GP delayed recalling patient for follow-up investigation

What happened

In spring 2012 Mrs C became short of breath and had a swollen ankle. She saw a registrar GP (a qualified doctor who is training to be a GP) at the practice. The GP arranged a blood test to check for heart failure.

In autumn 2013 Mrs C received a letter from the practice about the blood test it had carried out in the spring of the previous year. The practice said the result suggested that she had heart failure and should have further tests. It subsequently referred Mrs C to hospital, where staff found out that a valve in her heart was leaking.

Mrs C complained about the delay in finding this out and the possible failed opportunity to do something sooner for her.

The practice said that when it reviewed her records it had identified that no further tests had been done and so it arranged them.

What we found

The practice did not do enough when it received the blood test result in spring 2012. It must have been upsetting to find out about this and it made Mrs C worry about what could have happened. However, we found nothing to suggest that this failing had any adverse consequences for Mrs C.

Although the practice identified its mistake, this took a long time. The practice did not explain what it had done to prevent a recurrence, or apologise.

Putting it right

The practice acknowledged the delay in taking appropriate actions following the positive test result and apologised.

It provided an action plan explaining how it monitors the work of registrar GPs and saying what it has done or plans to do to make sure that it has learnt lessons from the failings.