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Case ref:201904820
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Date:July 2020
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Body:Highland NHS Board
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Sector:Health
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Outcome:Not upheld, no recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C complained about the care and treatment her child (Child A) received from a practice managed by the health board. Child A had initially attended the practice for treatment of tonsillitis. However, they continued to be unwell and Mrs C took them back to the practice a number of times over the subsequent months.
Mrs C complained that, despite raising concerns about Child A's symptoms with the GPs, her suspicion that Child A may have glandular fever was not properly investigated. Based on Child A's presentation, the practice concluded that they were suffering from post-viral symptoms. However, Mrs C stated that this was never communicated to her. Mrs C complained that the practice did not provide reasonable care and treatment to Child A in respect of their presenting symptoms.
We took independent advice from a GP. We found that the clinical decision-making and management in respect of Child A's presenting symptoms was reasonable. From the review of the consultation notes, it was likely that post-viral symptoms were discussed with Mrs C. However, we concluded that it was not possible to categorically confirm this from the medical records kept by the practice. While we did not consider this to mean that the practice failed to provide reasonable care and treatment to Child A, we did provide feedback about the fact that Mrs C was not left with a clear understanding of the diagnosis that had been made. However, on the basis of reasonable care and treatment being provided to Child A, we did not uphold this complaint.