Summary
Mr C complained to the medical practice about the treatment that his late wife (Mrs C) received for gout. A GP had prescribed tranquilisers instead of painkillers. After two weeks Mrs C started losing skin on her hands and the GP reduced the medication. Mrs C was later admitted to hospital, where she died, with the cause of death stated as kidney failure and diabetes. Mr C said that his wife should have been admitted to hospital sooner, as she was passing blood.
Although we noted that this was a complex medical case, we upheld Mr C's complaint. After taking independent advice from one of our medical advisers, our investigation found that there was a lack of documentation in the GP records about Mrs C's deterioration in the weeks before she was admitted to hospital. There was also a failure to check her kidney function in view of medication that had been prescribed, and the practice should have referred Mrs C for a specialist opinion or hospital admission sooner.
Recommendations
We recommended that : conduct a significant event audit to see if lessons can be learned from this complaint; apologise to Mr C for the failings identified in our report; and ensure that the GP concerned revises the presentation of acute renal failure and management of hypertension and discusses the case at his next appraisal.
Related reading
View Decision Report 201102334 as a PDF (13.06 KB) Updated: March 13, 2018