5. Mr Y complains about the Practice. He says he attended on 18 January 2019, complaining of pain in his right foot, caused by gout. He says he was prescribed allopurinol and told to start taking it immediately, however he understood it should not be started until an acute attack of gout has passed.
6. Mr Y says that he was in significant pain for a sustained period of time, and his recovery from the attack was delayed.
7. Mr Y is seeking a financial remedy.
8. On 18 January 2019, Mr Y attended an appointment at the Practice and saw a nurse practitioner. They noted Mr Y’s gout had flared up approximately two weeks ago, and that he had previously been prescribed allopurinol, which is a medicine used to lower levels of uric acid in the blood, but had not taken it for more than 18 months. On examination, Mr Y’s right ankle and big toe were inflamed. The plan was to restart allopurinol and cover with naproxen, which is a type of non-steroidal anti-inflammatory drug (NSAID) to reduce inflammation.
9. Mr Y saw his GP about the gout pain in his right ankle on 30 January 2019. The GP prescribed indomethacin. This is another type of NSAID used to reduce pain and inflammation, and they advised Mr Y to stop taking the allopurinol.
10. During an appointment on 13 February 2019, Mr Y’s GP noted there was still some remnant swelling over the dorsum of the right foot (the area facing upwards while standing), but his ‘pain is much better, movement is much better’. The plan was to continue with the indomethacin.
11. Mr Y attended another appointment with his GP on 29 March 2019. The GP noted Mr Y still had some problems in his right ankle. The plan was to try colchicine (medication used to treat gout) and ‘when he's been okay for a while, he can restart allopurinol’.
12. On 29 April 2019, Mr Y saw his GP who noted the colchicine was 'very good’ and Mr Y had no symptoms for two weeks. The plan was to restart allopurinol in two weeks.
13. Mr Y attended an appointment with his GP on 26 July 2019 due to a flare up of gout in his right middle finger distal interphalangeal (DIP) joint, which is the first knuckle from the top of the finger.
14. Mr Y’s notes show his GP continued to prescribe Mr Y with allopurinol throughout 2019-2021 to prevent a recurrence of gout. During an appointment on 6 February 2020, the GP noted ‘urate not ideal but no flare ups of gout’. Urate is salt derived from uric acid. When the body cannot process uric acid properly, urates can build up in body tissues or crystallise within the joints.
18. Mr Y had a history of gout. Patient.info says gout causes attacks of painful inflammation in one or more joints. It is a type of arthritis, and the pain of a gout attack can be severe.
19. Gout is caused by a chemical in the blood, called uric acid (urate). In people with gout, the amount of uric acid in the blood builds up. From time to time the level may become too high and tiny grit-like crystals of uric acid may form. The crystals typically collect in a joint. These crystals irritate the tissues in the joint to cause inflammation, swelling and pain. This is a ‘gout attack’.
20. Mr Y saw the nurse practitioner on 18 January 2019, after experiencing a gout attack. He reported he had previously been prescribed allopurinol, but had not taken it for over 18 months. On examination, Mr Y’s right ankle and great toe were red and inflamed, which our GP adviser says is typical for gout. The nurse practitioner advised Mr Y to restart allopurinol, and prescribed naproxen.
21. Mr Y says he mentioned to the nurse practitioner his understanding was allopurinol would cause the gout to worsen while he was having an attack. He says the nurse practitioner told him to start allopurinol straightaway.
22. The Practice acknowledged the nurse practitioner should not have prescribed allopurinol for Mr Y to start during an acute gout attack. The nurse practitioner says Mr Y had elevated uric acid levels and had previously been prescribed allopurinol but had been non-compliant with long term treatment. They said some recent clinical studies had supported starting or re-starting allopurinol during gout attacks.
23. Our adviser explains that the treatment of gout is two-fold. The acute attack is first treated, and if the uric acid remains high after the attack, allopurinol is given to reduce the uric acid level over the long-term. This reduces the likelihood of having an acute attack. NICE guidance on management of gout (February 2018) says pharmacological management to treat an acute attack is:
‘Prescribe either of the following first-line agents, provided that there are no contraindications: · A nonsteroidal anti-inflammatory drug (NSAIDs) at a maximum dose as early as possible and continue the treatment until 1-2 days after the attack has resolved · Co-prescribe a proton pump inhibitor (PPI) for gastric protection. For more information, see the CKS topic on NSAIDs - prescribing issues · Aspirin is not indicated in gout · Oral colchicine.
The choice of first-line agent depends on patient preference, renal function and co-morbidities’.
24. NICE prescribing information on allopurinol (February 2018) advises the prescriber to:
‘Start allopurinol after the acute attack has resolved. In circumstances where attacks are so frequent that this is not possible, the initiation of allopurinol can be considered before inflammation has completely settled’.
25. The nurse practitioner prescribed Mr Y with naproxen (an NSAID) and allopurinol together. This was a prescribing error and is not in line with the NICE advice above. This fell so far below what is expected by the relevant guidance that it was service failure.
Impact
26. As a result of the prescribing error, Mr Y says that he was in significant pain for a sustained period of time, and his recovery from the attack was delayed. He says the pain lasted for seven months.
27. Mr Y visited his GP on 30 January 2019 as his ankle and toe pain, and inflammation were no better. The GP recognised allopurinol should not have been started while Mr Y’s acute attack was ongoing. We understand this would have been concerning for Mr Y to hear. The GP stopped it and changed his NSAID to indomethacin. The GP also prescribed omeprazole (a PPI) to protect his stomach against the indomethacin.
28. Mr Y saw his GP again on 13 February 2019, when he reported his pain, swelling and movement of his joints was much better. The GP appropriately advised Mr Y to continue taking his NSAID and arranged blood tests to monitor his uric acid levels. Mr Y had blood tests on 8 March 2019, which showed his uric acid levels were slightly elevated at 460. The normal range is 200-430.
29. Mr Y attended an appointment with his GP on 29 March 2019. He said he still had some problems with his right ankle. The GP prescribed colchicine instead of a NSAID. During this consultation, the GP discussed Mr Y’s diagnosis of pre-diabetes and provided lifestyle advice. Our clinical adviser says Mr Y’s pre-diabetes is indicative he had risk factors that would perpetuate a high uric acid level.
30. On 29 April 2019, Mr Y reported the colchicine was ‘very good’, and he had no symptoms of pain or inflammation. The GP noted Mr Y could restart allopurinol in another two weeks but ‘warned about possible flare up’.
31. When Mr Y saw his GP on 26 July 2019, he reported that he had a flare up of gout in his right middle finger. The GP noted they discussed with Mr Y starting allopurinol when ‘things have settled for a few weeks’.
32. Mr Y says he had ‘extreme pain’ for seven months in his ankle and right hand because he took the allopurinol while his gout attack was ongoing. He says this caused social and physical limitations. Our clinical adviser said Mr Y’s gout attack was aggravated by starting the allopurinol at the onset of this attack, and this caused him to experience two to three weeks of added pain.
33. From the records, we can see Mr Y’s condition had improved when he saw his GP on 13 February 2019, when the lingering effects of the allopurinol had improved, and he responded to the NSAID’s. We therefore cannot link any additional pain Mr Y experienced after this, to the failing. We therefore partly uphold Mr Y’s complaint.
1. We have found that a medical practice in the Norfolk area (the Practice) incorrectly prescribed Mr Y with allopurinol to take during a gout attack, contrary to the relevant guidelines.
2. We have found this caused Mr Y to experience two to three weeks of added pain. We appreciate this would have been a difficult time for Mr Y and we are sorry to hear about how much pain he was in.
3. We partly uphold this complaint as we have not found that the failing caused additional pain for a longer period, as Mr Y says.
4. We recommend the Practice pay Mr Y a financial remedy of £500.
34. 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.
35. In its responses to Mr Y’s complaint, the Practice acknowledged the nurse practitioner should not have prescribed Mr Y with allopurinol during an attack of gout. It has apologised to him for the extra pain, distress, and loss of sleep he suffered.
36. After receiving Mr Y’s complaint, the Practice quickly acknowledged something had gone wrong and apologised to him. The Practice say it discussed this complaint at a significant event meeting in March 2019 and reinforced the British National Formulary (BNF) guidance about initiation of allopurinol to all clinical staff. This is in line with the Ombudsman’s principles for remedy on getting it right, being customer focussed, being open and accountable and seeking continuous improvement. We do not consider the Practice needs to make further systemic improvements.
37. Our principles state that public organisations should put things right and, if possible, return the person affected to the position they would have been in if the poor service had not occurred. If that is not possible, they should compensate them appropriately. Mr Y is seeking a financial remedy for the pain he experienced.
38. To decide on a level of financial remedy, we review similar cases where the person has experienced similar injustice, along with our severity of injustice scale. Following this review, we recommend the Practice pays Mr Y £500 in recognition of the severe pain he experienced as result of the prescribing error.
39. The Practice should comply with our recommendations within one month of the date of this report.