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Case ref:201607462
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Date:July 2017
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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:Not upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C complained that his GP practice had unreasonably delayed in informing him that he had a stroke diagnosis. Mr C presented at the emergency department with symptoms that were initially considered to be consistent with Bell's Palsy (weakness down one side of the face sometimes due to nerve damage). Mr C had a history of labyrinthitis (inflammation of the inner ear) and was also vomiting and dizzy when he presented to the emergency department. Staff were satisfied that Mr C had responded well to treatment/medication at that time. Mr C was seen about four months later at the ear, nose and throat department (ENT) when a scan showed what appeared to be a lacunar infarct (a type of stroke that occurs when blood flow to one of the small arteries deep within the brain becomes blocked).
The practice printed the results of the scan but assumed that the ENT department would follow up the diagnosis and the results with Mr C. However, the registrar who had seen the scan had missed the significance of the diagnosis. Mr C was advised of the diagnosis two months later after asking at his practice why he was eligible for a flu jab. He complained that the practice had unreasonably delayed in informing him of the diagnosis after printing the results of the scan.
We took independent GP advice. Despite the practice stating in their response to Mr C's complaint that they accepted they were partially responsible for following up the scan results due to the abnormalities identified (although they felt that ENT should have followed up on the results with him), we found that the practice could not be held responsible for the failure of the ENT department to follow up on the scan results or the failure to refer management of the findings back to the practice.
As a result, we did not uphold the complaint by Mr C although we did make a recommendation.
Recommendations
What we said should change to put things right in future:
- The findings of this investigation should be shared with the board.
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.