Clinical treatment outside hospital; GP : A GP Practice in the area of Swansea Bay University Health Board Report Date 17/02/2025 Case Against A GP Practice in the area of Swansea Bay University Health Board Subject Clinical treatment outside hospital; GP Case Reference Number 202401164 Outcome Upheld in whole or in part Miss B complained about the care and treatment provided to her late son, Mr C, by a GP Practice in the area of Swansea Bay University Health Board. Specifically, the investigation considered whether appropriate clinical care and treatment was provided in relation to Mr C’s mental health between November 2021 and December 2022.
The Ombudsman found that the Practice acted reasonably in relation to the mental health care and medication provided to Mr C. However, the clinical care provided by the Practice to Mr C fell below an appropriate standard, on the basis that it did not undertake an adequate or appropriate medication review on 3 August 2022. Although it was unlikely there was any reasonably foreseeable risk of Mr C’s overdose at the time his medication was reviewed, the level of uncertainty is an injustice to Mr C’s family. To that extent, the Ombudsman upheld this complaint.
The Ombudsman recommended that the Practice provide Miss B with a written apology for the failures identified by the Ombudsman’s investigation, offer redress of £500 in recognition of failings identified, and share a copy of the investigation report with the Practice GPs. It was also recommended that the Practice review its medication review process to include reasonable attempts at patient contact where clinically indicated or indicated by relevant guidance.