to identify learning and improvement

By: 16 August 2023

 We are asking the Practice to improve their complaints handling:

Rec. number

What we found

Outcome needed

What we need to see
4.

The Practice’s complaint response was unreasonable.

There is no evidence to support the Practice’s recording that the complaint was acknowledged or that the complaint was responded to within 20 working days in line with the Model Complaints Handling Procedure.

There was a failure to investigate and respond to all the concerns raised by C and provide an appropriate response that recognised the significance of the events for A and the impact of B’s death.

The response was undated.

The Practice’s complaint handling monitoring and governance system should ensure that:

  1. Complaints are properly investigated and responded to in line with the NHS Scotland Model Complaints Handling Procedure.
  2. Failings and good practice are identified, and learning from complaints is used to drive service development and improvement.
  3. Complaint responses recognise and acknowledge the significance and human impact of the events complained about, particularly when a death has occurred.

Complaint responses are clearly dated and records reflect when and how they are shared.

Evidence that the findings on the Practice’s complaint handling have been fed back in a supportive manner to relevant staff and that they have reflected on the findings of this investigation. (For instance, a copy of a meeting note or summary of a discussion.)

By: 19 July 2023

 

 

Related reading

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