A Fife woman lost her foot after she was incorrectly diagnosed with chilblains.
By the time the patient was finally referred to vascular experts, who found she was suffering from blood clots, amputation was the only option.
The woman’s GP practice has now been told to apologise to her after she complained to the Scottish Ombudsman about her treatment.
The patient, referred to in the watchdog’s report as Mrs C, went to her doctor because she was concerned that her right big toe was cold, blue and painful.
She was given painkillers but the pain continued.
Blood tests revealed she had a low iron count and she was prescribed with iron tablets, but the problems in her toe persisted.
Mrs C also reported she had a pain higher up her leg, which was diagnosed as a groin strain.
She continued to speak to medics about her health issues and a referral was made to the vascular service.
There, it was found she had blood clots in her leg and groin which resulted in her needing to have her foot amputated.
The ombudsman found the initial diagnosis of chilblains – a painful itch or swelling which is caused by poor circulation when exposed to cold — was not unreasonable, given the symptoms she was reporting.
But it said that when the symptoms persisted the practice should have considered an alternative diagnosis of critical ischaemia — peripheral artery disease which can threaten the limbs.
The probe found the diagnosis of tendonitis – groin strain – was unreasonable as Mrs C had not suffered an injury.
It also said “safety netting” advice should have been given when she was prescribed painkillers.
The ombudsman told the practice to apologise to the patient for the delay in staff considering an alternative diagnosis and for failing to carry out an appropriate examination and assessment of her groin problems.
The practice was also given recommendations to ensure things were put right.
These included ensuring staff are aware of considering alternative diagnoses when symptoms which have been put down to one ailment persist.
The practice has also been told to ensure staff carry out appropriate assessments.