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Case ref:201708571
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Date:February 2019
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Body:A Medical Practice in the Lothian NHS Board area
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C complained about the care and treatment that was provided to her late father (Mr A) by the practice on two occasions. Mr A was initially suffering with urinary problems and later, with symptoms of heart failure. Mrs C was concerned that there had been a failure to identify urinary retention as the cause of his symptoms and that, when he was seen by a GP registrar (trainee GP), a few months later, they attributed a seizure-like episode to medication changes, when he was actually suffering from aspiration pneumonia (a complication of pulmonary aspiration. Pulmonary aspiration is when you inhale food, stomach acid, or saliva into your lungs).
We took independent advice from a GP. We found that there had been no unreasonable failure to diagnose urinary retention and that Mr A's symptoms were more consistent with urinary infection when he was seen by the practice. Therefore, we did not uphold this aspect of Mrs C's complaint.
We found that, when Mr A was seen by the GP registrar, the relevant guidance for diagnosis of heart failure had not been followed. We found that it was not possible to rule out the medication changes as a cause of the seizure-like episode and there was no indication in the medical records that Mr A was suffering from aspiration pneumonia at the time he was seen by the GP registrar. We upheld this aspect of Mrs C's complaint as the issue around diagnosis of heart failure had not been identified as a training issue for the GP registrar.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Mrs C for the failings in the management of Mr A's suspected heart failure. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
What we said should change to put things right in future:
- Suspected heart failure should be managed in line with national guidance. Where this is not considered appropriate, a clear rationale for alternative action should be recorded.
- Issues with care and treatment provided by GP registrars should be taken forwards as part of the training process. Clear information should be available on a daily basis so GP registrars know who to approach for help and supervision.