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Case ref:202100607
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Date:May 2023
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Body:A Medical Practice in the Western Isles 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 properly investigate their hip pain symptoms, resulting in a delayed cancer diagnosis. C raised concerns that questions were not asked, or tests carried out, that might have led to an earlier diagnosis. The practice responded to the complaint and carried out a Significant Event Analysis (SEA). They noted that a muscular injury was suspected at the initial consultation. At the time of the second consultation, an x-ray had been incorrectly reported as normal by the hospital. Therefore, the practice were not alerted to any need for further tests at that time.
We took independent medical advice from a GP. We found the practice's management of C reasonable at the initial presentation. However, when C re-presented a month later with worsening bone pain despite a normal x-ray, further investigation (blood tests) should have been carried out. C was then diagnosed after orthopaedic (specialists in the treatment of diseases and injuries of the musculoskeletal system) review the following month. We upheld C's complaint. However, given the extensive nature of the disease identified, we did not consider that further investigation by the practice at the second consultation would have altered the overall outcome.
We also found that the SEA should have reflected the further investigation that should have been considered at the second consultation. We gave some feedback to the practice on learning from adverse events, with reference to Healthcare Improvement Scotland's relevant guidance.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for failing to carry out further investigations when they re-presented with ongoing and worsening pain. 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:
- Blood tests should be considered when patients present with worsening bone pain.
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.