A healthcare provider in the Knowsley area

4. Mrs R complains about care and treatment provided by the Practice in June 2018. She says the diagnosis provided by the GP at an appointment on 27 June 2018 was incorrect. She complains the GP diagnosed her with menopausal symptoms, however she was admitted to hospital later that day with an infection. She also complains about the complaint handling by the Practice.

5. She says because of this there was a delay in the diagnosis of a deep-seated pelvic infection, and this caused her distress. She says because of this her physical and mental wellbeing have been impacted adversely. She needed to take time off work following admittance to hospital. She also says the complaint handling has caused her distress, and she does not feel this has yet been resolved by the Practice.

6. By bringing this complaint to us she is seeking an apology, service changes and a financial remedy.

7. Mrs R has now changed her GP Practice. She says she had never felt that ill before and knew something was not right when she was diagnosed with menopause by the GP at the Practice, instead of an infection being detected. She also told us during a visit to the Practice, prior to 25 June 2018, a different GP mentioned her CRP level was higher than usual. CRP is C-reactive protein which can be measured in your blood and is a protein made by your liver.

8. Mrs R felt unwell on 22 June 2018, with pains throughout her body, back ache, hot sweats, feeling cold and unwell. She attended the Practice on 25 June 2018 for an appointment with her GP. The GP checked her temperature and informed her it was raised. Her GP asked her to have a blood test. Mrs R had a blood test on 26 June 2018. A receptionist at the Practice telephoned Mrs R and asked her to attend the Practice on 27 June 2018.

9. Mrs R attended her appointment at the Practice on 27 June 2018. She says the GP asked her how they could help her.

10. Mrs R explained to the GP she had returned to the Practice at its request following the blood test she had the day before. Her records indicate the GP did not record her blood pressure or take a urine sample at the time. The records show the GP recorded her abdomen as ‘soft non tender’, her ‘chest clear’ and ‘apyrexial’ (without fever).

11. The GP diagnosed Mrs R with menopausal symptoms. They explained to Mrs R the symptoms she presented with were due to this.

12. Mrs R then attended A&E later that evening. She told us this was because of pressure from her family. She had blood tests and an X-ray. She was later admitted to hospital on 28 June 2018. The hospital carried out a magnetic resonance imaging (MRI) scan. An MRI is a type of scan that uses strong magnetic fields and radio waves to produce detailed images. She was later diagnosed by the Trust with a deep-seated pelvic infection. She was treated by Trust staff with intravenous and oral antibiotics. The hospital discharged her on 6 July 2018. We do not underestimate the stress and pain Mrs R must have been in during this time.

13. Mrs R made a verbal complaint to the Practice in July 2018. The practice manager told her she needed to make her complaint in writing. She then submitted a written complaint to the Practice in October 2018.

14. Mrs R received a response from the Practice in June 2019, following contact from Mrs R’s daughter. Mrs R was dissatisfied with the Practice’s response to her complaint and brought her complaint to us. She contacted the Practice again in September 2019. The Practice acknowledged her follow-up complaint later in September 2019 and told her she would receive an update on her complaint by 18 October 2019.

15. We wrote to the Practice twice in December 2019 and again in February 2020 asking it to respond to Mrs R about the outstanding issues she had raised. Mrs R has not received a response.

16. The Practice then wrote to us on 5 October 2020. It explained the Practice now had a new contract holder, director, and registered manager. It did not however, specify from what date this change occurred. The letter confirmed the GP who assessed Mrs R was no longer at the Practice.

Diagnosis

20. Mrs R complains the GP at the Practice, who assessed her, incorrectly diagnosed her as having menopause symptoms. She attended A&E later that day and was then admitted to hospital. The hospital later diagnosed her with an infection. We understand this must have been a very difficult and distressing time for Mrs R and cannot begin to imagine the pain she must have been in.

21. The medical records show the GP recorded Mrs R’s problem as, ‘Hot flushes – menopausal (first)’. The records also state: ‘c/o hot flushes, dyspepsia and nausea.ass poor appetite. Very emotionally labile today and teary. Bloods show raised CRP and perimenopausal hormone denies dysuria’. Dyspepsia is also known as indigestion. Perimenopause is the transition period before menopause.

22. The GP prescribed, ‘Elleste Duet 2mg tablets’ and gave Mrs R information relating to menopause and its management. Elleste Duet is a type of hormone replacement therapy (HRT) used to treat symptoms of menopause. Understandably, this caused Mrs R added frustration as she told us this was not what she believed was wrong.

23. The Practice responded to Mrs R’s complaint about the diagnosis. Its response letter states, ‘It appears that [name of GP] could have potentially identified the infection and prevented you needing to attend Accident and Emergency’. The Practice also stated it could not take Mrs R’s complaint further as it is unable to speak with the GP who carried out the assessment.

24. We cannot conclusively say what the GP said to Mrs R during her appointment as we only have Mrs R’s account. However, the evidence suggests the diagnosis of menopause was not an appropriate diagnosis. This is because it is not consistent with Mrs R’s symptoms as described in her complaint letter to the Practice. She complained of, body pains, back ache, hot sweats, feeling cold and really unwell. Our adviser outlined these are symptoms of an infection. They also explained that menopausal symptoms were not consistent with Mrs R’s blood test result.

25. Mrs R’s blood test also showed a CRP level of 199 mg/L. The Association of Clinical Biochemistry & Laboratory Medicine: C-Reactive Protein (CRP) (2018) guidance explains CRP is a protein made by the liver. It is released into the blood within a few hours after tissue injury, the start of an infection or other inflammation. It is often the first evidence of inflammation or an infection in the body.

26. A CRP level of 199 mg/L is a sign of an acute infection. A diagnosis of menopause does not cause a raised CRP level. This is supported by the clinical advice we received from our adviser.

27. The General Medical Council (GMC) guidance for ‘Good Medical Practice (2013) states: ‘You must adequately provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must:

· adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social, and cultural factors), their views and values; where necessary, examine the patient · promptly provide or arrange suitable advice, investigations, or treatment where necessary · refer a patient to another practitioner when this serves the patient’s needs

28. The assessment carried out by the GP on 27 June 2018 was not in line with the GMC standard detailed above. This is because Mrs R’s raised CRP level indicated an infection and needed further consideration and action. Our adviser explained it was unlikely Mrs R was suffering with ‘hot flushes’ as recorded in her notes. Our adviser explained she was more likely suffering with hot sweats, the inability to get warm, body pains and feeling generally unwell, as detailed in her complaint letter. The GP did not record these symptoms and did not ‘adequately assess the patient’s conditions’.

29. In its response letter to Mrs R the Practice also stated it, ‘has not been able to identify why [the GP] did not take your blood pressure, pulse or check your urine when you were in on this day nor why your Vitamin D or B12 weren’t tested along with your other bloods’. The Practice also stated, ‘I am sorry that you had to go through this ordeal when it appears that [the GP] could have potentially identified the infection and prevented you needing at attend Accident and Emergency’.

30. On balance, Mrs R’s symptoms, together with her increased CRP level, is more in-keeping with an infection and not menopause. We also know a practitioner at the hospital where Mrs R was later admitted, diagnosed her with a ‘deep-seated pelvic infection’. This diagnosis was made by the practitioner, based on various tests.

31. In view of Mrs R’s raised CRP level, the GP should have recorded her pulse rate and blood pressure. This is in line with: NICE Guidelines [NG51] Sepsis: recognition, diagnosis and early management (2016). This guidance states:

‘1.1.1 Think 'could this be sepsis?' if a person presents with signs or symptoms that indicate possible infection.

1.1.2 Take into account that people with sepsis may have non-specific, non-localised presentations, for example feeling very unwell, and may not have a high temperature.

1.1.3 Pay particular attention to concerns expressed by the person and their family or carers, for example changes from usual behaviour.

1.1.4 Assess people who might have sepsis with extra care if they cannot give a good history (for example, people with English as a second language or people with communication problems).

1.1.5 Assess people with any suspected infection to identify:

· possible source of infection · factors that increase risk of sepsis (see section 1.2) · any indications of clinical concern, such as new onset abnormalities of behaviour, circulation or respiration.

1.1.6 Identify factors that increase risk of sepsis (see section 1.2) or indications of clinical concern such as new onset abnormalities of behaviour, circulation or respiration when deciding during a remote assessment whether to offer a face-to-face-assessment and if so, on the urgency of face-to-face assessment.

1.1.7 Use a structured set of observations (see section 1.3) to assess people in a face-to-face setting to stratify risk (see section 1.4) if sepsis is suspected.’

32. It is our adviser’s view there were a range of actions the GP could have taken following their assessment of Mrs R on 27 June 2018, in view of her raised CRP level. This action would have been dependent on the GP’s findings had they assessed Mrs R according to NICE Guidelines [NG51] Sepsis: recognition, diagnosis and early management (2016). This would have ranged from admitting Mrs R to hospital, taking telephone advice from a hospital physician, or arranging further investigations to investigate the source of the infection.

33. In summary, the GP failed to take account of Mrs R’s significantly raised CRP level. They also did not assess her symptoms in line with the GMC guidance above. This must have been very distressing for Mrs R as she continued to feel unwell. We can also see she then needed to visit A&E and be admitted to hospital for further treatment. We have therefore, found a failing.

Complaint Handling

34. Mrs R complains the Practice did not handle her complaint properly. She says she made a verbal complaint to the Practice during a meeting with the practice manager, after she had been in hospital in July 2018. She says the practice manager told her to put her complaint in writing. She put her complaint in writing and submitted it to the Practice on 16 October 2018.

35. Mrs R did not receive a response from the Practice until June 2019. This was after her daughter had contacted the Practice. The Practice stated in this letter: ‘Whilst we have been unable to speak with [the GP] because he has left the practice we understand that his professional performance is being reviewed by the relevant regulators for GPs that is the General medical Council and NHS England’.

36. Mrs R was dissatisfied with the response and contacted the Practice again on 17 September 2019. Within her letter, Mrs R stated the Practice should provide a response whether the GP is still working for them (or not) and asked for a more considered response.

37. The Practice issued a letter dated 26 September 2019 to Mrs R. In the letter the Practice stated: ‘I understand that at the time of the new management responding to the complaint in June 2019 (as a consequence of the failure of the previous management to respond to your complaint), [the GP] was not in the country and the practice had no means of bringing the complaint to his attention. However, [the GP] is currently practicing as a GP in England and I will be making contact with him today, to make him aware of the complaint, to share your correspondence and the response of the practice and to ask for his comments.’

38. The Practice also explained in this letter to Mrs R, ‘you should expect an update to the complaint within 28 days of your letter dated 17 September 2019, received by the practice on 20 September 2019, by Friday 18 October 2019’. The Practice did not send Mrs R this follow-up response.

39. The Department of Health and Social Care: The NHS Constitution for England (2015) guidance states:

· ‘You have the right to have any complaint you make about NHS services acknowledged within three working days and have it properly investigated · You have the right to discuss the manner in which the complaint is to be handled and know the period within which the investigation is likely to be completed and the response sent · You have the right to be kept informed of progress and to know the outcome of any investigation into your complaint, including an explanation of the conclusions and confirmation that any action needed in consequence of the complaint has been taken or is proposed to be taken’.

40. The Local Authority Social Services and National Health Service Complaints (England) Regulations (2009) says a complaint may be made orally, in wring or electronically. It also says where a complaint is made orally, the responsible body to which the complaint is made must make a written record of the complaint and provide a copy of the written record to the complainant.

41. The Practice’s Complaint Handling Policy (February 2019) says, ‘all complaints, written and verbal will be recorded, and written complaints will be acknowledged in writing with in three working days of receipt’. The policy also says, ‘Complaints should normally be resolved within six months. The Practice standard will be 10 days for a response’.

42. The Practice’s Complaints Policy and Procedure (January 2020) says, ‘complaints should normally be resolved within six months. The Practice standard will be 10 working days to complete an investigation and to provide a response back to the patient’.

43. The Department of Health and Social Care: NHS Complaints Guidance (2015) says that complainants can complain directly to the organisation within 12 months and this can be done verbally. This guidance says that a record should be kept of verbal complaints and a copy provided to the complainant. It also says responses should set out findings and were appropriate provide an apology and information about what is being done because of the complaint. It says the response should also include information about how the complaint has been handled and details of how to approach the relevant Ombudsman.

44. Parliamentary Health Service Ombudsman: Our Principles (2009) says organisations should ‘deal with complaints promptly, avoiding unnecessary delay, and in line with published service standards where appropriate’.

45. The Practice has not provided any further information or demonstrated it has contacted the GP in question or the GMC. Furthermore, the Department of Health and Social Care: The NHS Constitution for England (2015) also says, ‘the NHS is accountable to the public, communities and patients that it serves’ and explains organisations are accountable to their patients.

46. On 5 October 2020, the Practice acknowledged in a response to us, that record keeping at the time of the incident was inadequate. It says because of this, and the change in management, it has had difficulty considering this complaint. However, in a telephone call with the Practice on 20 November 2020 we confirmed the Practice had taken over the contract from the previous provider and had not established a new contract with National Health Service England (NHSE). This means they are liable for the actions of the previous management and named GP.

47. Having considered the above guidance and the Practice’s own complaints policy, the Practice has failed to comply with this guidance and its own complaint handling processes.

48. The Practice did not deliver a prompt response to Mrs R. It did not action her verbal complaint which is not in line with Department of Health and Social Care: NHS Complaints Guidance (2015). Further to this, the Practice did not provide an acknowledgement to Mrs R’s initial letter of complaint which is also not in line with Department of Health and Social Care: NHS Complaints Guidance (2015).

49. The Practice has not provided a response within six months of receiving Mrs R’s complaint or provided details to her about why this could not happen, which is not in line with its own Complaints Handling Policy (February 2019). It has also not responded to her letter of dissatisfaction which is not in line with Department of Health and Social Care: NHS Complaints Guidance (2015). Therefore, we can see a failing.

Impact

50. Following her visit to the Practice, Mrs R attended A&E and was admitted to hospital later that same day. Staff at the hospital she attended later diagnosed her with an infection. The GP not referring Mrs R for further investigation would not have caused the impact Mrs R describes. Mrs R says the delay in her diagnosis caused her physical and mental wellbeing to have been impacted adversely. She says she needed to take time off work following admittance to hospital. Mrs R also told us she lost weight and was extremely weak as a result of this infection. She also says she remained off work until 28 August 2018.

51. Mrs R has also explained she believed she would have been cared for, believed, and acknowledged as being genuinely ill, had the assessment been carried out by a different GP. We cannot take a view on this. However, our adviser explained, if Mrs R would have been admitted to hospital directly by the GP at the Practice, her medical treatment would have been the same. She would have still had to have taken time off work and undergone the tests and treatment. This would have naturally affected her physical and mental wellbeing. We are truly sorry for her experience.

52. We do consider the actions of the GP have clearly caused Mrs R considerable uncertainty, distress, and inconvenience. We also consider there was a delay between visiting the GP and attending A&E. We are sorry Mrs R did not receive an assessment at the Practice that was in line with guidance, and for Mrs R having attended A&E at the request of her family, and not the GP.

53. We also consider the impact caused to Mrs R was compounded by the fact the Practice took eight months to respond to her complaint and has still not replied to her letter of dissatisfaction. We understand this caused Mrs R additional stress and frustration. She also told us it has affected her trust in GPs for which we are truly sorry.

54. As such, we partly uphold Mrs R’s complaint and make the recommendations set out below.

55. Mrs R says the delay by the Practice in handling her complaint, and the responses it provided, caused her distress. She says she experienced further distress as the Practice informed her she would receive a response to her letter of dissatisfaction, but she did not.

56. We can see the Practice’s delay and lack of final response to Mrs R could have caused the distress she describes. While the Practice has acknowledged and apologised for the original delay in responding to Mrs R’s complaint, it has not yet responded to her letter of dissatisfaction. This has left Mrs R without a resolution. The Practice has failed to remedy this aspect of her complaint. As such, we make the recommendations set out below.

1. Mrs R complains about the care and treatment provided by a healthcare provider in the Knowsley area (the Practice). Having carefully considered the evidence, we partly uphold the complaint. This is because we have identified failings in relation to the diagnosis provided by the GP at Mrs R’s appointment at the Practice in June 2018. We have also found failings in the way the Practice handled Mrs R’s complaint.

2. We are sorry Mrs R experienced this and appreciate the distress these events caused. We consider the actions of the GP have clearly caused Mrs R considerable uncertainty, distress, and inconvenience. This impact is different to the impact Mrs R describes. We therefore partly uphold this complaint.

3. We recommend the Practice pay £100 to Mrs R. This is to account for the inconvenience and distress, caused by Mrs R having to attend A&E, and the further impact of her complaint not being responded to promptly. We also recommend the Practice apologises for the way it dealt with Mrs R’s complaint and for its actions, which were not in line with relevant guidance.

57. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

58. Our principles say that public organisations should put things right and, if possible, return the person affected to the position they would have been in the poor service had not occurred. If that is not possible, they should compensate them appropriately.

59. To determine a level of financial remedy, we reviewed similar cases where a similar injustice has arisen, along with our Severity of Injustice Scale.

60. After considering all the evidence, similar cases, and our Severity of Injustice Scale, we recommend that the Practice pay £100 to Mrs R. This is to account for the inconvenience and distress caused by Mrs R having to attend A&E whilst being ill, and the further impact of her complaint not being responded to promptly.

61. In considering the complaint handling aspect of Mrs R’s complaint, we recommend the Practice apologises for the way it dealt with Mrs R’s complaint. It should apologise for not responding in line with the relevant timeframes set out in the guidance. It should also apologise for not taking responsibility when Mrs R raised a complaint and not acknowledging Mrs R’s letter of dissatisfaction.

62. Our principles say that public organisations should look for continuous improvement and should use the lessons learned from complaints to make sure they do not repeat maladministration or poor service. In line with this, we recommend the Practice makes service changes in relation to the way it handles complaints in the future. This is to ensure complaints are dealt with in a timely, reasonable, and proportionate manner in line with the Practice’s own policies and national guidance.

63. We recommend the Practice should produce an action plan within three months of the date of our final report to address the failing in dealing with Mrs R’s complaint. This should identify the reason for the failing, where possible.

64. The action plan should explain the learning the Practice has taken from the issue, what it will do differently in future, who is responsible, the timescales for each action and how it will monitor these to ensure they successfully resolve the problems. The Practice should provide a copy of the action plan to Mrs R, our office, the Care Quality Commission, and NHS improvement.