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Case ref:201700873
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Date:December 2017
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Body:Shetland NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Ms C complained to us that that a GP at the health centre had failed to provide her with appropriate treatment during a consultation. She had attended the GP and had reported that a couple of days earlier she had been woken with severe pain on her left side. She wondered whether she had ruptured an ovarian cyst which she was known to have. Ms C said that the GP did not examine her or take her temperature. Ms C said that five days later she began vomiting and was admitted to hospital, where it was found that she had ruptured her bowel.
We took independent advice from a GP adviser. We found that the GP had suspected that Ms C may have ruptured an ovarian cyst and that they did arrange for an appropriate blood test and an ultrasound to be carried out. However, the adviser also said that the GP should have examined Ms C's abdomen and checked a urine sample as she had reported abdominal pain. Although the adviser felt that the GP should have performed a clinical examination, the adviser thought it was unlikely that Ms C had ruptured her bowel at the time she saw the GP as this would normally involve the onset of acute sudden symptoms. Ms C had also reported that her symptoms were improving when she saw the GP. The GP had carried out a Significant Event Analysis and they had recognised that they should have examined Ms C's abdomen. The GP said that they would examine patients' abdomen in future. We upheld the complaint.
Recommendations
What we asked the organisation to do in this case:
- Provide a written apology for failing to carry out an appropriate assessment. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.
What we said should change to put things right in future:
- The GP should ensure that full and appropriate assessments are carried out based on the patient's reported symptoms.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.