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Case ref:201909891
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Date:August 2021
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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, recommendations
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Subject:Clinical treatment / diagnosis
Summary
C complained that the practice failed to appropriately investigate their urinary symptoms over a two-month period; in particular, that they failed to take blood tests and arrange a prostate check. C was later admitted to hospital with an acute kidney injury and urinary retention.
We took independent medical advice from a GP, who considered that the practice had unreasonably failed to examine C's prostate in light of their persistent urinary symptoms and repeated negative results for infection. Therefore, we concluded that there was a failure to reasonably investigate C's urinary symptoms and we upheld this complaint. However, the practice provided us with evidence that reflection and learning had already taken place through a Significant Event Analysis and we were satisfied that appropriate learning had been demonstrated. We recommended that the practice should apologise to C for the identified failings but made no further recommendations.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for failing to examine their prostate in light of their persistent urinary symptoms and repeated negative results for infection. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
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.