Report Date

02/10/2023

Case Against

A GP Practice in the area of Betsi Cadwaladr University Health Board

Subject

Clinical treatment outside hospital; GP

Case Reference Number

202204444

Outcome

Upheld in whole or in part

Mrs X complained that the GP Practice did not recognise the severity of her mother Mrs Y’s presenting symptoms when she telephoned to request a GP appointment. She was offered a routine phone appointment two weeks later. No further enquiries or referrals were made by the GP Practice. Mrs X was hospitalised the following day and underwent emergency surgery for aortic dissection.

The Ombudsman found that there was an inadequate GP triage of Mrs Y’s symptoms when she contacted the GP Practice. Whilst her symptoms were not typical of aortic dissection, she presented with symptoms which were potentially serious in nature and required further exploration by a clinician that day, either over the phone or face to face. Because of the atypical nature of her symptoms, further enquiries about the nature of Mrs Y’s symptoms may not have resulted in her being dia

Mrs X complained that the GP Practice did not recognise the severity of her mother Mrs Y’s presenting symptoms when she telephoned to request a GP appointment. She was offered a routine phone appointment two weeks later. No further enquiries or referrals were made by the GP Practice. Mrs X was hospitalised the following day and underwent emergency surgery for aortic dissection.

The Ombudsman found that there was an inadequate GP triage of Mrs Y’s symptoms when she contacted the GP Practice. Whilst her symptoms were not typical of aortic dissection, she presented with symptoms which were potentially serious in nature and required further exploration by a clinician that day, either over the phone or face to face. Because of the atypical nature of her symptoms, further enquiries about the nature of Mrs Y’s symptoms may not have resulted in her being diagnosed and admitted to hospital more quickly than actually occurred. However, an opportunity to properly consider her symptoms, and potentially have her condition identified at an earlier stage, was missed. The GP Practice also failed to give advice to Mrs Y as to what action she should take if her symptoms worsened.

The GP Practice had introduced additional training following the complaint. As a result of the Ombudsman’s investigation the GP Practice agreed, within one month, to:

• Provide a formal written apology to Mrs Y;
• Consider how “worsening” advice could be offered to patients after GP triage when a routine appointment was offered.

The GP who undertook the triage would also discuss this case at his next appraisal.

agnosed and admitted to hospital more quickly than actually occurred. However, an opportunity to properly consider her symptoms, and potentially have her condition identified at an earlier stage, was missed. The GP Practice also failed to give advice to Mrs Y as to what action she should take if her symptoms worsened.

The GP Practice had introduced additional training following the complaint. As a result of the Ombudsman’s investigation the GP Practice agreed, within one month, to:

• Provide a formal written apology to Mrs Y;
• Consider how “worsening” advice could be offered to patients after GP triage when a routine appointment was offered.

The GP who undertook the triage would also discuss this case at his next appraisal.