Doctor failed to make adequate record of examination

What happened

Mrs D saw the first doctor at her GP surgery and complained of pain to her back, groin and hip. She was unable to walk unaided and told the GP that she thought the pain was coming from her hip replacement. The GP examined Mrs D, recorded her medical history and diagnosed sciatica. She prescribed painkillers for Mrs D.

The second GP visited Mrs D at home three days later because her pain had worsened and she was bedridden. This doctor examined her and referred her for an X–ray. She decided that Mrs D would be able to travel by car to where the X–ray would be taken, and she prescribed painkillers. The second GP then left.

Mrs D's husband called an ambulance as Mrs D was unable to walk. She was taken to A&E. She was later diagnosed with a fracture in a bone surrounding her hip replacement.

What we found

We partly upheld this complaint. The entry in Mrs D's clinical records of her first appointment was not a precise enough record of what was examined or what was found. However, there was insufficient evidence in either the GP or ambulance records to suggest that Mrs D had a fracture then, or at her later appointment. We could not conclude that Mrs D suffered an injustice as a result.

The second doctor should have called an ambulance to take Mrs D to hospital.

Putting it right

The Practice had already acknowledged that it had learnt that when patients feel there is a problem that is not being adequately addressed, they are usually right.

The Practice had also apologised for failing to telephone for an ambulance to take Mrs D to hospital.