A medical practice in the Hertfordshire area

4. Mrs D complains about the treatment she received at a medical practice in Hertfordshire (the Practice) between January 2017 and April 2017. She says that during her GP appointments throughout this period, her GP failed to correctly diagnose the pain in her left arm and shoulder. Specifically, she complains that:

· the GP failed to medically assess her pain and diagnose her correctly with severe tendonitis · During an appointment, which appears to have taken place on the 4 January 2017, the GP had a dismissive attitude towards Mrs D’s symptoms, would not see her without a discharge note from A&E, and discouraged her from presenting at A&E · During the initial complaint process, the Practice wrongly referred to her shoulder pain as being neurological in nature when in fact she has severe tendonitis.

5. As a result of her misdiagnosis, Mrs D says she has experienced ‘mental distress and physical pain’. She states the unnecessary stress has caused her to experience depression, and it has also affected her ongoing treatment regarding referrals to the appropriate specialists.

6. Mrs D would like a formal apology from her GP in acknowledgement they misdiagnosed her pain, and that she experienced unnecessary pain as a result. She would also like an apology for the GP’s refusal to assess her without a discharge letter. Mrs D is also asking for an acknowledgement from the independent medical adviser (who handled her complaint) that her pain was not neurological and that she has tendonitis.

7. Mrs D says she went to see her GP at the Practice in January 2017 with pain in her shoulder and an inability to lift her left arm above her shoulder. She says her GP did not do anything on this date to medically assess her pain. In April 2019, she received a diagnosis of severe tendonitis at hospital A. She states her symptoms had continued until this time. Mrs D says that during an appointment with her GP, which we believe to have taken place on 4 January 2017 while she was registered with the Practice, her GP had a dismissive attitude towards her symptoms, would not see her without a discharge note from A&E, and discouraged her from presenting at A & E.

8. NHS England arranged an investigation of her complaint by an independent medical adviser in May 2020. This investigation stated the problem Mrs D brought to her GP in January 2017 had been neurological in nature and her diagnosis of tendonitis was unrelated to this. Mrs D disputes the findings of this investigation and states that she could have been diagnosed with tendonitis earlier had her GP properly assessed her.

GP failed to medically assess Mrs D’s pain and diagnose her correctly with severe tendonitis

12. Before we decide if we should carry out a detailed investigation into a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and, we have not found any indications that something has gone wrong.

13. Mrs D complained to us that her GP failed to medically assess her pain and diagnose her correctly with severe tendonitis. She said an earlier diagnosis was possible and would have avoided the pain and distress she suffered from early 2017 until her diagnosis in April 2019.

14. During our assessment of Mrs D’s complaint, we looked at the symptoms of frozen shoulder and tendonitis, as listed on the NHS website, and reviewed her medical records. We discussed the case with a clinical adviser who analysed whether there was a missed opportunity to diagnose Mrs D with tendonitis during the period of January to April 2017.

15. The NHS website lists the symptoms of tendonitis as joint pain, stiffness, and that it can affect how a tendon moves. The NHS describes frozen shoulder as being when a shoulder is painful and stiff for months, sometimes years. Our assessment found Mrs D referenced feelings of weakness in her left arm but did not refer to pain or stiffness in her shoulder during any of the GP appointments she attended between January and April 2017.

16. As the symptoms of frozen shoulder and tendonitis are pain in the shoulder and reduced mobility/ability to move the shoulder, there is no indication from her GP records she had frozen shoulder at the time she saw her GP. Furthermore, she saw three different practitioners (in A&E on 27 January 2017, her GP on the same date, and a Neurologist on 27 March 2017) none of whom identified the symptoms of frozen shoulder.

17. We also noted the discharge letter from the Minor Injuries Unit at hospital B, dated 27 January 2017, details a nerve injury to her right arm and not her left shoulder. We have reviewed this information in accordance with the General Medical Council’s Good Medical Practice, November 2020 which states that doctors:

· ‘must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must: a) 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 b) promptly provide or arrange suitable advice, investigations or treatment where necessary c) refer a patient to another practitioner when this serves the patient’s needs’

18. As we have explained above, the records indicate Mrs D did not present to her GP with any symptoms of frozen shoulder, or tendonitis in her left shoulder, during the period that she was registered with the Practice. There is no indication her GP needed to take any action to arrange suitable advice, investigations, or treatment in relation to possible frozen shoulder/tendonitis in her left shoulder.

19. This indicates the Practice acted in line with the GMC guidance when it suspected nerve pain and referred her accordingly. For these reasons, we have seen no indications of failings for this aspect of the complaint.

The GP had a dismissive attitude towards Mrs D’s symptoms, would not see her without a discharge note from A&E and discouraged her from presenting at A&E

20. Mrs D told us her GP had a dismissive attitude towards her, and was not interested in listening to her symptoms, during an appointment that seems to have taken place on 4 January 2017. She stated her GP told her they were not able to discuss her medical issues as she did not have the discharge report from the hospital and that consequently, they refused to see her.

21. Initially, Mrs D told us she believed this appointment had taken place in March 2017. We contacted the Practice and it advised us that she had not attended an appointment on this date. After review of her appointment notes and a further discussion with Mrs D, we concluded it was likely this appointment had taken place on 4 January 2017.

22. Close assessment of Mrs D’s notes has revealed that there is nothing documented to indicate her GP refused to see her during any appointments, or telephone consultations, from January to April 2017. At each of the appointments, where a GP saw Mrs D, they have documented her history and put in a comment of action they took, for example on 4 January to chase the A&E report.

23. In the evidence received from our adviser, we have considered their view that it is normal practice for a GP to wait for the correspondence to come through after a patient has attended at a hospital, and the hospital would make a recommendation in writing to the GP. This is because patients may not give an accurate report of further care required, and that it would be usual procedure to wait to see what the letter entailed before arranging any further investigations or referrals.

24. GMC Good Medical Practice guidance is relevant here. It states doctors: ‘must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must: a) 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 b) promptly provide or arrange suitable advice, investigations or treatment where necessary c) refer a patient to another practitioner when this serves the patient’s needs’

25. As there is nothing in Mrs D’s notes to suggest the doctor refused to see her, discouraged her from attending A&E, or dismissed her symptoms, the evidence indicates the Practice acted in line with the GMC guidance. It appears to have taken Mrs D’s symptoms into account (history). The Practice seems to have been available to see her or have a discussion over the telephone (as there is evidence of such appointments in the records). It also then seems to have followed up or referred to another practitioner (chase A&E report on 4 January and make a neurology referral on 16 January).

26. This evidence indicates the Practice acted in line with the relevant GMC guidance. The evidence therefore does not indicate any failings in the GP’s actions.

Complaint process

27. Mrs D says the independent medical adviser who responded to her during the initial complaint process did not give her direct answers to her complaint and drew upon assumptions that her left shoulder pain was neurological. She states she has now had a full scan and has a confirmed diagnosis of severe tendonitis.

28. The Ombudsman’s Principles of Good Complaint Handling say organisations should be open and accountable. This means ‘they should give clear, evidence-based explanations, and reasons for their decisions. When things have gone wrong, public bodies should explain fully and say what they will do to put matters right as quickly as possible.’

29. In the complaint process, the independent adviser stated the symptoms presented to Mrs D’s GP did not include any reference to pain of any kind in her arm or shoulder. The independent adviser who responded to Mrs D on behalf of NHS England referred to the NHS website, which states that frozen shoulder symptoms include pain and stiffness in the shoulder.

30. The response went on to state that as Mrs D’s account of her symptoms does not mention pain, she was not diagnosed with frozen shoulder as she did not present with the correct symptoms. This explanation is evidence-based and clear. The clinical opinion presented is the same as that we have seen, which strongly suggests Mrs D did not have symptoms of frozen shoulder or tendonitis during the period of January – April 2017.

31. Regarding the assessment of her symptoms as being neurological in nature, the neurologist did not make a specific diagnosis of Mrs D’s symptoms when she says they saw her on 7 January 2017. They did state she had multiple neurological issues and a feeling of weakness in her left arm.

32. Having considered all the evidence there is no indication the Independent Adviser was at fault for saying Mrs D’s symptoms were neurological in nature. Therefore, the response appears to be accurate, evidence based and clear. It seems to have been in line with our principles of good complaint handling. Based on this there is no indication of a failing in the complaint handling.

1. We have carefully considered Mrs D’s complaint about a medical practice in the Hertfordshire area (the Practice). We have seen no indication that anything went seriously wrong. We have reviewed all the relevant evidence, and this indicates the Practice provided a service to Mrs D in line with relevant standards.

2. We are sorry to hear about Mrs D’s concerns about the care she received. We recognise she has suffered difficult symptoms and that this has been a distressing experience for her.

3. It seems we cannot link the events Mrs D complains of to her diagnosis with severe tendonitis. We also consider the evidence indicates the Practice did not dismiss Mrs D’s symptoms, refuse to see her, or discourage her from attending A&E. We consider the Practice handled Mrs D’s complaint in line with our standards.