GP prescribed wrong medication to older woman at the end of her life

What happened

Mrs F was diagnosed with rheumatic heart disease in 1976 and had fainting episodes that became more frequent in the 2000s. In 2012, Mrs F had a home visit from a GP at the Practice, who prescribed medication that she took on the next two mornings. Following a reported 'funny turn' (afaint), the same GP made a second home visit. Mrs F's daughter, Ms J, contacted her mother's usual GP to query the medication, and several home visits and further contact followed. Mrs F died at home six days after the medication was prescribed.Her cause of death was listed as congestive cardiac failure in addition to rheumatic heart disease.

Ms J complained because she believed that the medication the first doctor prescribed her led to her mother's 'agonising and rapid' death. She was also unhappy about the delay in her mother receiving pain relief and antisickness medication.

She also complained about the usual GP's attitude and behaviour, including that he swore at family members.

Ms J passed her complaints to the NHS Area Team because she thought the Practice was taking too long to respond. She was unhappy about how the Area Team handled her complaint because of the length of time it took. She also felt the Area Team did not address all the issues she had raised, so she complained to us.

What we found

We partly upheld this complaint. While the medication the first doctor gave Mrs F could be used, the decision to prescribe it without taking into account her medical history or giving her adequate information was unreasonable. There was also a failing in that the medication was not stopped when it was thought to be causing Mrs F to faint.

We did not find this medication had any effect on Mrs F's subsequent death, but it is likely to have contributed in part to the episodes of fainting she experienced at that time, in turn causing Ms J distress.

We did not conclude that Mrs F's death was caused by any action taken by the Practice. The overall clinical care was reasonable and in line with established good practice.

We identified that Mrs F's usual GP could have given her morphine and antisickness medication sooner so she would have had earlier relief from the pain and nausea. We found the GP's acknowledgement and apologies to be reasonable, but recommended that the Practice took action to make sure that it changes doctors' future practice as a result.

Also, the usual GP's attitude and behaviour was not acceptable. As a result, Ms J and her family had been caused additional upset and distress. They lost trust in the GP at a time that is difficult for any family. We acknowledged that the GP identified his poor behaviour and apologised for this, and we found it reasonable that the Area Team took this issue up with the practitioner performance team, and will manage the GP's future performance via the formal appraisal route. However, we were not satisfied that enough had been done to resolve the remaining upset and concern and set recommendations accordingly.

We also identified several failings in how the Area Team handled the complaint. The length of time it took to complete the complaint process was unreasonable, and the responses did not give sufficient weight to the lack of detail in the records about the prescription prescribed.

Putting it right

We made four recommendations to the Practice: a letter to Ms J to acknowledge the failings; an action plan to include staff training and information sharing on patient safety with regards to the prescription; training and reflection exercises, including a patient satisfaction survey for the named GP; and a review of medication prescription processes to avoid future delays.

We made two recommendations to the Area Team: that it sends a letter acknowledging the impact of the failing, and that it undertakes to draw up an action plan to review complaint handling processes to avoid future delays.