Decision Report 201305291

Summary

Mrs C went to her medical practice with a thickened and discoloured toenail. The GP suspected a fungal nail infection and sent clippings for testing but the results were negative. The practice took no follow-up action until, after seeing a private podiatrist (foot specialist), Mrs C went back to her GP almost a year later. At the recommendation of the podiatrist, the GP made an urgent referral to a dermatologist (skin specialist). Mrs C was diagnosed with a malignant melanoma (a type of skin cancer) and her toe was later amputated. She complained that the practice unreasonably failed to refer her for further diagnostic tests. She also complained that the practice did not respond appropriately to her complaint about this.

Mrs C had complained by phone to the practice manager. During the call she said that she did not want to speak to the GP. Despite this, the GP called Mrs C a few minutes later. Mrs C spoke to the manager again the following day, who confirmed that she had passed Mrs C's message to the GP but that he had phoned her anyway, thinking that it would be of help. Mrs C then complained in writing and the GP responded but Mrs C did not receive the letter. About four months later, she chased up the response and was provided with a copy.

Our investigation, which included taking independent advice from a medical adviser, found that the cancer was very rare and difficult to diagnose, and that national guidelines confirmed this. The adviser commented that in general practice it is usual for patients who are having investigations to be told to return for review when the results are available. The GP had noted on Mrs C's record 'RV [review] with results' when the nail clippings were sent for investigation. Mrs C did not return for review but our adviser said that as the results were normal, no further investigation was required at this time. When Mrs C did return, having been reviewed by a podiatrist, the GP then took appropriate and timely action to follow the podiatrist's recommendations.

Mrs C was concerned that when discussing the negative fungal infection results with her, the GP did not advise her to make an appointment with the in-house podiatrist. The GP said that he was certain that he had advised Mrs C to do so, but conceded that he had not documented this. We were unable to determine which version of events was correct, but overall our adviser was of the view that the care and treatment provided to Mrs C was reasonable.

On the handling of Mrs C's complaint, our view was that in view of Mrs C's specific request not to speak to the GP, it was inappropriate for him to call her. While early and direct discussion of a complaint can bring about a speedy resolution, in this case contact was not helpful. However, we did consider that it was reasonable for the GP to have written the response letter to Mrs C. This contained the GP's personal apologies for the experience Mrs C had been through and also his explanations of why he had not thought the condition in her toe was serious at the outset.

We noted during our investigation that the practice's complaints literature was out of date, but that the timescales for both the previous and current NHS guidance on complaints handling had been met. Also, Mrs C was given the correct information about the next stage of the complaints process at the correct time. Although we did not uphold this complaint, we brought this to the attention of the practice.