16/04/2021
Clinical treatment outside hospital
Upheld in whole or in part
202001850
Non-public interest report issued: complaint upheld
A GP Practice in the area of Aneurin Bevan University Health Board
Mrs B complained about the care and treatment provided to her husband, Mr B, by a GP Practice in the area of the Aneurin Bevan University Health Board (the Practice). She complained that when her husband, Mr B, attended the Practice with symptoms and a family history of diabetes, the GP did not undertake any appropriate tests that day to check for diabetes. After the appointment, as Mr B was very unwell, Mrs B rang NHS Direct Wales and, on the advice provided, took Mr B to the Emergency Department, where he was admitted ,treated, and diagnosed with diabetes. Mrs B also complained about the Practice’s handling of her complaint.
The Ombudsman found that the GP should have undertaken tests during the appointment, and that these would have revealed the severity of Mr B’s condition and shown the necessity of getting immediate treatment. He therefore upheld this element of the complaint. The Ombudsman found that the Practice had already made appropriate changes to its internal guidance and planned for future training to prevent a similar issue in the future. He found that although these responses to the incident were thorough and appropriate, they had not been fully communicated to Mr & Mrs B in the Practice’s complaint response, the content of which was unsatisfactory. He therefore also upheld this element of the complaint.
The Practice agreed to apologise within 1 month to Mr and Mrs B for the failings identified and to provide them with a copy of the new Diabetes protocol and £250 payment for the injustice caused. It also agreed to share the Ombudsman’s report with relevant staff to facilitate learning.