16. When we consider a complaint, we look at whether there are signs the events complained about made mistakes. If we can see indications of mistakes, we go on to consider whether they had a negative effect on the individual which the organisation has not put right.
Scan report
17. Mrs E complains the Practice failed to act on her scan report from April 2023 which showed she had a 10cm dermoid cyst on her ovary. A dermoid cyst is a benign, sac-like growth. Mrs E explained that after she reviewed her own medical records on her NHS app, she realised the Practice had not acted on the result of her scan report, nor informed her of the findings. Mrs E said this caused her a lot of stress, anxiety and sleepless nights. Mrs E requires surgery to remove the cyst.
18. The Practice explained to Mrs E that two clinicians reviewed the scan but missed the finding of the cyst. The Practice apologised to Mrs E for the mistake and confirmed a Serious Event Report would be carried out.
19. The conclusion of the Report was the mistake was made because of human error. The Practice documented the error had been discussed at a doctors’ meeting with all clinicians where they discussed how this could have been avoided and how to learn from the event. The Practice considered whether double checking future reports could be a possibility and whether it might review the document and feedback to hospital department to make the form clearer.
20. As a learning point, the Practice documented it had procedures in place so that the requesting doctor, who is more aware of the context of a result (or the duty doctor if they are away), reviews the report. It also documented patients have access to all documents, so this can act as a double checking process.
21. We can see from the evidence available to us that an error clearly occurred here. The Practice has recognised it did not consider the scans and take action on that evidence as it should have done, which is not in line with the GMC’s ‘Good Medical Practice’ section 7. This says ‘If you assess, diagnose, or treat patients, you must work in partnership with them to assess their needs and priorities. The investigation or treatment you propose, provide or arrange must be based on this assessment, and on your clinical judgement about the likely effectiveness of the treatment options’.
22. There is no dispute between Mrs E and the Practice about what happened and the mistakes that occurred, and so we have gone on to consider whether the Practice has done enough to put right the impact caused to Mrs E.
23. We understand from the information provided that due to the size of the cyst, Mrs E requires surgery to have it removed. We understand from our Adviser and the evidence available that this was always going to be the case, whether the Practice diagnosed Mrs E’s cyst in April when the scan results came in, or later. We have not seen anything to suggest that earlier action by the Practice would have allowed Mrs E to avoid having to have surgery.
24. We have considered the emotional impact the error has had on Mrs E. Mrs E says she has been left feeling stressed and anxious because of the results. We understand it must have been worrying for Mrs E seeing the results in her records in July and knowing this had been reported in April and should have been looked into sooner. We have thought about the steps the Practice has taken in response to her complaint.
25. As we have set out above, the Practice has recognised its mistakes and apologised to Mrs E for its error. It has also shown that it has taken on board learning from her complaint and has considered how to improve services so that in future, where scan reports are sent to the Practice, the requesting doctor will review these as they are aware of the patient’s symptoms and history. We understand from our discussions with our Adviser that these steps are appropriate and in line with clinicians’ obligations as set out in the Royal College of Radiologists’ guidance referenced above.
26. This shows us that the Practice has taken Mrs E’s complaint seriously and taken steps to put right the frustration caused by its mistake. This is in line with our ‘Principles for Remedy’, which say organisations should return people to the position they were in before the mistake occurred or compensate them appropriately. We are satisfied this recognition of errors, apology and improvements to services is an appropriate remedy and enough to put right the frustration and worry caused.
27. Having carefully considered all the evidence available to us, and in light of the details above, we have decided to take no further action as although the Practice made some errors it has already put things right. We know Mrs E continues to worry about the care provided and her ongoing condition, so we help the explanations provided are helpful and give her some reassurance.
Complaint Handling
28. Mrs E complains the Practice did not take her complaint seriously as it did not provide a formal response to her complaint.
29. We can see from the correspondence Mrs E provided that she made an official complaint to the Practice in August 2023. We understand that Mrs E’s complaint was not treated as an official complaint and was sent directly to the complaints manager without an acknowledgement email being sent.
30. Following this, the complaints manager emailed Mrs E apologising for the clinical error and offering Mrs E an appointment with her usual GP. The complaints manager advised that the Practice was going to discuss her complaint at the upcoming Significant Events of Learning meeting.
31. The complaints manager responded to Mrs E’s complaint on 28 September via email. They apologised for the GP missing the information on the scan and filing it under ‘no further action’. The complaints manager apologised for any distress and avoidable frustration the events had caused.
32. We discussed this with the Practice and explained that the Local Authority and NHS Complaint Regulations indicate NHS organisations should conduct an investigation and provide a formal written response. We asked the Practice to tell us a little more as to what happened after Mrs E made her formal complaint and why the Practice did not provide a formal written response.
33. The Practice explained that it was unsure the complaint was ‘closed’ but believed there was not much more it could do, above what it had already provided. It confirmed it had taken the complaint seriously and it believed it had tried to help Mrs E at every available opportunity in the written responses to Mrs E, which were via email. The Practice apologised for any oversight in sending a formal response, further to the more informal correspondence it had already sent.
34. The NHS Complaint Regulations section 14 say ‘the responsible body must send the complainant in writing a response, signed by the responsible person […]’.
35. We can see that Mrs E was frustrated and upset with the Practice and felt that not receiving a formal response indicated the Practice was not taking her complaint seriously.
36. In our discussions with the Practice, it asked us to send on its apologies to Mrs E for its error, and we consider this to be an appropriate remedy for Mrs E’s frustration, in line with our Principles for Remedy.
37. With the above in mind, and based on the evidence we have seen, we consider the Practice has taken steps to put right the impact its errors caused. As such, we will take no further action.
38. We recognise this was a stressful and concerning time for Mrs E, so we hope that we have clearly explained how we thought about what she told us and how we reached our decision in this case. We also hope that she is reassured that as a result of her complaint the Practice has taken action to learn and that she has therefore contributed to improvements in its service.