GP practice failed to provide adequate palliative care for older patient

What happened

In summer 2013, a Macmillan nurse told the Practice that the hospital was going to refer Mrs C to its specialist palliative care team because it had done all it could.

During that period, GPs from the Practice saw Mrs C because of her back pain and prescribed Oramorph (used to relieve severe pain).

The next month, the Practice received confirmation that Mrs C had been referred to the specialist palliative care service. On the same day, a doctor visited Mrs C at home. He noted that her family was worried that she was in severe pain. The doctor recorded that there was no spinal tenderness and that Mrs C's shoulders hurt when pulled at full–length movement.

Three days later the palliative care team saw Mrs C in her home. They agreed to liaise with Mrs C's oncologist (cancer specialist) about her back pain and suggested a scan of her spine. Mrs C had a fall that afternoon. When Mrs C was admitted to hospital, staff found that Mrs C's cancer had spread, particularly to her spine, causing some of her vertebrae to collapse.

The next month Mrs C was discharged from hospital into a nursing home, where sadly she died nearly two weeks later.

Mrs C's family complained that the doctor had been reluctant to visit Mrs C at home. They raised concerns about one particular visit. They said that the doctor who visited had seemed annoyed and had examined Mrs C roughly.

They complained that he had told them that he was not convinced that Mrs C was in pain. They considered the doctor should have acted to address Mrs C's back pain.

The senior partner at the Practice responded to the complaint. He enclosed a letter from the doctor that outlined the care Mrs C had received. He disagreed with the family's version of the home visit. The senior partner's covering letter said that 'it looks as though we got this wrong on this occasion for which I apologise'.

What we found

The Practice took a reactive approach to Mrs C's care. It failed to place Mrs C on its palliative care register, follow up on the referral to the specialist palliative care team or to put in place a plan for her management. The doctor's assessment, that Mrs C was not in pain, was incorrect. These failings meant that the Practice did not have a discussion with her family about the approach it would take and the support that was available. This led to Mrs C's family feeling unsupported and distressed at seeing her in pain.

Failings in the Practice's complaint handling led to Mrs C's family feeling upset, angry and confused.

Putting it right

The Practice apologised to Mrs C's family and paid them £500. It also took steps to stop these failings happening again.