Decision Report 201405101

Summary

After Ms C was diagnosed with Lyme Disease (an infection transmitted by the bite of ticks) in 2014, she complained that her GP practice had failed to identify the symptoms of the condition at a consultation a year earlier. Ms C said that in 2013 she presented with a tick bite and large surrounding rash on her arm but the doctor she saw on that occasion did not offer her blood tests or antibiotics. Ms C was concerned that an electronic record of the consultation differed to the hand written entry by that doctor in her medical records and that a second doctor did not put accurate information in a referral letter to an infectious diseases specialist. Ms C also complained that a health care assistant was unprofessional with matters related to her blood test in 2014.

We took independent advice from one of our medical advisers who is a GP, and found that there was no evidence to indicate that Ms C had a bite mark on her arm or that the rash was typical of that associated with Lyme Disease. We considered, on balance, that the first doctor's assessment, diagnosis and suggested treatment were reasonable at the time. We also found that the electronic medical record did not differ materially from the handwritten record. Furthermore, the referral letter to the infectious disease specialist was consistent with the recorded entries in the medical records and were not inaccurate or misleading.

We concluded that it was good practice that the health care assistant had sought advice from a senior colleague regarding the blood test and took steps to appraise himself of the laboratory guidance. Whilst it was difficult for us to comment on the discussions between Ms C and the health care assistant, we obtained electronic records which provided an audit of the likely advice that Ms C was given by him during a phone conversation about the blood results.

We, therefore, did not uphold the complaints.