Decision Report 201500514

Summary

Miss C complained to her mother (Mrs A)'s medical practice about how they dealt with Mrs A in the last two days of her life. Miss C then complained to us that a GP failed to diagnose and treat Mrs A's condition; that reception staff wrongly referred her mother to NHS 24 rather than arranging for a house call from a GP; and about the practice's handling of her complaint.

We looked at the practice's file on Miss C's complaint and at Mrs A's medical records, and we took independent advice from one of our GP advisers. We found that Mrs A had a number of risk factors for a heart condition, and we decided that the GP should have taken these into account by reviewing Mrs A's blood pressure and pulse, given the possibility of a heart-related cause for her symptoms. We concluded that the assessment and treatment provided by the GP was not of a reasonable standard. We also concluded, on the balance of the available evidence, that reception staff were wrong to refer Mrs A to NHS 24, rather than offering an emergency appointment at the practice or a home visit from the on-call GP. We also found that the practice's handling of Miss C's complaint was not in keeping with the principles set out in the national NHS complaints handling guidance. We upheld Miss C's complaints.

Recommendations

We recommended that the practice:

• apologise to Miss C for not providing a reasonable standard of care, treatment and service to Mrs A;
• apologise to Miss C for the failure to deal with her complaint adequately;
• provide us with evidence of how practice medical staff learned from this case;
• review the practice protocol for late calls and emergency appointments; and
• refresh their understanding of national complaints guidance and review their complaints procedure to ensure that the procedure, and staff practice in dealing with complaints, is in line with the guidance.