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Case ref:201405728
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Date:February 2016
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Body:A Medical Practice in the Greater Glasgow and Clyde NHS Board area
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Sector:Health
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Outcome:Some upheld, action taken by body to remedy, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C complained about the treatment her mother (Mrs A) received from the practice. Mrs A had been unwell with cold/flu-like symptoms and a sore chest. She was prescribed antibiotics and advised to return if there was no improvement so that a chest x-ray could be arranged. Mrs A returned a few days later as she was still unwell. No shortness of breath or chest pain was noted and Mrs A was sent for a chest x-ray. The next day, Mrs A requested a home visit but was asked to attend at the practice following a phone conversation with a doctor. During the consultation, Mrs A collapsed. Cardiopulmonary resuscitation (CPR) was started and an ambulance was called but Mrs A died. Later, the family had difficulties in arranging a time to speak with a doctor about what had happened. Mrs C complained about the clinical treatment that was provided as she considered there was a failure to diagnose Mrs A's heart attack or take appropriate action. She also complained that the practice had failed to communicate adequately following Mrs A's death.
After taking independent advice from one of our medical advisers, who is a GP, we did not uphold Mrs C's complaint about the treatment provided. The adviser considered that the standard of care provided to Mrs A was reasonable and that practice staff had tried to resuscitate her to the best of their ability. We found that there is no formal requirement for practices to have a defibrillator available and that defibrillation would not have saved Mrs A's life. However, we did make a recommendation that the practice consider obtaining a defibrillator.
We found the practice had acknowledged failings in their communication with the family and had apologised for this. We noted that their protocol had been updated to prevent a recurrence of such an error in future. We upheld this element of Mrs C's complaint, but in light of the action already taken by the practice, we did not make any recommendations about this.
Recommendations
We recommended that the practice:
- consider obtaining access to a defibrillator for use in emergency situations.