Decision report 201200172

Summary

Mrs C complained that the GPs treating her late mother (Mrs A) failed to fully investigate her symptoms and take timely and appropriate action. She also complained that one of the GPs refused to refer Mrs A to the gastroenterology clinic (a clinic specialising in medicine of the digestive system) for further investigation.

Mrs A was a long-term sufferer of coeliac disease (a condition in which the small intestine fails to absorb and digest food) and was reviewed on an annual basis at a gastroenterology clinic. She also had a skin condition which was linked to the disease, and suffered long-standing back pain. Although Mrs A was prone to constipation because of the medication she took for her conditions, from mid-2010 she had told the practice that she had increasingly severe constipation, sometimes for four to five days. The advice she received from the practice was to increase her laxatives (medication taken to cause or encourage bowel movements). Blood tests taken in early April 2011 returned abnormal results, which the practice attributed to the infective skin condition Mrs A had at the time. They referred Mrs A urgently to the dermatology department (the department dealing with skin conditions). In early May, the department told the GPs that they should seek a further opinion on Mrs A's condition. Mrs A was referred to the gastroenterology clinic that month, where tests revealed that she had inoperable bowel cancer. Mrs A died the following month.

We upheld two out of three of Mrs C's complaints. Our investigation, which included taking independent advice from one of our medical advisers, found that there were delays in fully investigating Mrs A's symptoms and making timely and appropriate referrals for specialist advice. Mrs A had a long-term medical condition, and was taking medication that affected her bowels. Our adviser said that her initial symptoms in 2010 should not, therefore, have triggered a specialist referral. However, when these symptoms continued, and increased in severity despite a significant increase in her laxative medication, this should have triggered action from the GPs. The adviser was of the view that while it was reasonable for the GPs to address the issue of the infective skin condition, they appeared to do so to the exclusion of any other possible underlying condition and did not take a proactive and holistic approach. Although the adviser noted that, even if they had acted more urgently, the outcome for Mrs A was likely to have been the same, we upheld this complaint as we found that there was unreasonable delay in referring Mrs A to a specialist.

One of the complaints referred specifically to how quickly the GPs dealt with blood test results. The adviser was of the view that the results were dealt with in a timely manner, although the referral which followed was to the wrong specialism. Therefore, on balance we did not uphold that complaint. Another complaint was that one of the GPs refused to refer Mrs A to the gastroenterology specialist. Our investigation found no evidence that the GP actually refused to refer Mrs A to this specialist. However, we found that the fact that all the GPs focussed their attention on the skin condition had the same effect, and so we also, on balance, upheld this complaint.

Recommendations

We recommended that the practice:

• issue a written apology for the failings identified;
• conduct a significant event audit of this case, with any findings and recommendations to be discussed at the GPs' next annual appraisals; and
• undertake a review of a sample of patient records to ensure that clinical note taking complies with the standards set by the General Medical Council's 'Good Medical Practice: Providing good clinical care'.