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Decision Report 201706213

  • Case ref:
  • Date:
    May 2019
  • Body:
    A Medical Practice in the Lothian NHS Board area
  • Sector:
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis


Mr C complained about the care and treatment his daughter (Ms A) received from the practice. Ms A contacted the practice about severe abdominal pain and was given advice over the phone. Four days later Ms A was admitted to hospital where she had her appendix and part of her bowel removed. Mr C felt that it was unreasonable that the practice did not examine Ms A in person when she called them and that this failure could have led to a potentially serious situation.

We took independent advice from a medical adviser. We found that the practice failed unreasonably to adequately assess and examine Ms A. Therefore, we upheld Mr C's complaint.


What we asked the organisation to do in this case:

  • Apologise to Mr C for the failings in assessment and examination. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.

What we said should change to put things right in future:

  • The doctor involved should reflect on the complaint and findings in their next appraisal.
  • The doctor involved should follow the relevant guidance on assessment and management of abdominal pain in women of childbearing age.

Updated: May 22, 2019