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Case ref:201407708
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Date:October 2015
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Body:A Medical Practice in the Tayside NHS Board area
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Sector:Health
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Outcome:Not upheld, no recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C, who is an advice worker, complained on behalf of Mr A about the care and treatment he received from the medical practice. Mrs C said Mr A, who has cerebral palsy, was seen by doctors at the practice for a year with sharp abdominal pains but the practice failed to diagnose that Mr A had a hernia (a condition where an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall). Mrs C also complained that one of the doctors at the practice failed to carry out a physical examination of Mr A at one of the appointments.
We obtained independent medical advice from one of our GP advisers. They said that they could see no evidence in Mr A’s medical records that he had either the symptoms or signs of a hernia during the 12 months that he was seen by the practice, and that the hernia identified at the end of the 12 months was most likely a new presentation. We found that Mr A was provided with a reasonable standard of care by the practice.
Our adviser also explained that there was no requirement for a patient to be examined for a chronic condition every time they attended a GP practice and that if a patient presented with new symptoms or a significant change, then an examination would be reasonable. When Mr A was seen by the doctor, he did not present with any new symptoms, and as he had been seen 24 hours previously by a senior surgical doctor at Perth Royal Infirmary for an examination, we did not consider it unreasonable that the doctor did not physically examine Mr A. We did not uphold Mrs C's complaints.