Clinical treatment outside hospital; GP : A GP Practice in the area of Aneurin Bevan University Health Board Report Date 20/01/2025 Case Against A GP Practice in the area of Aneurin Bevan University Health Board Subject Clinical treatment outside hospital; GP Case Reference Number 202400402 Outcome Upheld in whole or in part Mrs T complained that although her GP Practice (“the Practice”) accepted it did not make a referral to a Breast Clinic following her appointment on 9 September 2021, it had not considered the impact its error had caused on her treatment and prognosis when in May 2023 she was diagnosed with terminal Stage 4 breast cancer. We also considered what actions the Practice had taken in response to Mrs T’s complaint and whether these were sufficient to mitigate the chances of a similar incident happening in the future.
The investigation found that a GP at the Practice failed to refer Mrs T twice to the Breast Clinic and these were significant service failures. The impact of these failures were that Mrs T’s diagnosis and treatment were delayed and it was more likely than not that an earlier diagnosis would have resulted in a better prognosis and a higher chance of a cure.
The investigation also found that whilst the Practice had taken strong, robust action in response to Mrs T’s complaint, there were some further actions it could take to mitigate the chances of such an instance happening again.
Mrs T’s complaint was upheld.
The Ombudsman recommended that the Practice within 1 month: • Apologise to Mrs T.
• Make a financial redress payment of £2,500 to reflect the significant services failures.
• Ensure the case is discussed with the GP in question at their next appraisal.
• Share guidance on safety netting with all its clinical staff.
The Practice agreed to the Ombudsman’s recommendations.