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Case ref:202106072
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Date:March 2023
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Body:A Medical Practice in the Grampian 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 on behalf of their partner (A). A had a telephone consultation with the practice and reported haemoptysis (coughing up blood) and a fever. A also reported that they had taken a lateral flow test for COVID-19 which was negative. A did not take a PCR test for COVID-19 prior to contacting the practice. The practice considered it was likely that A had COVID-19 and advised that they self-isolate for ten days after symptoms started. A's condition deteriorated and several weeks later they were admitted to hospital and diagnosed with bacterial pneumonia.
C complained that the practice did not offer A a face to face appointment and subsequently failed to correctly diagnose their condition of bacterial pneumonia, instead focussing on COVID-19 as being the cause of A's illness.
The practice considered that they had been following the guidelines in place at the time and had correctly signposted A to the COVID-19 Hub for further assessment. We took independent advice from a GP. We found that there was no evidence in the clinical record that A had been signposted to the COVID-19 Hub and that haemoptysis was never listed as one of the common symptoms of COVID-19 infection. We found there was a failure to offer A a face to face appointment, particularly given they had reported haemoptysis.
We welcomed that during our investigation the practice reflected further and accepted that A's complaint of haemoptysis merited further clinical consideration and assessment. Given that the practice have taken appropriate and sufficient action to learn and improve from this complaint, we did not recommended that they take any further action. However, we recommended that they apologise to C and A for not offering A a face to face appointment.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C and A for not offering a face to face appointment which may have led to bacterial pneumonia being considered. 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.