NHS Lothian apology after medication delay when GP forgot prescription pad on home visit

An investigation by the Scottish Public Services Ombudsman (SPSO), a government watchdog that holds local authorities to account, upheld complaints made about the region’s health board and issued recommendations.

The patient – referred to only as ‘A’ in a newly-published report – was diagnosed with a lung infection during a consultation with an out-of-hours GP from the unscheduled care service operated by NHS Lothian.

After being told the infection could be treated with Co-amoxiclav, a type of antibiotic, the visiting doctor realised they were not carrying the medication in their vehicle.

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The Ombudsman found the GP “had attended the consultation without a prescription pad.”

The report stated the practitioner “subsequently arranged for A’s prescription to be faxed to a pharmacy on their return to base to be provided to A the next day”.

However, the following day was a public holiday and the pharmacy was closed —resulting in a 48-hour wait for the patient to receive the emergency medication.

NHS Lothian subsequently apologised for the “distress that this had caused A and their family” and said it “could not explain why the GP had attended without a prescription pad”.

Staff were reminded “to ensure that prescription pads were checked prior to carrying out home visits and that prescriptions were only faxed to pharmacies that could provide medication in a timely manner”.

But the SPSO said this reminder was “insufficient to ensure that a similar occurrence did not happen again.”

The health board also confirmed that it was in the process of “developing a checklist system and a written policy and protocol specifying the checks that staff were required to complete at the start of each shift prior to commencing home visits”, which the ombudsman said was “likely to be appropriate to address the issues arising in this case”.

The SPSO added: “We took independent advice from a GP. We found that it had been unreasonable for the GP to attend the consultation without a prescription pad and to fail to ensure that the antibiotics A required were available to them sooner based on A’s presentation at consultation.”

Summing up, the watchdog ruled A – who has since passed away – was not provided with “reasonable care and treatment” and ordered NHS Lothian to issue an apology to their child, who made the complaint.

It said in future, out-of-hours GPs “should be in possession of all required equipment prior to the commencement of each shift”.

The health board has been asked to provide the ombudsman with evidence that it has implemented the recommendations.

Jenny Long, Primary Care Director, NHS Lothian, said: “I would like to publicly repeat the apology we made to the family of A for the failings in this case.

“We have accepted the report from the Ombudsman and we are taking the recommendations seriously.

“As part of that we have already put a new policy and protocol in place as well as a checklist system to ensure something similar does not happen again.”