Mrs W complained that she had gone to her GP and A&E at the Trust regularly but they did not properly investigate her symptoms. She was later diagnosed with cancer.
What happened
Mrs W went to her GP Practice and saw four different doctors over a two–year period. During this time, the Practice missed seven opportunities to arrange for her symptoms to be fully assessed and did not act on abnormal blood results. When it finally referred Mrs W to hospital, the Practice did not give enough information on the referral and so the Trust did not treat it as urgent.
Mrs W went to A&E five times in a five–month period. On the first two occasions, staff assessed her properly, but they should have done more at the next three visits to find out what was wrong and what was causing Mrs W's ongoing pain.
What we found
The Practice should have taken a better history, followed up test results and carried out further blood tests. The GPs should have reviewed Mrs W's previous visits each time they saw her and should have made a detailed referral to a specialist.
The Trust should have taken more action on Mrs W's third visit to A&E. When Mrs W went to A&E for the fourth time, the doctor should have noted and acted on symptoms that could have indicated a more serious problem. After Mrs W's fifth visit, staff should have arranged urgent scans.
The delay in diagnosis caused Mrs W pain and anxiety. Although it has not shortened her life, some of her symptoms are irreversible and she may have permanent pain.
Putting it right
The Practice produced an action plan to identify what had gone wrong and what needed to happen to stop this happening again. The Practice paid Mrs W £5,000 to compensate her for the poor outcome caused by the delays in getting appropriate treatment, and £140 to refund the cost of a private consultation she paid for when the Practice did not arrange appropriate investigations. The Practice also apologised to Mrs W.
The Trust apologised to Mrs W. It also produced an action plan to identify what had gone wrong and what needed to happen to prevent a recurrence. The Trust paid Mrs W £1,000 to compensate her for the pain and mental distress she suffered, as well as the failings in care.
A GP practice
East Kent Hospitals University NHS Foundation Trust
Kent
Came to an unsound decision
Did not apologise properly or do enough to put things right
Did not take sufficient steps to improve service
Apology
Compensation for financial loss
Compensation for non-financial loss
Recommendation to learn lessons or draw up an action plan