Source · SPSO (Scottish Public Services Ombudsman)

A Medical Practice, Forth Valley NHS Board

SPSO (Scottish Public Services Ombudsman) Partly Upheld Reference 201100847 Sector Health Category Clinical treatment / Diagnosis Decided 01 January 2012

Full decision

Summary

Ms C complained on behalf of her late mother (Mrs A) about the care and treatment that she received from her GP practice. Mrs A attended the surgery for a period of two years with repeated complaints of breathlessness, pain in the back and rib cage, and a cough. She made the practice aware of a family history of lung disease and lung cancer. She was treated for numerous chest infections but received little or no relief from her symptons. Mrs A's condition deteriorated and she was admitted to hospital and diagnosed with terminal cancer of the lung, liver and upper chest. Mrs A died shortly after. Ms C complained that the practice failed to properly investigate Mrs A's symptoms within a reasonable time and that they failed to suspect her condition and refer her to hospital within a reasonable time.

We found that the practice carried out reasonable investigations, but that they should have had a high index of suspicion of lung cancer given Mrs A's strong family history and that she was previously a heavy smoker. Our medical adviser said that the practice should have considered referring Mrs A to a respiratory specialist when her respiratory symptoms had persisted for more than six weeks and were unexplained. However, we also found that even if the diagnosis had been made sooner, this was unlikely to have affected the outcome because Mrs A probably had a non-curable disease at presentation. Having said that, an earlier diagnosis might have improved her quality of life because it would have allowed treatments to be explored that might have alleviated some of her symptoms.

Recommendations

We recommended that the practice: • undertake a significant event audit and review their practice on management of respiratory symptoms to ensure that they refer for specialist advice within a reasonable time; and • apologise for the failures identified.

Related reading

View Decision Report 201100847 as a PDF (19.24 KB) Updated: March 13, 2018

View original on SPSO (Scottish Publ… website

Other decisions involving A Medical Practice, Forth Valley NHS Bo…

Reference Date Summary Outcome
201101237 01 Mar 2012 Mr C complained about the care and treatment he received from his medical practice. Specifically, he said that he had … Not Upheld
201004154 01 Oct 2011 Mrs C complained that she was removed from the practice list without warning or reasonable explanation. She also complained that … Partly Upheld
View all decisions for this organisation