Highland GP practice criticised over stroke death patient failures, Scottish Public Services Ombudsman rules
A GP surgery failed to immediately refer a patient to hospital over "highly abnormal" heart readings just hours before they died of a stroke, a report has found.
The Scottish Public Services Ombudsman has ordered the Highland surgery, which has not been named, to apologise to the patient's family for failing to provide them with a "reasonable standard of care" on the day of their ECG, or electrocardiogram test.
However, the ombudsman also stressed that it was not possible to determine if the patient - referred to only as 'A' - might have survived if they had been admitted to hospital in response to the ECG results.
This was because the cause of death was due to a bleed on the brain while doctors tried to deal with the stroke - an "unfortunate but recognised" potential side-effect of the medication patient A was given to try to treat the stroke they had suffered.
The report, published this week, said the chain of events began when patient A, who was "described as fit and well", had "developed severe diarrhoea".
"Although [this] subsided, A continued to feel unwell and breathless," said the ombudsman.
"A was seen by an advanced nurse practitioner (ANP) and referred for an ECG as an outpatient a few days later".
When patient A had the tests they were not seen by a doctor and returned home. They suffered a stroke that same afternoon and died in hospital the next day.
One of patient A's relatives - referred to only as 'C' - complained about their parent's care, arguing that A only spoke to a doctor by phone rather than face-to-face "over a series of appointments".
They also believed that the surgery has "misinterpreted" A's ECG and that they should have been admitted to hospital "as an emergency" as soon as the results came in.
"C believed that had the practice provided a reasonable standard of care, A's death could have been prevented," said the ombudsman. "Although C met with the practice and received two responses to their complaint, they continued to believe the practice's response was inadequate and brought their complaint to this office."
Issuing their ruling the SPSO said: "We found that A’s care prior to their ECG was of a reasonable standard. It was noted that C disagreed with A’s medical records, but it was not possible to determine precisely what was said at A’s appointments. We did not uphold these parts of C’s complaint.
"We found that A’s ECG was highly abnormal, indicating A’s heart was lacking in oxygenated blood flow. This should have resulted in a face-to-face appointment, followed by an immediate hospital referral. Therefore, we upheld this part of C’s complaint. However, it was not possible to determine whether A would have survived with an earlier admission as the cause of A’s death was a bleed on their brain. This was an unfortunate but recognised side effect of the medication given to A to treat the stroke they had suffered.
"Finally, C complained about the practice’s complaint handling. We found that the practice failed to handle C’s complaint reasonably and upheld this part of their complaint."
It has ordered the surgery to apologise to C for the failings it had identified in its reports, and also to the family "for the failure to provide A with a reasonable standard of care on the day of their ECG".
It has told the practice to ensure ECG results are "accurately interpreted" and that they should take into consideration "the condition of the patient and their medical history".
They also told it to ensure it carries out complaint investigations in line with NHS procedures.
