Decision report 201202544

  • Case ref:
    201202544
  • Date:
    February 2013
  • Body:
    A Medical Practice in the Highland NHS Board area
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment; diagnosis

Summary

Mr C complained to us about the treatment he received from his medical practice for problems with his neck. GPs at the practice saw Mr C five times during a five month period. He had reported a number of symptoms, including neck pain. Mr C reported that at one appointment he specifically raised concerns about cancer, but there was no record of this conversation in his medical file. He also reported being able to feel a lump, but none of the GPs who examined him during this period were able to find this until his final appointment. He was then referred for an urgent ultrasound scan (a special scanning technique that uses sound waves to produce internal images of the body), which found a lump that turned out to be cancerous. Mr C had a history of unexplained deep vein thrombosis (blood clots) dating back two to three years. He was concerned that this put him at increased risk of developing cancer, but that his GPs had not taken this into account.

In our investigation we examined Mr C's medical records and evidence from Mr C. We also took independent advice from one of our medical advisers. Our investigation found that, while there was conflicting information about one consultation, no evidence of a neck lump was found before the final consultation. While the GPs should have taken Mr C's history of unexplained deep vein thrombosis into consideration in making a diagnosis, without any evidence of a lump there was no evidence to act on. We also found that the practice had clearly set out the issues that were discussed at each consultation over the five month period, and had passed on an apology from one of the GPs involved.

Updated: March 13, 2018