Decision report 201104307

Summary

Mrs C complained that the medical practice did not provide reasonable care and treatment to her husband (Mr C). Mr C had gone to the practice complaining of back and neck pains; pins and needles in his fingers, and difficulty walking and working. After several appointments, he saw Doctor 1, who recorded that he told Mr C that the problem was probably related to his spine and nerve entrapment. Doctor 1 also recorded that he had referred Mr C to physiotherapy and neurology (which deals with problems of the nervous system). He later completed a referral to physiotherapy, but there is no evidence that he completed a referral to neurology at that time.

Mr C saw another GP, Doctor 2, several days later. Doctor 2 recorded that Mr C had worsening pain in his arms, spine and back and some muscle spasms in the lumbar region. He also recorded that Mr C had weakness and numbness in his hands and was awaiting a neurology appointment. Mr C then saw Doctor 1 again. This was nearly three weeks after Doctor 1 had agreed to refer him to physiotherapy and neurology. Doctor 1 recorded that the pain was increasing despite analgesia (pain relief). He also completed a letter for urgent referral to neurology, as there was no sign of a referral being completed after the earlier visit. Mr C went to the accident and emergency department of a hospital (A&E) two days later. He was transferred to another hospital and an MRI scan (a diagnostic procedure used to provide three-dimensional images of internal body structures) led to a diagnosis of a serious back condition. Mr and Mrs C considered that this condition could have been prevented had the practice acted sooner.

After taking independent advice from one of our medical advisers, we found that the practice's general care and treatment of Mr C was reasonable, apart from the delay in sending the neurology referral letter. That said, Doctor 1 referred him to neurology urgently when it became clear that the initial (non-urgent) referral had not been done. In addition, he was transferred to another hospital for urgent treatment after attending A&E. In view of this, it is unlikely that the failure to complete the initial neurology referral had any significant impact on Mr C’s subsequent care and treatment.

Mrs C also complained that the practice’s response to Mr C’s complaint unreasonably contained inaccuracies. However, we found that the comments in the practice’s response were confirmed by Mr C’s medical records.

Recommendations

We recommended that the practice:

• issue a written apology to Mr C for the failure to send the referral letter.