Delayed diagnosis of HIV resulted in pneumonia and increased risk of other illnesses

Organisation we investigated: A GP Practice in Merseyside

Date investigations closed: 14 October 2019

The complaint 

Complainant S complained that the GP Practice missed opportunities to test for human immunodeficiency virus (HIV), resulting in a two and-a-half-year delay in diagnosis. Complainant S said that the delay denied them the chance to treat their condition at an early stage, which has impacted on their general health.

What we found 

Complainant S was not known to have any problems with their immune system. They attended the GP Practice on two separate occasions, in quick succession, with shingles. The relevant guidelines say that GPs should refer or seek specialist advice if a person with no immune system problems has two episodes of shingles. This did not happen. 

Two and a half years later, Complainant S was diagnosed with stage 4 HIV after becoming unwell with pneumonia. HIV has an incubation period of 10 to 15 years to reach stage 4 after the virus has been contracted. We found that it was more likely than not that Complainant S had HIV when they were seen for shingles.   

The sooner a person is diagnosed with HIV, the better the outcome in terms of life expectancy and quality of life. Following diagnosis, Complainant S’s HIV is now at undetectable levels. However, it took a year to reach this level when it would normally take six months. Furthermore, Complainant S continues to have a CD4 count below 200. CD4 are the types of cell that HIV kills. Complainant S’s low CD4 count means they are at increased risk of some illnesses, such as pneumonia. 

We found the delay in diagnosing HIV means that Complainant S is at significantly higher risk of contracting pneumonia and has an increased risk of other illnesses in future. 


Complainant S attended the GP Practice on two separate occasions with shingles. The GP Practice did not refer Complainant S for any immune system checks. 

Two and a half years later, Complainant S went to the GP Practice feeling very unwell. The GP Practice told Complainant S to go to A&E. Complainant S was found to have pneumonia and hospital staff carried out immune system tests. Complainant S was then diagnosed with stage 4 HIV. 

Putting it right 

We recognised the GP Practice had undertaken HIV awareness training as a result of the complaint. However, it had not put things right for Complainant S. We recommended the GP Practice pay them £2,000 in recognition of the missed opportunity for an earlier diagnosis of HIV, the avoidable contraction of pneumonia and the ongoing distress and worry Complainant S has for their future health.  

The GP Practice complied with our recommendations.

This case summary is featured in the Ombudsman's Casework Report 2019.