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Selected Investigations Completed April - September 1998 > Part I, Case no. E.721/97-98
Matters considered: Panel acted maladministratively in the process by which it reached a finding which criticised a witness not subject of complaint; health authority failed to issue copy of panel's report
Complaint against: Avon Health Authority
Summary of case
On 11 November 1996 a man telephoned Dr U, who was the on-call doctor that day, about his wife's condition. Dr U listened to his description of symptoms and agreed that a GP would visit. Dr U conveyed her concern about the patient's condition to a colleague, Dr V, who went to see the patient. The next day the patient's condition deteriorated and she was admitted to hospital where she died three days later. On 25 November 1996 the patient's son asked Avon Health Authority to review the patient's clinical management. An independent review panel was convened to consider the care provided by Dr V. On 2 April 1997 a clinical assessor for the panel telephoned Dr U about the events of 11 November 1996. Dr U was unable to recall the details she had relayed to Dr V about the patient's condition. On 10 June 1997 Avon Health Authority wrote to Dr U's practice enclosing an extract of the panel's report. The panel concluded that Dr U had failed to pass on clinical information to Dr V and that this constituted a serious breakdown in communication.
Findings
The Ombudsman upheld both complaints. He found that the independent review panel had erred by not taking direct evidence from Dr U and for including in its report comments which could be construed as critical of her without providing her with an opportunity to give an account of her actions. The Ombudsman also found that in failing to send Dr U a copy of the report, the Health Authority had failed to comply with the statutory Directions to Health Authorities on handling complaints about family health services.
Remedy
The Health Authority apologised and agreed to communicate the Ombudsman's findings to those people to whom they were required to send the panel's report and to any other person Dr U and the Health Authority agreed should be told. They also agreed to send Dr U a full copy of the panel's report.
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