Source · SPSO (Scottish Public Services Ombudsman)

A Medical Practice in the Lothian NHS Board area

SPSO (Scottish Public Services Ombudsman) Not Upheld Reference 201902551 Sector Health Category clinical treatment / diagnosis Decided 01 July 2020

Full decision

Summary

Mrs C complained about the care and treatment her late brother (Mr A) received from the practice. Mr A attended two consultations at the practice as he had experienced shortness of breath on exertion for the previous few weeks. The GP arranged for a chest x-ray and blood tests to be carried out. These tests did not highlight any concerns but Mr A confirmed that his breathing difficulties were ongoing. The GP felt his breathing difficulties could have been caused by angina (chest pain caused by reduced blood flow to the heart muscles) and increased his medication for this with the intention to refer Mr A for more specialist assessment if his symptoms persisted. Mr A died suddenly one week after his second consultation. Following a post-mortem, it was confirmed that the primary cause of death was a pulmonary embolism (a blockage in one of the pulmonary arteries in the lungs, caused by a blood clot). Mrs C complained to the practice and queried why the GP did not look at Mr A's medical history, as this included details of a previous blood clot. In addition to this, Mrs C queried why no further investigation was carried out after the second consultation when Mr A's x-ray results were confirmed as clear. In their response to Mrs C's complaint, the practice concluded that the GP's clinical assessment and decision-making, based on the information at the time, was considered and reasonable. Mrs C was unhappy with this response and brought her complaint to us.

We took independent advice from a GP. We found that the care and treatment the practice provided to Mr A was reasonable. We were satisfied that appropriate consideration was given to Mr A's medical history in respect of blood clots when assessing his breathing difficulties. We also concluded that the practice's actions, after Mr A's x-ray results were known, were reasonable and appropriate. We were satisfied that the records indicated the practice had a firm treatment plan in place for Mr A and had clearly detailed the reasons for this approach. Therefore, we did not uphold Mrs C's complaints.

Related reading

View Decision Report 201902551 as a PDF (24.74 KB) Updated: July 22, 2020

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