PUBLIC INTRODUCTION

Primary Care Case Study (2025–2026)

Introduction

Medication Switching, Missed Indicators & External Validation

This case study documents a series of administrative, clinical, and communication failures experienced by a patient within primary care between 2025 and 2026. It is published as part of CURB’s public‑facing forensic archive and is supported by contemporaneous evidence, GP correspondence, Health Board responses, and specialist findings.

The purpose of this introduction is twofold. For public readers, it provides an accessible overview of how fragmented communication, non‑clinical medication switching, and missed diagnostic indicators can place patients at risk. For investigators and professionals, it offers a structured, contradiction‑resistant entry point into the systemic issues identified across sixteen capsules.

Across this period, the patient experienced:

• an unsafe non‑clinical inhaler switch that destabilised long‑controlled asthma
• repeated minimisation of urinary symptoms despite positive indicators
• contradictory explanations for clinical decisions
• missing or uncommunicated test results
• loss of continuity across rotating clinicians
• repeated breaches of consent during student‑involved consultations
• reassurance offered in place of investigation
• delays that forced the patient to seek private diagnostic testing

These failures occurred while the patient was managing complex symptoms and caring for a child with significant needs. The cumulative effect was a collapse in continuity, a loss of clinical oversight, and a shift in responsibility from the healthcare system to the patient herself.

This case study consolidates the evidence, chronology, contradictions, and procedural gaps that underpin the events documented. It is designed to support transparency, public understanding, and systemic learning.

What This Case Shows

This case highlights:

• how non‑clinical medication switches can create avoidable clinical risk
• how missed indicators and contradictory explanations undermine safety
• how fragmented communication leads to delayed diagnosis
• how consent breaches destabilise clinical care
• how patients become responsible for coordinating their own safety
• how external clinicians become the only route to structured assessment
• how systemic gaps remain visible even after escalation

The case remains ongoing. Capsule 16 documents that new risks emerged even after a turning point was reached, demonstrating that systemic vulnerabilities persist beyond individual consultations.

How to Navigate This Case Study

This case study is presented in a capsule‑based structure to support clarity and accessibility. Each capsule examines a specific systemic failure, followed by a conclusion that draws together the overarching themes.

To continue:

Click 38a — Systemic Failures Overview

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