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Home > Publications > Selected Cases > Selected Investigations Completed December 2002March 2003 > Case no. E.318/01-02
Complaint against a GP in the Islington Primary Care Trust area
Summary of Case
Mrs F complained that Dr C failed to act promptly when her son, 26 year old Mr P, presented with symptoms of endocarditis (an infection of the lining of the heart chambers, heart valves and great vessels). Mr P was a new patient at the GP practice when he first complained to Dr C in August 1999 of a bad back; Dr C gave him a thorough examination and prescribed medication for a muscle spasm. Mr P returned, as requested, two weeks later, complaining this time of a cough and tiredness. Dr C treated him for a chest infection and arranged for blood tests and an X-ray. Dr C saw Mr P for a third time in October. Mr P’s chest infection was resolving and he felt better; his X-ray was clear. His blood results were abnormal, however, and Dr C arranged for these to be repeated. This was done in November, two days after Mr P had returned to see Dr C for a fourth time, suffering from night sweats, weight loss and tiredness. In Dr C’s absence, another GP at the practice, Dr R, noted that the results were still abnormal; she wrote to Mr P asking him to make another appointment with Dr C. Just prior to taking two months leave, Dr C saw Mr P’s blood test results and telephoned him; Mr P confirmed that his condition was unchanged. (Dr C subsequently told the Ombudsman that his working diagnosis was lymphoma; he therefore asked Mr P to come in and see his locum who, he expected, would make an urgent referral.) A week after speaking to Dr C on the telephone, Mr P came into the practice again, asking to be referred to a consultant. Dr R carried out a thorough physical examination of him and noted several significant signs. She also requested further blood tests and arranged an urgent referral via a registrar in haematology (after first trying to speak to a consultant). Unhappy that the appointment that she was given was too far into the future, Dr R also discussed the situation with her practice colleagues. After receiving Mr P’s blood test results, which were persistent and worsening, Dr R telephoned Mr P and asked that he see the practice nurse for repeat blood tests the next day. Mr P attended for those tests. Two days later, he suffered a stroke and was admitted to hospital. He was subsequently diagnosed as having endocarditis. Mr P died after undergoing surgery for a cerebral embolism and for aortic valve replacement.
Findings
Two clinical assessors – both GPs – were appointed to advise the Ombudsman. They concluded that Dr C’s actions up until the end of November were both timely and appropriate; they criticised him, however, for leaving it to a colleague to make the urgent referral which he had identified as necessary, and for failing to make a definite arrangement for Mr P to be seen by that colleague. The Ombudsman’s assessors concluded that Dr R’s examination of Mr P had been exemplary and her decision to refer him appropriate. However, they criticised her for failing to act on her concerns about the timing of the referral appointment (by either admitting Mr P as an emergency, or by discussing his case directly with a consultant, for example) and for failing to change her course of action when she received further deteriorating blood results. The assessors did not criticise either Dr C or Dr R for failing to diagnose endocarditis, an extremely rare condition; nor were the assessors able to say whether the outcome would have been any different if Mr P had been seen by a consultant as early as November. The Ombudsman upheld Mrs F’s complaint.
Remedy
Both Dr C and Dr R apologised for the shortcomings identified.
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