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Decision Report 201705177

  • Case ref:
    201705177
  • Date:
    May 2018
  • Body:
    A Medical Practice in the Ayrshire and Arran NHS Board area
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Ms C complained to us that the practice had failed to provide appropriate care and treatment to her late mother (Mrs A). She said that her mother had attended the practice on a number of occasions and was given a diagnosis of a chest infection, whereas she was in the final stages of lung cancer. Ms C was concerned that the practice had concentrated on a chest infection being the cause of her mother's symptoms. In addition, a chest x-ray which was taken showed signs of a cavity in her lung which was not followed up or mentioned to Mrs A or her family.

We took independent advice from a GP adviser and concluded that there were some failings in the level of care provided. During the initial consultations it was appropriate for the GP to arrive at a potential diagnosis of a chest infection and we found that appropriate investigations including an x-ray and blood tests were performed. However, we considered that once the chest x-ray result had been received which showed a cavity on the lung, then further action should have been taken. This would either have been to repeat the chest x-ray within a defined time frame with a view to onward referral to a chest specialist, or to make a direct referral at that time to a chest specialist. Further action should also have been taken as Mrs A's blood results revealed that she was anaemic. We also concluded that, although the final outcome would not have altered, the diagnosis would have been reached sooner and this would have allowed Mrs A and her family to make decisions regarding future care and support which would be required. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Ms C for the failure to follow upon the blood results and x-ray result.

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.

Updated: December 2, 2018