Decision report 201202334

Summary

Mrs C complained about the care and treatment a medical practice provided to her father (Mr A). Mrs C raised concern that the GP had not carried out a physical examination of Mr A when she first raised concern that he was confused. Mrs C said that despite her father living alone and having mobility problems, a phone discussion had only taken place where the GP prescribed antibiotics for a suspected urinary tract infection.

Mrs C continued to raise concerns with the medical practice about Mr A’s confusion. The GP then visited Mr A at home and thereafter referred him to a specialist for further assessment as she suspected he was suffering from the onset of dementia. Mrs C remained concerned about Mr A's health and contacted NHS 24. Mr A was subsequently taken to hospital by ambulance and further tests identified that he had suffered a stroke.

As part of our investigation we obtained independent advice from a medical adviser. We concluded that the initial phone consultation carried out by the GP was insufficient. We found that the GP, who was in fact a doctor in training, should have organised a home visit when Mrs C first reported her father's symptoms so that he could be fully assessed and his future management discussed with Mrs C.

Recommendations

We recommended that the practice:

• apologise for the failings identified;
• carry out a significant event analysis of Mr A's case; and
• draw our findings to the attention of the GP in training.