Decision report 201202435

Summary

Mr C's daughter (Miss A) who was three years old, was taken to her medical practice because she was vomiting. Mr C complained that GPs there failed to appropriately investigate Miss A's symptoms and that this led to a delayed diagnosis of a brain tumour. Miss A's parents had taken her back three days after the first visit, and further vomiting was reported. The GP recorded that a referral to a paediatrician should be considered if the current pattern of vomiting continued. Miss A's parents brought her to the practice again three months later. It was recorded that she had a viral infection and that she had had a few episodes of vomiting. She returned to the practice again nearly eight weeks later. It was recorded that the vomiting had continued for a number of months and that she vomited approximately every two weeks. The GP prescribed medication for stomach problems.

Miss A was taken to the practice again ten days later, which was her fifth visit about vomiting. It was recorded that she was vomiting as before and this had been for a few months on and off. She was prescribed further medication. It was recorded that her parents should call the practice if this was not working and she would then be referred to a paediatrician. Two weeks later, Miss A was referred to a paediatrician in view of the unexplained vomiting. This was noted as a routine (not an urgent) referral.

Miss A attended the practice again two weeks later, before she had seen a paediatrician. It was recorded that the vomiting was on-going and that she had been tired lately and had a bradycardia (slow heart rate) when lying down. A referral was made to a private paediatrician, as her parents had private health insurance. Mr C's wife phoned the practice later that afternoon, however, as Miss A's condition had worsened and she was now more drowsy. It was arranged that Miss A would be taken to hospital for assessment, where she was admitted. The next day, another hospital phoned the practice to tell them Miss A had been admitted there, as she had a brain tumour that required urgent neurosurgery.

Our investigation found that the practice carried out a significant event analysis to assess why their GPs did not refer Miss A for a specialist opinion earlier. They considered the National Institute for Health and Care Excellence (NICE) referral guidelines for suspected cancer, which say that when a child presents with the same symptoms several times, but there is no clear diagnosis, they should be referred to hospital urgently. The practice acknowledged that under these guidelines Miss A's referral could have been made earlier, as an urgent case. In addition, the GP who saw Miss A at her second visit had recorded that referral to a paediatrician should be considered if the current pattern of vomiting continued. Despite the fact that Miss A did continue to vomit and attended the practice a further three times, she was not initially referred to a paediatrician. When the referral was eventually done, it was marked as routine rather than urgent. This was a balanced decision, but having carefully considered the matter, we upheld Mr C's complaint. In view of the action taken by the practice as part of the significant event analysis, however, we did not find it necessary to make any recommendations.