Decision report 201200931

Summary

Mr C's son (Mr A) attended his then medical practice in June 2011 complaining of left hand rib pain and pain in his elbows, right hip and shoulder, left wrist and lower back. He was examined by the GP, blood tests were taken and he was prescribed pain medication. Mr A's pain worsened and he had a further phone consultation with his GP. Advice was given, and Mr A was encouraged to join a different practice closer to home, as he no longer lived in his current GP's area.

Mr A transferred to a new medical practice. Before his first consultation there, Mr A's pain worsened again and he attended a hospital accident and emergency department (A&E) where x-rays were taken, showing evidence of possible cancer. He was referred to the hospital chest clinic, but the chest physician reviewed the information and decided that he did not need to see Mr A. When Mr A attended his first consultation at the new medical practice, his health records had not yet arrived from the previous practice. Because of the time it took to add Mr A's information to the computer system, important results from A&E were not available at his next appointment. Before Mr A had his second consultation at the practice, the chest physician from the hospital contacted them and advised that Mr A had nothing to be concerned about. Mr A was treated with pain killers on the understanding that he had a cracked rib.

Mr C complained that the new practice did not ensure they had all of Mr A's records and test results to hand when examining him, and that the GPs who examined him did not conduct thorough examinations, preferring to prescribe stronger pain medication to alleviate his symptoms. Having taken independent advice from one of our medical advisers, our investigation found that the initial lack of records during the first consultation was outwith the practice's control. The call from the chest physician then reassured them that there was nothing sinister in Mr A's chest x-ray. We considered that, once the records arrived, they could have been made available to the GPs before they were added to the computer system. Given, however, the advice provided by the chest physician, we took the view that it was very unlikely that the treatment offered to Mr A would have been any different had his x-ray results and other records been available. We noted that the practice have since changed their procedures to ensure that GPs are made aware of any patient information that has not yet been added to the computer system.