GP failed to take appropriate action when patient developed wound infection

What happened

Miss A received antibiotics from her GP practice and staff took a swab, which came back clear. There were delays in her follow-up appointment at the hospital because of administrative problems. When she went to the Practice more than two and a half months after her surgery, her wound had still not healed properly. She had by then received an appointment for an outpatient review at the hospital, for a date more than five weeks later.

The GP 'discussed concerns' with Miss A and noted the date of the follow-up appointment. When Miss A attended the hospital, an infection was diagnosed in the wound site and she had to undergo further reconstructive surgery.

Miss A also complained about the treatment she received for an ear infection.

What we found

The GP failed to keep an adequate record of the consultation in question. There was no evidence that he examined the wound and he did not make any note of its condition.

He failed to appreciate the severity of the situation, and he should have contacted the hospital consultant to arrange a review within the next few days. The failure to take action and the poor standard of record keeping were unacceptable.

The treatment Miss A received from the Practice for her ear infection was appropriate.

Putting it right

Following our report, the Practice wrote to Miss A apologising for the shortcomings we identified.

The Practice has conducted a significant event analysis to identify what learning it should take from this case. It will make sure that the GPs at the Practice review their communication and record keeping and that the GP discusses this complaint at his appraisal.