Clinical treatment outside hospital; GP : A GP Practice in the area of Cwm Taf Morgannwg University Health Board Report Date 06/10/2021 Case Against Cwm Taf Morgannwg University Health Board Subject Clinical treatment outside hospital; GP Case Reference Number 202003164 Outcome Not Upheld Mr B complained about the care and treatment provided to his late brother, Mr F, by a GP Practice (“the Practice”) in the area of Cwm Taf Morgannwg University Health Board. Mr B complained that between 6 February 2017 and 2 January 2020, the Practice failed to carry out appropriate and timely investigations that might have enabled an earlier diagnosis of lung cancer, and failed to carry out appropriate and timely investigations that might have enabled an earlier diagnosis of emphysema (a condition that damages the lungs’ air sacs).
The investigation found that, although the Practice had failed to refer Mr F for a chest X-ray in line with NICE guidance, even if a chest X-ray had been undertaken, it would not have identified Mr F’s lung cancer at that time. Therefore, Mr F was not caused an injustice by the failure to refer for a chest X-ray. The first complaint was not upheld.
With regard to the second complaint, the investigation identified that the Practice had failed to arrange a spirometry test (a measure of how much air can be breathed out in one forced breath) or a chest X-ray. However, a spirometry test would not have discovered Mr F’s emphysema, which would only have been determined by a CT scan or lung biopsy. Even if Mr F had been diagnosed with emphysema more promptly, this would not have made a significant difference to the management of his symptoms or his clinical outlook, and therefore the failures identified did not cause an injustice to Mr F. The second complaint was not upheld.
The Ombudsman suggested that the Practice should ensure that Significant Event Analysis meetings should consider all relevant consultations and relevant guidance in future. He also suggested that the Practice share a copy of his report with the Second GP.