Decision Report 201703718

Summary

Mrs C complained about the care and treatment given to her late father (Mr A) by the practice. Specifically that, during the three years prior to a diagnosis of a very rare form of cancer, there were failures to take action on his symptoms, not all tests that were due were carried out, and there were delays in making required referrals. Mrs C believed that this led to a delay in Mr A's diagnosis and affected his outcome.

We took independent advice from a GP. We found that Mr A had a history of dizziness and cardiology problems and he had a pacemaker. It was only after he had persistently raised white blood cells that a referral was made for him to attend hospital but, while the referral was agreed it was not sent for a number of months. Blood tests confirmed his white blood cell count and he was referred to haematology (medicine of the blodo) for further testing where his count was shown to be reduced. Nevertheless, we found that it would have been reasonable for the practice to have arranged repeat tests a few weeks later to ensure that his results had returned to a normal range, and this did not happen. An earlier diagnosis could perhaps have been made, but we could not conclude that an earlier diagnosis would have changed Mr A's outcome. Because of the the delay in making the referral and the failure to repeat tests, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for not arranging further follow-up tests and for the delay in the referral.

What we said should change to put things right in future:

• In circumstances like this, follow-up blood tests should be arranged. GPs within the practice should ensure they are familiar with the condition Mr A had.
• Referrals should be sent in a timely manner.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.