Delay in starting investigation into GP Practice

What happened

Mr M contacted the Practice in summer 2013 as he had been suffering from hiccups for four days and had mild diarrhoea. The GP called him back and booked Mr M in for an emergency appointment that afternoon. At the appointment, the GP examined Mr M and noted that he had a reflux like pain (reflux is when acid produced in the stomach passes into the gullet) which seemed to be eased by food, and that his chest was clear. He prescribed Mr M lansoprazole to treat the reflux, and referred him for a non–urgent chest X–ray. Mr M died the following day.

Mrs M complained to NHS England in winter 2013 about the treatment her husband received. NHS England did not start the investigation until early 2014, and sent the final response to her in spring 2014

What we found

We partly upheld this complaint. We decided that the Practice did not misdiagnose Mr M, as his diagnosis was made in line with current guidance. We could see that the treatment plan, and the advice to return to the Practice if his symptoms worsened, were in line with the National Institute for Health and Care Excellence guidance. There was nothing to indicate that this guidance should not have been followed.

NHS England's investigation was thorough and consistent with the facts. But there were no reasonable explanations for the delay by NHS England in starting the investigation, and it failed to keep Mrs M informed about the reasons for the delay.

Putting it right

NHS England apologised to Mrs M for the way it handled her complaint and paid her £200 compensation for the additional distress this caused. It also explained how it planned to improve its complaint handling.