Decision Report 201401568

Summary

Mrs C complained about the care the treatment her late mother (Mrs A) had received from the medical practice in the months prior to her death. Mrs A had been admitted to hospital as it appeared she had suffered mini strokes. However, following her admission she was diagnosed with metastatic cancer (cancer that spreads to other parts of the body), and died shortly thereafter.

We took independent advice from one of our GP advisers, who said that Mrs A had been suffering from anxiety symptoms and memory problems for which she had been prescribed medication. Our adviser considered that Mrs A had been regularly reviewed by the practice, and there was no pattern or evidence to suggest Mrs A had an underlying diagnosis of metastatic cancer or the medication she had been prescribed masked any symptoms of metastatic cancer or strokes.

Although we considered the care and treatment Mrs A received was mostly reasonable, we found certain aspects of her care fell below this standard.

While, generally, the medication Mrs A was prescribed and its monitoring was appropriate, one of Mrs A's medications which had been stopped was still being prescribed.

We found a failure to action the results of a liver function test result although we accepted the result would not have triggered any concerns of underlying metastatic disease.

While communication with Mrs A's family was of a reasonable standard, we found that one of the doctors had used insensitive and inappropriate language during a home visit to Mrs A, and the practice could have done more to ensure that they had complied with a specific request from Mrs A's family to be present during a home visit given Mrs A's memory problems and that they were her carers.

Recommendations

We recommended that the practice:

• ensure they discuss Mrs A's case and the complaint as a significant event review, paying particular attention to safe acute and repeat prescription prescribing for the elderly and in their communication with carers of patients;
• share with relevant staff our adviser's comments concerning the apparent failure to action and follow-up the abnormal liver test result, and advise what action has been taken to ensure this does not recur;
• provide confirmation that the doctor in question will discuss the inappropriate use of colloquial language at his yearly appraisal; and
• apologise to Mrs C and her sister for those aspects of Mrs A's care which fell below a reasonable standard.