Decision Report 201609357

Summary

Mr C complained about a consultation that his brother (Mr A) had with an out-of-hours service doctor. Mr A was referred to the on-call doctor by NHS 24 when he called to report pain in his chest and both arms. Mr A was examined by the on-call doctor who considered that muscular pain was the likely cause. Mr A returned home, however, later that evening he was taken to the emergency department by Mr C and was ultimately diagnosed with a heart attack. Mr C complained to the board about the consultation with the on-call doctor as he considered that Mr A's condition should have been identified sooner. Mr C was also concerned that the board's response to his complaint was unreasonable.

We took independent advice from a GP experienced in out-of-hours care. We found that Mr A did not have the typical presentation of a heart attack and consequently, this could not have been foreseen by the on-call doctor. We found that arriving at what later turned out to be an incorrect diagnosis did not mean that the on-call doctor was at fault and we found that there was evidence that they had adequately and appropriately assessed Mr A. We did not uphold this aspect of Mr C's complaint.

Regarding Mr C's complaint about the board's response to his concerns, we found that there was a minor inaccuracy in the response and that there was a lack of evidence that Mr C had been kept properly updated when the timescale for responding to his complaint passed. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that the timescales for responding to his complaint were not made clear. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.