GP practice failed to urgently refer patient

What happened

In early 2012 Ms J, Mr D's daughter, became concerned because her father's speech suddenly deteriorated, he choked when he tried to swallow, and later he had problems walking and with his balance. She took him to the Practice, and one of the GPs referred Mr D to a neurologist, but Mr D could not go to the appointment. This was because his daughter had taken him to A&E with a suspected stroke, and he was an inpatient at an acute stroke unit. Doctors at the stroke unit later discharged him with a diagnosis of small vessel disease, a condition that affects the small arteries in the heart.

Mr D's symptoms deteriorated and in mid–2012 his speech and language therapist asked the lead GP at the Practice to refer him to both a neurologist and an ear nose and throat (ENT) specialist, but the GP only referred him to ENT. During an appointment in June 2012 the lead GP advised Mr D that he had a stroke. In the autumn 2012, the speech and language therapist wrote to the GP again with concerns about Mr D. The lead GP then referred Mr D to a neurologist, although the GP did not treat it as urgent. The referral letter made reference to Mr D having had a stroke.

By the time Mr D saw the neurologist and was diagnosed with MND, he could not feed himself or be fed through a tube, and the symptoms were too advanced for him to have any palliative treatment. He died at the end of 2012.

Miss J believed that the long delay in diagnosis caused her father unnecessary pain and suffering and meant that it was too late for him to receive food at the end of his life.

What we found

The GPs at the Practice missed many opportunities to refer Mr D urgently to a neurologist, and some of their consultations with him were not in line with the General Medical Council's guidance, Good Medical Practice. We considered that Mr D's clinical records did not fully reflect his deterioration, and that the lead GP's working diagnosis of 'stroke' was unhelpful and misleading. We found it unacceptable that the lead GP had not referred Mr D urgently because she did not know how to do this on the system she used.

Putting it right

The Practice accepted our findings and recommendations. It apologised for the failings we identified, drew up an action plan to address the failings, and paid Mr D's daughter £4,000 in recognition of the impact the failings had on the family.