Doctors failed to check man's blood pressure or to consider possible side effects of medication

What happened

Mr D, who is in his eighties, went to an outpatient appointment at the Trust in early summer 2013 where he was prescribed Bisoprolol. He went to a further appointment in autumn 2013 when he was reviewed and discharged by the clinic. No changes were made to his medication.

Towards the end of the year his GP practice contacted Mr S to say it had received a letter from a consultant at the hospital requesting blood tests for his father. A nurse went to his home shortly afterwards to take blood samples. Later the same day Mr D collapsed at home. A nurse came to see him, and when she found Mr D had low blood pressure she had a discussion with the GP and referred him to A&E.

Mr S was concerned that Bisoprolol could be causing side effects for his father. He rang the Trust to discuss the outcome of the blood test results and whether Bisoprolol could be causing his father's symptoms.

The Trust later responded to the queries, explaining that there had been an error by the GP Practice and that the Trust had not requested any blood tests. This had been communicated to the GP Practice.

Mr S said that when the nurse visited his father again at home in early 2014 she took his father's blood pressure and then spoke with the GP who arranged to take his father off Bisoprolol.

When Mr S complained to the Trust, he was told it was the GP's responsibility to monitor his father's medication and that Trust staff had acted correctly in the way it dealt with his query about blood tests.

What we found

There were no failings in the way the Trust handled Mr S's questions about the blood tests results, or about its complaint handling.

However, there was no evidence in Mr D's records to show that doctors at the Trust checked his blood pressure before Bisoprolol was prescribed in summer 2013 or when he returned to the clinic for review in autumn that year. This was not in in line with established good practice. This was despite clear documentation by the doctors that Mr D had experienced recurrent falls. It was recorded that he had suffered 'some severe injuries that needed butterfly stitching' and that he appeared 'battered and bruised'.

We do not know for certain whether his recurrent falls and subsequent injuries were attributable to episodes of low blood pressure, or that the low blood pressure was directly or solely caused by Bisoprolol. However, there was a loss of opportunity to make an informed decision about whether Bisoprolol was a suitable medication for him in summer 2013, and a further missed opportunity to assess his blood pressure in autumn 2013 and to consider whether this was contributing to his falls.

We cannot say what would have happened if Mr D's blood pressure had been assessed. In any event, doctors may have decided to continue prescribing Bisoprolol as the most appropriate medication for him or they may have changed the medication and he could have still fallen. However, we cannot reassure Mr D that everything that should have been done was done to minimise the risk of him falling.

Putting it right

The Trust apologised to Mr D for the failings identified in the way he was monitored during his outpatient appointments in summer and autumn 2013. The Trust paid Mr D £500 in recognition that not everything that should have been done, was done, to minimise the risk of him falling. It also prepared an action plan to try to prevent similar occurrences within the same clinical outpatient department.