Decision Report 201707319

Summary

Ms C began to experience stiffness and pain, to the extent that she was struggling with everyday tasks. Her GP prescribed her steroids (a type of anti-inflammatory medicine), which improved her symptoms. Her GP then referred her to rheumatology (the branch of medicine concerned with immune-mediated disorders of the musculoskeletal system) at Royal Alexandria Hospital. Ms C complained that, when she attended her rheumatology appointment, her condition was not appropriately assessed. Ms C said she was told to stop taking steroids but when she did this, her symptoms returned. Ms C raised concerns that she was not given any follow-up appointment to check on her condition. She also complained that, when her GP raised concerns about her worsening symptoms with rheumatology, no action was taken.

We took independent advice from a consultant rheumatologist. We found that there was a lack of useful clinical information in the clinic note and GP letter relating to Ms C's initial rheumatology appointment. As a result, the adviser was unable to confirm if her assessment was reasonable or not. We found that consideration should have been given to reducing Ms C's steroid dose gradually before it was stopped. We found that Ms C should have been given a follow-up appointment or the means to contact rheumatology directly for advice if her symptoms returned. We also found that when her GP contacted rheumatology with concerns, Ms C should have been offered a prompt review. In addition, we found that phone conversations, in which advice was given to Ms C's GP, were not recorded in her medical records.

We found that due to these failings, there was an unreasonable delay in diagnosing Ms C's underlying condition of inflammatory arthritis (an autoimmune condition that causes joint pain and swelling). We upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to appropriately document and update both Ms C and her GP on her rheumatology appointment; not giving Ms C a follow-up appointment or the means to contact rheumatology directly for advice; and the delay in offering Ms C a rheumatology review when her symptoms returned and worsened. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Appropriate clinical information should be documented in clinic notes, given to GPs and copied to the patient, with enough detail to understand how a clinical decision or diagnosis has been reached.
• Patients should receive appropriate follow-up care and a prompt rheumatology review if required.
• Clinical advice, which is given to GPs, should be recorded appropriately.