Decision Report 201603169

Summary

Miss C complained to us that the practice had failed to provide her with appropriate care and treatment when she developed problems following back surgery. In particular, she felt that her GP should have taken a urine sample as she was having difficulty urinating and that as she was suffering from pain and swelling at the surgery wound site, a referral should have been made to a specialist consultant. Miss C continued to be in pain for a number of days before contacting the out-of-hours service where she was admitted to hospital for further surgery.

The practice said that it was not appropriate to take a urine sample as the urinary symptoms which Miss C reported were consistent with a diagnosis of a urine infection and that appropriate antibiotics were prescribed. In regards to the wound site, it was felt that the problem was a build-up of fluid which would resolve naturally over time.

We took independent advice from a GP and concluded that there was no requirement for her GP to take a urine sample as the diagnosis of a urine infection was reasonable. However, we found that the GP should have referred Miss C for an urgent specialist orthopaedic opinion as she had developed an acute complication following the surgery. Miss C's symptoms of swelling and pain at the wound site had only been present for three days but it had been three weeks since Miss C's original back surgery. We therefore upheld this complaint.

Recommendations

We recommended that the practice:

• apologise to Miss C for not referring her for a specialist opinion for her spinal condition.