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Case ref:201500619
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Date:September 2015
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Body:A Medical Practice in the Lothian NHS Board area
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Sector:Health
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Outcome:Upheld, action taken by body to remedy, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C underwent an x-ray to investigate back pain he was experiencing. The report of this x-ray also recorded the possible presence of an aortic aneurysm (swelling of the main blood vessel that leads away from the heart and down the body). The report recommended that Mr C's GP arrange for him to be sent for a further ultrasound to assess it further. Mr C was not informed of the presence of the aortic aneurysm and no ultrasound was arranged. Mr C complained that this was unreasonable.
We found that the practice had recognised the error, which occurred because the GP who recalled Mr C for an appointment was not the GP who saw Mr C. In order to prevent this happening again the practice had altered their report handling procedures. The practice apologised to Mr C.
We took independent advice from one of our GP advisers. The adviser confirmed that the practice should have arranged for an ultrasound to be carried out. The adviser was satisfied that the action taken by the practice since the error was brought to their attention was reasonable and sufficient.
We upheld this complaint. However, in light of the action already taken by the practice we had no further recommendations to make in that regard. As their complaints handling procedure was not in line with government guidance, we made a recommendation to address this.
Recommendations
We recommended that the practice:
- ensure that the complaints handling procedure is fully compliant with the Patient Rights (Scotland) 2011 Act and the Scottish Government 'Can I help you?' guidance.