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Case ref:201406015
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Date:April 2015
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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:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Ms C, who suffers from back problems, attended the practice as she had pins and needles in her foot. Hospital anaesthetists had previously advised her to contact her GP if she had any symptoms affecting her legs, bladder, bowel or back. She said that when she went to an appointment, the GP did not appear interested, prescribed inappropriate medication and failed to examine her legs.
Ms C complained to the practice, who said that the GP had suggested the medication as it could assist with nerve-related symptoms and that he was aware that Ms C already had an urgent neurology referral. The GP also advised Ms C to seek further medical assistance should her symptoms worsen. Ms C brought her complaint to us.
After taking independent medical advice from our GP adviser we upheld the complaint that the GP failed to adequately examine Ms C despite her reported symptoms and known medical history. We found that the GP should have carried out a more thorough examination which should have involved testing reflexes and muscle strength in the feet and legs; checking for loss of anal tone by performing a digital rectal examination; checking for numbness in the perineum (region between the thighs); and checking the location of the pain to see if it ran along the sciatic nerve.
Recommendations
We recommended that the practice:
- provide a written apology for the failings identified; and
- discuss the complaint at the GP's next annual appraisal.