Home > Publications > Selected CasesHealth > Selected Investigations Completed AprilJuly 2002 > Case no. E.166/01-02
Complaint against: A GP in the Essex Health Authority area
Summary of Case
On Saturday 3 July 1999 Mrs E visited her former husband, Mr E, in his sheltered accommodation. She found him in bed, unable to pass urine and in pain. Mrs E tried to telephone Mr E's GP, Dr R, but there was neither a reply nor a recorded message that allowed her to leave a message or directed her to another number. The GP was contacted via the ambulance service and agreed to visit Mr E. After almost two hours Dr R had not arrived so the ambulance service tried to contact him again but were unable to as his mobile telephone was switched off. Another doctor was asked to visit and arrived at the same time as Dr R. The second doctor left and Mrs E explained to Dr R that Mr E needed to go to hospital. Mrs E said that Dr R had not examined Mr E. Dr R said that he had carried out an examination but had not been able to feel Mr E's bladder. Mrs E felt it was only at her insistence that he arranged for Mr E to be admitted to hospital. Dr R said that he arranged Mr E's admission to hospital largely because there was no one to look after him at home. When admitted, it was confirmed that Mr E was suffering from urinary retention with incontinence due to overflow of urine from the bladder.
Mrs E complained to Dr R about the difficulties she experienced trying to contact him and the time it took him to visit Mr E on 3 July; his failure to examine Mr E and his reluctance to arrange for Mr E to be admitted to hospital. Mrs E was granted an independent review (IR) which took place in March 2000. It made a number of recommendations in relation to Dr R's contact arrangements and record keeping. The South Essex Health Authority later contacted Dr R on several occasions enquiring about the action he planned to take in response to the panel's findings, but Dr R did not respond.
Findings Both aspects of the complaint were upheld. The Ombudsman's independent clinical assessors criticised Dr R's contact arrangements and the delay in his visiting Mr E. They also concluded that it was unlikely that Dr R had conducted an adequate examination. The assessors said that there were inadequacies in Dr R's referral letter to the hospital and in his clinical records, which did not adequately record his visit on 3 July or previous visits to Mr E. On the basis of their advice, the Ombudsman concluded that the care Dr R provided on 3 July 1999 fell far short of the standard Mr E was entitled to expect.
In relation to Dr R's response to the IR panel's recommendations, Dr R failed to provide an adequate explanation during the course of the investigation as to why he did not respond to the former Health Authority's requests for information, despite being sent five letters over a period of eleven months. This meant that although Mrs E's complaint had been investigated and aspects of Dr R's practice found to be wanting, she was not informed of the ultimate outcome.
Remedy Dr R said that since the panel reported he had made a number of changes to his contact arrangements, including making more use of the deputising service and buying a new mobile telephone. He also said that he has improved his record keeping. The assessors made a number of recommendations relating to Dr R's practice which Dr R agreed to implement with support from the Health Authority.
Full text of this investigation
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