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Mr R complained about the treatment of his late wife (Mrs R) by a GP she saw as part of the Out of Hours GP service (under the governance of the Health Board). After telephoning the service Mrs R was directed to see the GP at the designated Out of Hours centre (based at a major hospital). She suffered from lymphoedema to her left arm following cancer treatment and complained about feeling unwell with a developing blister rash on her left arm. The GP diagnosed shingles, giving her a prescription of a common antiviral drug. The following morning Mrs R collapsed at home and was admitted to A&E at the same hospital; she died later that day from complete organ failure as a result of sepsis. Mr R complained that the GP had failed to examine his wife properly, or to diagnose her correctly. He also complained about how the Health Board had handled his complaint.

The investigation found that there was no record of the GP performing a number of basic assessments including temperature, pulse, and blood pressure. The Ombudsman’s clinical advisers also found that the GP had failed to have proper regard to Mrs R’s pre existing lymphoedema. Whilst Mrs R’s presentation might have suggested shingles, the GP ought to have also ruled out the blisters as a symptom of sepsis given it was well known that lymphoedema had a propensity to develop infection, which could lead to sepsis. An evident failure to consider this was unreasonable. Had it been considered, Mrs R could have been given antibiotics, or admitted to hospital that day – the GP ought to have adopted a risk-averse approach. This might have affected the outcome given that prompt intervention in suspected sepsis is critical to survival prospects.

The Ombudsman also found maladministration in the Health Board’s complaint handling: ranging from delays, fundamental errors in letters and no acknowledgement or response to a relevant third party. In recognition of the seriousness of the issues, the following recommendations were made, all of which the Health Board accepted:

• Written apologies to Mr R and to a relevant third party;

• Redress of £4,000 to Mr R for the failures identified in the care of Mrs R and £500 for the complaint handling failures;

• The Lead Clinical Director should undertake a sample review of the GP’s Out of Hours clinical consultation records (minimum 6 sessions) and that all GPs delivering Out of Hours services should be reminded of the importance of performing full assessments/examinations of patients and of recording those; and that

• The Health Board should ensure it had robust measures in place to secure timely and good quality responses to complaints.

Lymphoedema: Fluid retention and tissue swelling due to a compromised lymphatic system. Such tissue is at risk of infection.

Sepsis: Sepsis is a life threatening condition caused by severe infection spreading from a point of origin throughout the body leading to organ failure if untreated quickly with antibiotics and fluids.]

A copy of the full report is available below.