Summary
Mr C visited the practice about his cough. He was referred for an x-ray, which took place the following day. Mr C contacted the practice three times for the results and was told that they had not arrived. Mr C's symptoms worsened and he was admitted to hospital with pneumonia and heart failure. Mr C complained that the practice did not have adequate procedures in place to identify that his x-ray report was missing.
Normally, a paper copy of the x-ray report would be sent to the practice and uploaded to the practice's information management system. In this case, for reasons we were unable to establish, the report was not uploaded. This suggests the report may not have been received. The GP at the practice was able to access the report through the hospital's computer system when they realised that the report had not been received. However, the GP was only prompted to do this after receiving notification of Mr C's hospitalisation.
The practice apologised to Mr C and explained that there was a gap in their protocols for occasions when information was not received in the normal way. They explained that they had updated their protocols for dealing with patient phone calls regarding x-ray results. The new protocol meant that, if a patient contacted the practice three weeks or more after an x-ray for which no report had been received, reception staff would advise the GP who requested the x-ray. The GP would then check for the report on the hospital's computer system. The practice were also piloting a new process to keep copies of x-ray requests with the aim of ensuring the practice followed up on any results not received after four weeks.
We took independent advice from a GP adviser. We found that the practice did not have adequate procedures in place to identify that Mr C's x-ray report was missing and so we upheld his complaint. We recognised that the practice had apologised and made changes to their protocols to prevent a recurrence, and we felt that there were no further actions required.
Related reading
View Decision Report 201502640 as a PDF (11.55 KB) Updated: March 13, 2018