Decision Report 201501920

Summary

Mr C attended the practice on three occasions between 2010 and 2013 for blood glucose tests (a standard test for blood sugar levels, used in diagnosing diabetes). Mr C was not diagnosed with diabetes until a fourth blood test later in 2013. He has complained that, based on these test results, the practice could have diagnosed his diabetes earlier than they did.

We took independent advice from a GP adviser. They noted national guidance and the protocols in place in the practice for diagnosing diabetes. They also reviewed the test results from Mr C's blood glucose tests. They identified that it was not clear whether the first test, in 2010, had been a 'fasted' blood sample (ie whether Mr C had been told to fast prior to the blood test). They noted that this would have had an impact on what further action was appropriate. Given that the GP involved at that point had since retired, and that the actions could have been reasonable, they were not critical. However, the second blood test results showed concerns and should have been immediately responded to. Instead, Mr C was advised to return for another test in six months. When he had another blood test 18 months later, the test results were conclusive of diabetes, and the adviser noted that the error in identifying this had already been picked up by the practice in their response to the complaint.

We concluded that the GP had not taken reasonable steps in their response to Mr C's second blood test, as further tests should have been taken at that time. We agreed with the practice's assessment of their response to Mr C's third blood test. We were also concerned that the local protocols in place for the assessment of blood glucose results did not fully reflect the national guidance.

Recommendations

We recommended that the practice:

• ask the GP involved to consider reviewing this case in conjunction with the World Health Organisation (WHO) Guidance on the diagnosis of diabetes and identifying any learning point at their next appraisal; and
• review their protocols for the management of abnormal diabetic blood results, to ensure they are in line with the WHO Guidance.