A Fife man lost his leg after a wound was allowed to become infected by maggots.
Now both the GP’s practice and NHS Fife have been told to apologise to the unnamed patient for failings in his care.
The man, known as Mr A, suffered from inadequate blood supply which meant he had had his right leg amputated below the knee.
He was then admitted to hospital with the same issue in his left foot and an ulcer and the plan was to delay amputation as long as possible.
When he was discharged he was being seen twice a week by district nurses.
Some months later, the medical practice was contacted by a district nurse who had noticed some deterioration in his foot.
A GP didn’t consider a visit was necessary and instead prescribed antibiotics.
Four days later Mr A’s wife contacted the practice as her husband had received no subsequent visit from a district nurse.
A second GP visited him but did not examine the wound, only prescribing more antibiotics.
It was two days later that a district nurse called the practice as she had found a maggot infestation in his wound.
A GP visited and Mr A was taken to hospital where his leg was amputated above the knee.
Mrs C complained to the Scottish Ombudsman about the actions of the two GPs, the practice’s communication with the board, the missed visit by the district nurse and NHS Fife’s communication.
Both the practice and NHS Fife had acknowledged failings had occurred and apologised.
The Ombudsman upheld Mrs C’s complaint about NHS Fife, saying it had failed to ensure twice weekly visits from a district nurse as required under his care plan.
He also found the board’s communication was below a reasonable standard.
In addition he made recommendations to address a number of issues, after determining that while NHS Fife generally complied with wound management guidance, formal assessments weren’t conducted regularly.
He also upheld the complaint against the medical practice.
While the first GP acted appropriately in prescribing antibiotics, the second GP should have examined the wound given Mr A had already been given medication but his symptoms were worsening.
He also found the surgery’s communication with the board was below a reasonable standard.
NHS Fife deputy chief executive Rona King said: “I would like to take the opportunity to reiterate our apology to those concerned.
“On this occasion we fell short of our normal high standards of care.
“We have since reviewed our systems and implemented all recommendations.”
