Decision Report 201203949

Summary

Mr C had a history of heart problems and was previously a patient of the practice. He said that, while he was their patient, they twice lost blood samples although the explanation given was that they were lost by the hospital. Mr C also complained that on one occasion when he attended the practice while experiencing heart symptoms, he was seen by a nurse and then sent home after discussing his condition with a doctor, having been told he might have shingles. He said that when he returned home, he was so ill that he required an emergency ambulance to take him to hospital.

To investigate the complaint, we obtained independent advice from one of our medical advisers, and took this into account with all the available information, including the complaint correspondence and relevant clinical records. We upheld the complaint, as our adviser identified a number of problems in handling Mr C's blood samples. They also said that when Mr C went to the practice he appeared to be suffering from a number of symptoms indicating the likelihood of a heart attack, which should have been addressed differently. In accordance with relevant guidance he should have received a detailed assessment by a doctor and been treated with glyceryl trinitrate spray to relieve pain.

Recommendations

We recommended that the practice:

• review their transport procedures after blood samples are taken from patients;
• carry out a review of their system and submit the results to their Community Health and Care Partnership lead for an external review;
• review their management and procedures of 'walk in patients' and clarify and review their Practice Nurse/Advanced Practice Nurse competencies/ autonomy;
• discuss Mr C's case as part of the GP appraisal process;
• carry out a significant event analysis; and
• note the 'identification and management of acute myocardial infarction' within their appraisal learning needs and review SIGN Guidance 93 (guidance for dealing with such matters).