Foreword
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In the past I have published reports of completed investigations which raised issues of general interest. Since my jurisdiction changed to allow me to investigate clinical complaints I have begun to identify issues which are more technical and will be of most interest to a clinical audience.
During 1998-99 I completed two investigations covering such issues. In March 1998 I began investigation of a complaint made by a woman whose father was treated at the Royal London Hospital (case number E.1422/97-98). The man suffered from chronic obstructive pulmonary disease. The woman complained that her father's condition was not properly assessed and monitored, and that his care was inadequate. My investigation showed that the man's deterioration was due to an excess of oxygen, rather than too little, as the family believed. The investigation was severely hampered by poor record keeping by nursing and medical staff. The second complaint was made by a man whose young son was visited at home by a locum general medical practitioner (GP) from a deputising service in the Birmingham Health Authority area (case number E.2211/97-98). He complained that the locum GP had failed to take account of his son's symptoms, and had made an inappropriate diagnosis, despite being told about the possibility of malaria. I upheld the complaint. My investigation showed that the GP should have referred the boy urgently to hospital for a blood test, in accordance with Department of Health guidance.
I have decided to publish my reports of these cases, to be laid before each House of Parliament in accordance with section 14(4)(b) of the Health Service Commissioners Act 1993 (as amended). I hope that they will provide useful material for health professionals.
A summary of these cases is provided (E.1422/97-98 and E.2211/97-98). Subsequent pages contain the full text of my investigation reports; but the names of the complainants, the patients, and the health professionals have been removed in order to preserve confidentiality.
June 1999
M S Buckley
Health Service Commissioner for England
