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Case ref:201103642
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Date:November 2012
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Body:A Medical Practice in the Lanarkshire NHS Board area
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C complained that her late husband Mr A (who had terminal cancer), had suffered during his illness up to his death. Mrs C stated that in her view, she could not believe so many things had gone wrong with the care and treatment Mr A had received from the practice over 17 months. These issues were a failure to follow up Mr As admission to a hospital in the boards area after the hospital had discharged him; that a practice GP had provided incorrect information about Mr A during a home visit and that the practice failed to follow the appropriate processes and procedures when completing the Do Not Resuscitate Form (the DNR).
Our adviser considered all aspects of Mrs Cs complaint and said that Mr A had lung cancer and that it was the responsibility of the hospital clinician that arranged Mr As investigation to follow up and act on the results, not the practice.
Our adviser stated that a practice doctor had provided incorrect information during a home visit; however, the practice doctor had speedily corrected this and apologised.
The adviser stated that the DNR Form (as part of end-of-life care), assists with the management of terminally ill people and compliments the expertise of those using it. We took account of the advisers advice and considered that the practice had followed the correct DNR procedures. Mrs Cs complaint was partially upheld.
Recommendations
We recommended that the practice:
- re-examine along with the District Nursing Team as a whole, their role in this case within the Liverpool Care Pathway continuous Quality Improvement Programme (to include the completion of the DNR form), to see (and reinforce) if there are lessons to be learned and how they can be applied to prevent such a scenario arising in the future (reference to both complaints 3 and 4).