GP did not make sufficiently detailed notes about consultations or make appropriate referrals

Summary 240 |

When Mrs A asked her GP to refer her daughter, B, for paediatric and mental health care, the GP did not make suitable referrals, or keep detailed notes. The GP's actions contributed to the delays Mrs A experienced in accessing suitable help for B.


What happened

Mrs A's daughter B was 15 and had several health problems and disabilities. She became unwilling to go to school after an assault by another pupil. Mrs A asked B's GP to refer B back to the paediatric service, but not to paediatrician Dr K. The GP did not note that B did not want to see Dr K again, and as a result referred B to Dr K. This was not acceptable to Mrs A, or B, and various delays occurred, some of which were caused by the Practice. B eventually saw an appropriate paediatrician, by which time she had not been to school for several months.

What we found

The GP did not make sufficiently detailed notes about some of the consultations with Mrs A. This led to unnecessary delays in B seeing a paediatrician, and a lack of appropriate information in some of the referrals he made for her.

The GP failed to make an appropriate referral to the children and adolescent mental health services for B.

Putting it right

The Practice apologised to Mrs A and put a plan in place to learn lessons from its failings and make sure they did not happen again.

Health or Parliamentary
Health
Organisations we investigated

A GP practice

Location

Dorset

Complainants' concerns ?

Replied with inaccurate or incomplete information

Result

Apology

Recommendation to learn lessons or draw up an action plan