Complaint against: A GP in the North Wales Health Authority area - Appendix
Health Service Ombudsman for Wales
Investigations about aspects of the NHS complaints procedure
Case No. W.6/98-99
General Practitioner's response to the report of an independent review (IR) panel
Appendix - The IR panel's conclusions and recommendations together with Dr Z's remarks
(Note: Text in normal font is the IR panel's conclusions or recommendations; text in italic font is a summary of Dr Z's responses as contained in her letter of 16 February.)
1. 'The panel recognises Dr Z's difficulties in finding a cause other than thrush for Miss X's pruritus [itching].'
2. 'There were discrepancies in the evidence given by Dr Z and Miss X, but we do not believe that either was intending to mislead us.'
'Dr Z was considered to be a caring GP but perhaps relied too heavily on assumptions rather than carrying out regular examinations.'
Dr Z wrote:
'You were examined on every occasion as [one of the assessors to the panel] points out in the report. The only false assumption that I apparently made .... was the assumption that you were sexually active during the period 1994/5 when apparently you were not. Had I known this at the time it would have cast a different interpretation on your symptoms.'
3. 'Dr Z's requests that Miss X return in 2 weeks (15.11.94) in 1 week (2.6.95) and the nurse's suggestion that she should see [Dr Z] if the itching continues (24.7.96) may not have been given with sufficient emphasis to [Miss X].'
Dr Z wrote:
'When I saw you during that period I was very worried about your cervix, as in 1986 and 1990 you had several months of recurrent infections in association with cervical disease. I can remember suggesting to you that if we did not manage to get the infection cleared ... then you would have to return to the hospital ....'
4. 'The onus is principally on the patient as it would be difficult for GPs to remind patients who do not attend when asked to do so.'
5. 'Dr Z was justified in this case in trying to eliminate infections .... She had at the time less reason to be suspicious of [a locally cancerous condition of the vulva] but, nonetheless, she should have also kept this in mind.'
6. 'We felt that closer attention by [Dr Z] to previous notes might have led to her asking [Miss X] whether the pruritus continued. If she had known the condition had been as persistent as it appears to have been she might have been referred sooner.'
Dr Z wrote:
'At no time did you tell me about your severe itching .... In 1994 and 1995 your main complaint was discharge which is clearly documented in the notes but with the passage of time this may have faded in your memory.'
'.... as I was unaware of the great problems you were having with itching .... I could not have asked. In 1996 I noted the nurses entry saying you were using lots of Canesten Cream. I asked you had you any problems and you said no.'
7. 'The right time for referral is a matter for an individual GP's judgement. Some may refer sooner than others but the panel felt that Dr Z did not act irresponsibly in not referring Miss X at an earlier date.'
'However, we feel that in this case Dr Z may have relied too much on her own observations and could have listened more carefully to [Miss X]. If Miss X had been made more aware of the importance of returning to check that treatments were effective, the underlying development of [a locally cancerous condition of the vulva] may not have gone unsuspected.'
Dr Z wrote:
'Whenever you came in you always seemed in a hurry. The first time I became aware of .... the severity of your symptoms was when I received the booklet of evidence to be used at the review panel.'
1. 'In order to encourage patients to return to check the efficacy of treatments there should be a system of appointments so that they do not feel they are wasting their time by having to wait an hour or more to see a doctor. The appointment could then be made as the patient leaves the surgery.'
Dr Z wrote:
'We have as you know an open surgery with no appointments. We do have a system where if we think someone has something serious we enter their name in a book and check whether they return as directed. I also occasionally ask people to come back and just sit outside my door and I take them straight in if it is something I want to do a quick check on. Neither of these solutions applied to you. I felt you needed a further consultation ....'
2. 'Doctors need to be sensitive to the patient's own observations as to changes in his or her symptoms.'
3. 'Doctors should refer back to their notes so that they can at least enquire as to whether previous symptoms are still causing trouble. We feel that in this case suspicions may have been aroused sooner if the patient had been questioned about the pruritus when she visited the doctor on other matters.'