Decision Report 202202227

Summary

C complained about the practice on behalf of their spouse (A). A is paraplegic (affected by or relating to paralysis of the legs and lower body) and was receiving district nursing treatment for various wounds, including one on the large toe of their left foot. The condition of A’s left foot deteriorated and they were showing signs of infection. A was seen by a district nurse who took photographs of A's foot and showed them to the duty GP at the practice. The GP made an urgent referral to vascular surgery, which was sent the next day, but did not assess A themselves or communicate the management plan to them. A’s condition worsened and a few days later they required immediate admission to hospital and urgent surgery. A subsequently required amputation of some of their toes. C complained that A’s outcome may have been better had they been assessed by the duty GP and/or admitted to hospital the same day.

We took independent GP advice. We were not critical of the fact the duty GP did not carry out a face to face assessment of A. We found that the GP followed the relevant guidelines by making an urgent referral to vascular surgery, which was a reasonable assessment. However, we found that the GP should also have made direct contact with the vascular surgery team for advice as to whether A required to be seen the same day. We found that the GP also should have communicated their management plan to A and to C, as they acknowledged in their complaint response. This would have allowed the opportunity to raise any concerns with the GP directly. On balance, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the communication failings we have identified. 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:

• When making an urgent referral to vascular surgery for a patient with critical limb ischaemia, GPs should contact the vascular team directly for advice as to whether same day assessment is required. GPs should discuss the management plan with 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.