Case study - Anatomy of a complaint

Key fact: The new state-backed indemnity scheme will cover claims, but it is not expected to provide protection against a wide range of issues, such as (but not limited to) GMC hearings, complaints or inquests when it is launched in 2019.

Mr P, a management consultant, attended his GP surgery with flu-like symptoms and saw Dr A who diagnosed a chest infection and prescribed antibiotics. Mr P returned a week later with similar symptoms and Dr A referred him for a chest x-ray and prescribed further antibiotics. The x-ray was carried out the next day, after which another GP at the surgery, Dr B, advised Mr P that the x-ray was clear and that he could continue to take his medication.

The following week Mr P was reassessed by Dr C, a locum GP, who made a note of a detailed examination in Mr P’s records. He documented that Mr P was suffering from muscular back pain, and recommended pain relief and a return visit to Dr A in two weeks’ time.

Two weeks later, Mr P re-attended the surgery. Dr A noted some chest discomfort and made a referral to physiotherapy for the back pain, which took place five days later. The day after that, Mr P felt unwell and collapsed due to a loss of sensation in his legs.

He was admitted to hospital where an MRI scan was performed. This revealed infective discitis at T5/T6 and Mr P underwent an emergency laminectomy. Following the surgery, Mr P was left with T4 ASIA A paraplegia. He underwent rehabilitation at a spinal injury centre.

Mr P made a complaint to the GP surgery about all three doctors. Medical Protection has experienced complaints advisers who are there to assist members through to the conclusion of a complaint. The team has a wide array of resources to assist members in understanding the complaints process, such as drafting a response to the complainant and how to approach meetings with complainants.

Mr P also made a complaint to the GMC and to NHS England. Medical Protection instructed solicitors to represent the doctors, who drafted a letter on each of the doctors’ behalf to the GMC. This letter helped to convince the GMC that there was no case to answer, and the complaint was closed with no further action.

The complaint to NHS England was considered by the local Performance Advisory Group (PAG), but following Medical Protection assistance with a response that included the doctors’ reflections on the incident – the investigation was closed with no further action.

The practice was advised to undertake a significant event analysis in order to establish what happened, why it happened, what could have prevented the adverse incident and what steps should be taken to prevent a future recurrence. 

Dr A in particular was left feeling anxious and stressed as a result of the experience; because of this, Medical Protection referred him to our confidential counselling service as a benefit of membership.

On closing the case, Medical Protection reminded Drs A, B and C of the importance of taking detailed notes in case they had to justify their actions again. They took heed of this advice, and booked a place on one of our risk management workshops to develop their skills further.

They were also directed to the wide range of resources on offer to members, to help avoid future problems arising: our range of e-learning, publications, online articles and case studies are an essential educational benefit, compiled and delivered by highly-trained medicolegal experts.