Ombudsman criticises doctors who failed to diagnose patient

TWO GPs have been criticised by the NI Public Services Ombudsman (Nipso) after they failed to properly diagnose a man who suffered five strokes in a week two years ago.

The surgery, based in the Western Trust area, has since sent a written apology to the complainant, the patient’s brother, after a Nipso investigation and a subsequent ‘internal analysis’ found several failings in their procedural process, which they say have now been amended.

The patient, who is not named in the report, first came to see a GP on March 7, 2022 at the surgery in question, complaining of numbness in his left arm.

He saw a locum GP who diagnosed him with having a trapped nerve, and prescribed him the anti-inflammatory medicine, Ibugel.

The next day, the man rang the surgery, telling the receptionist that his condition had worsened, and now he had a ‘trailing’ leg and the numbness in his arm had worsened.

The man never spoke to a GP; instead, a second doctor gave advice through the receptionist and prescribed the man diazepam. It is used to treat conditions, including anxiety, muscle spasms, and insomnia.

The man agreed to take the medication, but told the receptionist he was in a ‘very bad way’.

The receptionist advised him if his condition worsened overnight to contact either the surgery again or an emergency department.

Later that day, the patient called an ambulance, which took him to the South West Acute Hospital in Enniskillen.

EXAMINATIONS

After a number of tests and examinations on March 9, they indicated that the patient had suffered five strokes in seven days.

In the coming days, the complainant’s brother, contacted the GP practice, raising concerns over how his sibling was not diagnosed by either GP, and the complained about the treatment his family member received on March 7 and 8.

After an investigation by Nipso, Ombudsman Margaret Kelly found that the first GP had failed to record his consultation with the patient.

She also said that the GP had failed to carry out a blood pressure check, which would’ve helped to diagnose a stroke.

Ms Kelly said that the second GP should’ve spoken to the man to help inform them of a diagnosis.

The report states that the surgery had told Ipso that both GPs ‘considered stroke as a possible diagnosis’, adding that the second GP also ‘shared appropriate safety net advice’ with the patient about possibly attending the emergency department.

Since this event, the GP surgery carried out a ‘Significant Event Analysis’, which they said identified “several procedural failings”.

The Ombudsman recommended that the surgery share the findings of the report with staff and that they provides training to relevant staff on the importance of documentation, and provides training to staff on the importance of assessing patients in line with statutory guidance.