Communication problems between GP practice and pharmacy

What happened

Mrs B was diagnosed with an illness that meant she had a very short life expectancy. Mr B felt that there had been no continuity in his wife's care from the practice. He said that different doctors at the practice were responsible for her, and this led to failures in how Mrs B's illness was monitored and how staff prescribed her medication.

Mr B said that Mrs B's care and treatment by the practice had been criticised by other practitioners involved in her care. He also complained that authority to undertake a cremation was unnecessarily delayed and that the practice investigated his complaint poorly.

What we found

Although it was not ideal that the practice was unable to provide a single doctor to oversee Mrs B's condition, this did not affect the quality of care she received. The remarks made by other health professionals were made during a post mortem review meeting of the multidisciplinary team that treated Mrs B to investigate how it could improve its practice. This has led to positive improvements in the way the multidisciplinary team operates. The practice was only one element of the multidisciplinary team.

The practice followed national guidance with regard to the cremation certificate, and the delay involved was minimal.

There were problems with repeat prescriptions. The practice explained that this was a communication problem with a local pharmacy but it did not give Mr B an adequate response. This also indicated a shortcoming in the practice's complaint handling processes.

Putting it right

The practice acknowledged the identified shortcomings and agreed to give Mr B more detailed explanations and a suitable apology.