A MEDICAL practice in the NHS Ayrshire and Arran health board area has been found to have acted unreasonably after it failed to urgently refer a patient – who later died – to a with regard to a patient that a regulatory body said should have been referred to a specialist.

The Scottish Public Services Ombudsman (SPSO) has asked the medical practice to apologise to the family of the patient that died shortly after a complaint had been submitted.

The patient, referred to as A in an SPSO report, had a long history of degenerative disc disease affecting their spine, as well as a history of stomach cancer.

The report, which did not reveal the name or exact location of the medical practice, states: “[Patient] A visited or contacted the practice several times over three months regarding pain in the neck and shoulder, numbness in the right hand and jerking of the right leg.

“Tests were undertaken, medication and therapies prescribed and a referral to an orthopaedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system) was made. Following a fall at home, A was admitted to hospital where a spread of cancer to A’s spine was diagnosed.”

After the patient’s spouse complained to the practice a review was carried out, which found: “A’s orthopaedic referral could have been upgraded to urgent when it was clear A’s symptoms were not being controlled, but stated that it was doubtful this would have had any impact on the outcome.”

The patient’s spouse was unhappy with this response and reached out to the SPSO, who upheld the complaint.

The SPSO, after consulting a GP, found that “the practice took reasonable action in response to A’s symptoms and condition until a point.”

They added: “However, when it was clear that A’s symptoms were not being controlled and began to worsen, the practice’s actions were unreasonable.

“We found that the potential significance of test results reported to the practice and the potential link with A’s symptoms were not reasonably recognised by the practice until they reviewed A’s care and treatment as a result of our investigation of the case.”

It was agreed this wouldn’t necessarily have saved the patients life, adding: “While we noted that earlier action by the practice may have led to an earlier admission to hospital, it was extremely unlikely to have prevented A’s death.”

The practice has been told it must “review how it deals with blood samples that are significantly outwith the normal range.”

They must also: “Review their policy on home visiting patients who are too frail or too unwell to attend the practice to ensure there is a clear criteria for accepting or refusing a home visit and that safeguards are in place when a request is turned down.”