GP Practice failed to appropriately monitor patient who was on a potentially fatal drug

What happened

Ms J was prescribed methotrexate which is an anti–rheumatic drug that reduces the activity of the body's immune system. It can affect the blood count and liver function, and make patients more vulnerable to infections. A rheumatology clinical specialist nurse at the Trust reviewed Ms J regularly and liaised with her GP Practice under a shared care scheme. The Practice prescribed the drugs and carried out regular fortnightly blood tests.

When Ms J found out her blood test results showed some serious problems, she contacted the nurse who told her to stop taking the methotrexate immediately.

Ms J's blood test results had also shown serious problems on other occasions, but the Practice had not contacted Ms J or the nurse to tell them.

When the Practice stopped seeing Ms J under the shared care system she thought it was because she had complained about what had happened. She complained to the local Area Team and it took over six months to send Ms J a final response to her complaint

What we found

The Practice had not taken appropriate action when Ms J's blood test results showed problems that could have led to significant liver damage. Also, the local Area Team had not handled Ms J's complaint in line with the Local Authority Social Services and NHS Complaints (England) Regulations 2009.

Putting it right

The Practice apologised to Ms J and paid her £500 compensation. It also put an action plan in place to learn lessons from the failings and make sure they did not happen again.

The local Area Team apologised, paid Ms J £250 for its poor complaint handling, and put an action plan in place to improve its complaint handling.