Prescribing without reviewing - medical case study

Case study on prescribing failures

  • Date: 25 May 2012


Mrs G, who was 84 years old, had looked after her granddaughter as a child and had lived with her for almost her entire life. Her granddaughter described her grandmother as “an amazing lady” who was “perfectly healthy” before she suffered a fall and underwent hip surgery.

Following surgery, Mrs G was discharged to a nursing home with a prescription which included diclofenac (a non-steroidal anti-inflammatory drug — NSAID), and given a two-week supply of the discharge medications. Mrs G was described by her granddaughter as being at this time “very mobile … and had most of her faculties with her”. She said Mrs G was looking forward to moving out of the home to live with her.

In the meantime, following receipt of the hospital’s discharge summary, administrative staff at Mrs G’s GP practice added the medications, including diclofenac, to her list of repeat medications.

Eleven months later

The practice continuously prescribed diclofenac to Mrs G for the next 11 months, without review and without an accompanying proton-pump inhibitor (which may help protect against NSAID-associated duodenal ulcers).

Mrs G went to live with her granddaughter as arranged. Her granddaughter soon noticed that Mrs G was having difficulty with food and that her health was deteriorating. Things came to a head on Christmas Day, when Mrs G was “violently sick, was as white as a ghost, could not move and was in pain”. She was taken to hospital and underwent emergency surgery for a perforated duodenal ulcer. Sadly, she died two months later from septicaemia, acute renal failure and urinary tract infection. Mrs G’s death caused her granddaughter “immense grief due to the fact that I only recently lost my mother”.

Realising that Mrs G had taken diclofenac continuously for 11 months, her granddaughter complained to the practice. The practice accepted their failure to check and review Mrs G’s medication, and they also conducted a significant event review. The main learning point from that review was that doctors (not administrative staff) should add medication to repeat medication lists so that they can consider appropriate co-prescribing, and that they should prescribe NSAIDs in accordance with the practice’s protocols.

Mrs G’s granddaughter then brought her complaint to the Parliamentary and Health Service Ombudsman. She said that although the practice had admitted errors, they had not said why they had occurred. She wanted to know why it had taken her grandmother’s death to highlight the mistakes, and whether her death had been preventable.

The investigation

The Ombudsman found that the errors in Mrs G’s case occurred partly because the practice’s administrative staff were inappropriately involved in the processing of her medication. However, the major cause was the failure by doctors at the practice to follow their protocols, or the professional standards relating to prescribing and reviewing medication. They issued repeat prescriptions for the entire 11 months that Mrs G received diclofenac. As a result, no consideration was given to whether Mrs G still needed diclofenac, or whether a proton-pump inhibitor should be prescribed. The advice at that time from the British National Formulary was that NSAIDs should be used with caution in elderly patients and that a proton-pump inhibitor may be considered for protection against NSAID-associated gastric and duodenal ulcers. Mrs G’s granddaughter specifically asked whether her grandmother’s death had been avoidable. The Ombudsman could not say that the ulcer and the chain of events which led to her death were the consequence of the diclofenac prescription. However, the prolonged prescription, especially without a proton-pump inhibitor, put Mrs G at increased risk of developing the duodenal ulcer. The Ombudsman upheld this complaint.

What happened next

The practice apologised to Mrs G’s granddaughter for their failings. The Ombudsman’s report was discussed at a significant events meeting, attended by all their doctors, nurses, receptionists and clerical staff. Robust procedures were put in place for prescribing and reviewing medication, and the practice increased awareness of the need to follow their review processes strictly and to monitor the prescription of NSAIDs. The practice nurse is now qualified in prescribing and conducts the medication reviews.

Key points

  • Prescribe responsibly, according to good practice guidelines.
  • Ensure any prescribing system provides thorough checks for repeat prescriptions.
  • Monitor the issue of repeat prescriptions and prescribe dosages that are appropriate for the patient and their condition.

© Parliamentary and Health Service Ombudsman 2012. Content adapted from a case study in: Care and Compassion? Report of the Health Service Ombudsman on ten investigations into NHS care of older people. pp31-32.


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