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Case ref:201204914
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Date:July 2013
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Body:A Medical Practice in the Ayrshire and Arran NHS Board area
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Sector:Health
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Outcome:Not upheld, no recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C went to the practice because he had lower back and left leg pain, together with numbness. After his second visit, he was referred for physiotherapy, and then to hospital for a consultant opinion and an MRI scan (a scan used to diagnose health conditions that affect organs, tissue and bone). The hospital, however, returned the referral to the practice on the basis that there were no 'red flag' symptoms (symptoms indicating a possible serious condition).
Three days after being referred, Mr C went to a hospital accident and emergency department with increasing pain and numbness. He was ultimately given a scan that confirmed a central prolapsed disc (where the centre of a disc in the spine pushes out into the spinal column) which required emergency surgery. Mr C questioned the treatment he had been given by the practice, as he believed they should have done more. He claimed that as a consequence, his outcome was poorer than it would have been.
To investigate this complaint we considered all the available documentation and relevant clinical records. We also obtained independent advice from one of our medical advisers. We did not, however, uphold Mr C's complaint. Our adviser said that, overall, Mr C's care and treatment had been entirely appropriate and reasonable. The adviser also said that the practice had correctly identified red flag symptoms and made an appropriate, immediate referral, which the hospital had declined to accept.