Scan results not passed to patient for many months because of inadequate appointment system

What happened

Ms C had a CT scan in summer 2013. Staff sent the results to the Practice the next month. Unfortunately the GP Practice did not tell Ms C they had arrived and there were conflicting accounts about what happened. The Practice alleges that an appointment was made to see her, but Ms C said she was on holiday at the time that the appointment was arranged, and so could not have agreed to it.

As a result of this, Ms C was not told that she had polycystic ovaries (a condition that affects the ovaries) until she went to an appointment in spring 2014. She queried why she had not had the results. She was then offered treatment or a referral to secondary care, but she decided that she had lost faith in the Practice and changed to another GP.

What we found

We partly upheld this complaint. The Practice's version of events was unable to be substantiated due to a lack of evidence. We saw that the systems in place did not provide adequate safety–netting, and that the diagnosis should have been communicated to Ms C.

However, we did not see that the delay in this case had resulted in an injustice to Ms C, as she was asymptomatic during the six months and the delay in beginning treatment had no effect on her health.

We also found that the GP who she saw in spring 2014 acted appropriately upon discovering the scan result.

Putting it right

The Practice apologised to Ms C for the impact that the failings had on her. It also prepared an action plan to show how it will improve its system regarding the receipt of test results. This will minimise the risk of this happening to future patients.