Decision Report 201806793

Summary

C complained that the practice failed to provide them with effective treatment for a skin complaint and that they waited an unreasonable length of time before they saw a doctor.

We took independent advice from a nurse adviser and a GP adviser. C had first attended two nurse consultations, a week apart, as they had developed an itchy rash on their back. We noted that the initial working diagnoses (insect bites/fungal infection) and the care and treatment provided at this point was reasonable. Ten days after C's first consultation, they contacted the practice again. As the triage telephone call mentioned 'shingles' as another possible diagnosis, a referral to see a GP should have been made at this time. However, C was given an appointment with an advanced nurse practitioner. Although C was being treated with an allergy tablet, there was no documented working diagnosis of what was causing the itch. We found that the management of C at this time was not reasonable.

C contacted the practice again the following day and requested to be seen by a GP. This was the fourth time C had contact with the practice in eleven days since the onset of the rash, which was getting worse and becoming painful. Although the advanced paramedic practitioner who saw C on this occasion sought advice of a GP regarding treatment, we considered that it was unreasonable that C was not referred to be seen by a GP at this time.

C made a further request for a GP appointment two weeks later and again was given an appointment with an advanced paramedic practitioner. We found that this was unreasonable given that this was C's second request for a GP appointment, they had seen nurse and paramedic practitioners four times over a period of several weeks and had attended the out-of-hours service, during which time their rash was getting worse/not responding to prescribed treatment and was painful.

Due to their ongoing symptoms, C attended again at the out-of-hours service when they were prescribed an oral steroid and advised to contact their GP to expedite a dermatology (diseases of the skin, hair and nails) appointment as soon as possible. At this time, C had still not seen a GP in the practice and we considered this to be unreasonable. When C eventually saw a GP, an urgent referral to dermatology was made. The care and treatment provided by the GP at this time was reasonable.

Taking into account all of the evidence and the advice we received, we found that the practice failed to provide C with reasonable care and treatment. As such, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to have an appropriate management plan in place and for failing to refer C to be seen by a GP earlier. 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:

• Where a patient presents on several occasions with an acute condition that is not responding to treatment, an appropriate management plan should be in place. Where a patient has seen advanced practitioners on two occasions and requires to be seen a third time with the same acute condition, consideration should be given to having a GP review the patient.

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.