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Case ref:202004102
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Date:June 2021
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Body:Grampian NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:Clinical treatment / diagnosis
Summary
C complained to the board about the treatment which they received when they attended the out of hours service (OOHS) at Aberdeen Royal Infirmary. C said that they had already reported problems with back pain and loss of feeling to their GP practice. However, the OOHS doctor who attended to C did not conduct examinations or arrange investigations such as a scan, and told C to see their GP the following day. C was taken by ambulance to hospital the following day and, after a CT scan, they were diagnosed as having cauda equina syndrome. C felt that the doctor at the OOHS should have completed a more thorough examination and that the correct diagnosis would have been reached sooner and would not have had such a drastic effect on their health.
We took independent advice from a GP. We found that that although the OOHS doctor obtained a good history from C and conducted a reasonable examination, they failed to action C's progressive neurological symptoms and new onset bladder problems. These required referral for an orthopaedic (conditions involving the musculoskeletal system) opinion or further investigations that day. Therefore, we upheld the complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for the failure of the OOHS GP to fully consider the red flag symptoms presented which indicated the possibility of developing cauda equina syndrome. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
What we said should change to put things right in future:
- The OOHS GP should ensure that when red flag signs are evident when a patient presents that they conduct a full examination and consider whether an urgent referral to a hospital specialist is appropriate. In addition, the OOHS GP should discuss this complaint at their annual appraisal.
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.