Clinical treatment outside hospital; GP : A GP Practice in the area of Aneurin Bevan University Health Board Report Date 28/09/2023 Case Against A GP Practice in the area of Aneurin Bevan University Health Board Subject Clinical treatment outside hospital; GP Case Reference Number 202203921 Outcome Upheld in whole or in part Mrs D complained about the care and treatment provided to her husband, Mr D, by Aneurin Bevan University Health Board (“the Health Board”) and his GP Practice. Mrs D’s complaint that the GP Practice missed opportunities to carry out assessments, investigations and/or referrals that would have led to the earlier identification of Mr D’s cancer was partially upheld. The investigation found that the clinical treatment provided to Mr D by the Practice prior to 21 December was appropriate. However, it found that there was a failure to send a stool sample for analysis which meant that GPs assessing Mr D’s symptoms were deprived of potentially significant clinical information. The investigation found that there was a failure to make an urgent suspected cancer referral on 21 December which placed Mr D at avoidable risk of harm.
The Ombudsman also upheld Mrs D’s complaints that the Health Board failed to investigate and treat Mr D’s cancer in a timely and appropriate manner and failed to keep Mr D appropriately informed about and involved with decisions about his care. The investigation found that there was an unreasonable delay by the Health Board in the investigation of Mr D’s symptoms following a GP referral on 11 August 2021. Although it was not possible to say whether his cancer would have been diagnosed earlier, this missed opportunity was an injustice to Mr D. The investigation also found that there was a failure by the Health Board to provide appropriate communication and support for Mr D following his cancer diagnosis, causing him avoidable distress.
The Practice agreed to the Ombudsman’s recommendations to apologise and make a financial redress payment to Mrs D of £250, and to share the report and learning points with relevant clinicians. The Health Board agreed to the Ombudsman’s recommendations to apologise and make a financial redress payment to Mrs D of £750, to share the report and learning points with relevant clinicians, and to review its process for listing patients for endoscopies.