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Case ref:201508841
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Date:October 2016
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Body:A Medical Practice in the Ayrshire and Arran NHS Board area
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Miss C complained about care provided by her GP practice. She attended the practice a number of times over a period of six months with various symptoms which were ascribed to depression and treated as such.
When Miss C began displaying slurred speech, her GP urgently referred her to hospital where she was diagnosed with a brain tumour.
We sought independent advice from a medical adviser. Their view was that Miss C's symptoms were reasonably ascribed to other causes and it was not until the symptom of slurred speech occurred that it became clear there might be another cause for Miss C's condition. The adviser said the GP then took appropriate action by urgently referring Miss C. For this reason we did not uphold this complaint.
We did however uphold the complaint about post-operative care as the practice had acknowledged that their normal practice is to contact patients once they have been discharged from hospital and this did not happen in this case. The practice said they intended to carry out an Enhanced Significant Adverse Event (ESAE), and we made a recommendation in relation to this.
Recommendations
We recommended that the practice:
- apologise to Miss C for the failings they identified; and
- share with Miss C any learning from the ESAE.