A practice in the Ipswich area

3. Mrs B complains the Practice prescribed her medication between January and July 2025 without regularly checking if the medication had adverse effects on her other medication or liver.

4. Mrs B says as a result she had multiple hospital admissions which could have been avoided if her medication was correct. She says this has led her to decide to pursue only palliative treatment going forward.

5. Mrs B wants an apology, service improvements, and financial compensation.

6. Mrs B was admitted to hospital between September and October 2024 with symptoms of liver disease.

7. Mrs B was discharged from hospital in early January 2025 because of having worsening stomach and leg swelling, weakness, and dizziness. This happened before Mrs B became a patient at the Practice.

8. Mrs B registered as a patient at the Practice in January 2025.

9. Mrs B’s daughter called the Practice in late January, who visited Mrs B one day later noting she had a low mood and was upset and weak from her hospital admission. The Practice wrote Mrs B had no urine symptoms and had pain in her hips and buttock area. The Practice prescribed paracetamol pain relief and asked for urine and blood tests to be taken.

10. Mrs B’s care home called 999 in early February following advice from the Practice because Mrs B has ascites (abnormal build-up of fluid caused by advanced liver disease) and her stomach was swollen. Mrs B was admitted to the hospital and was discharged four days later.

11. The hospital admitted Mrs B for one day in mid-February for left sided facial droop and slurred speech, thought to be drug induced parkinsonism which is motor symptoms such as slowness, rigidity, and tremors.

12. The hospital saw Mrs B in mid-March for one day when she began taking medication used to treat vascular parkinsonism.

13. Mrs B was admitted to hospital again in late March and diagnosed AKI and pneumonia. Mrs B decided she wanted to receive palliative care only and was discharged to the care home four days later.

17. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

18. Mrs H represents her mother in the complaint. She complains the Practice did not review her mother, Mrs B’s, medication thoroughly ensuring there were no adverse effects with other medication or her liver. Mrs H says her mother’s hospital admissions could have been avoided including the decision she made to only receive palliative care.

19. The Practice said it reinstated Mrs B’s medication as prescribed prior to her hospitalisation and registration with the Practice. It said it would not usually change long term medication for a new patient, but as her medical needs changed due to illness, her medications were adjusted appropriately.

20. It said they did not see the repeat prescribing of bisoprolol (used to treat high blood pressure) and carvedilol (used to treat high blood pressure) started by her old practice and continued at the hospital. The Practice apologised for not seeing this sooner.

21. GMC guidance on deciding if it is safe to prescribe, section 19, tells clinicians: ‘You should only propose, prescribe or provide medicines treatments and devices if you have adequate knowledge of the patient’s health, and you are satisfied that the medicines serve the patient’s needs. You must consider:

• the suitability of the mode of consultation you are using, for example face to face or remote, taking account of any need for physical examination or other assessments • whether you have sufficient information to prescribe safely, for example if you have access to the patient’s medical records and can verify relevant information.’

22. GMC Reviewing medicines guidance paragraph 92 to 96 tells clinicians how to prescribe and review medications. It sets out what clinicians should consider such as risk and side effects assessing. It also tells clinicians to act appropriately on information and advice given by healthcare professionals who have reviewed or changed patient’s medications.

23. The records show Mrs B registered at the Practice in mid-January 2025. Mrs B had been discharged from hospital early January to a residential home as her liver disease was progressive and life limiting.

24. The Practice received Mrs B’s medication information which was checked three days after registering with the Practice to ensure these were available to her.

25. This is in line with GMC Reviewing medication paragraph 96 which tells clinicians, ‘You should consider and act appropriately on information and advice from pharmacists and other healthcare professionals who have reviewed a patient’s use of medicines.’

26. The records show while Mrs B was a patient at the Practice she had four hospital admissions. When the hospital discharged Mrs B from its care, a summary including medication changes was sent to the Practice to action.

27. The Practice visited Mrs B in late February 2025 noting since being discharged from hospital in early January while not a registered patient, she was prescribed two blood pressure lowering medications by her previous GP.

28. The Practice stopped prescribing Mrs B carvedilol because hospital specialists from the stroke clinic asked for this to be done and because a second similar medication was already being prescribed.

29. This is in line with GMC reviewing medication paragraph 96 and GMC deciding if it is safe to prescribe paragraph 19 because the Practice acted in line with advice from other professionals and had sufficient information to prescribe safely to Mrs B.

30. The Practice also found Mrs B was taking similar medication prochlorperazine (used to stop sickness, vertigo, and anxiety) and betahistine (used to treat dizziness, ringing in the ear and hearing loss) which was prescribed by her previous GP practice before being registered with itself.

31. The Practice referred Mrs B to the elderly care team in late-February asking for her medication to be reviewed, specifically because she was frail with worsening symptoms and from finding the duplication of medication. This is in line with GMC Good medical practice, Providing good clinical care, paragraph 7 which tells clinicians to ‘refer a patient to another suitably qualified practitioner when this serves their needs’.

32. Our adviser told us discharge teams and pharmacists check a patient’s medication before discharging them from the hospital. A GP Practice and its pharmacists then update the patient’s medication records from the information received.

33. Our adviser also told us when medication is prescribed by specialists for conditions such as Mrs B’s liver, or other specialties, it is beyond the scope of a GP to amend these. The specialist would consider if medication would have side effects for Mrs B’s other medication and inform the GP to make changes as necessary.

34. We understand Mrs H was concerned the Practice should have completed more frequent reviews of Mrs B’s medication, meaning the two blood pressure medications taken would have been found sooner and that further hospital visits could have been avoided.

35. We can see from the records Mrs B’s previous GP prescribed these while under its care and were not changed while having hospital treatment. As the hospital specialists made no changes to Mrs B’s medication the Practice followed its instructions in line with GMC guidelines.

36. Based on the evidence we have seen, the Practice acted in line with GMC prescribing and reviewing medication guidelines by prescribing medication already approved by specialists and prescribed these when checked as appropriate by medical professionals from her hospitalisations.

37. We understand and acknowledge the distress Mrs B’s family feel from her decision to only receive palliative care. We hope our explanation goes some way to explaining how the Practice acted in line with GMG guidelines in prescribing medication.

1. We have carefully considered Mrs B’s complaint about a Practice in Suffolk (the Practice). We are sorry to hear about Mrs B’s experience with the prescribing and reviewing of her medication. We understand how distressing it is to feel you are not getting the care you need.

2. Having investigated her complaint, the evidence suggests the Practice treated Mrs B in line with relevant guidance. We hope she is reassured by what we have seen.