A healthcare provider in the Nottingham area

6. Mr D complains about the healthcare provider regarding poor care and treatment provided to him between 3 December and 19 December. Following a diagnosis of post viral vasculitis in his left leg on 3 December, his GP made an urgent referral to the local dermatology clinic on 5 December. Mr D is unhappy that:

• He was not seen by the dermatology clinic within an appropriate timescale for an urgent referral. Due to an administrative error, Mr D’s initial urgent appointment was offered with a two week timeframe (18 December), instead of one week.

• The consultant dermatologist should not have prescribed Betnovate cream or prednisolone 5mg tablets without having first examined him.

7. Mr D says the situation caused him stress, anxiety and impacted him financially.

8. Mr D seeks an apology, service improvements and a financial remedy.

9. On 28 November, Mr D attended his GP Practice with blisters on his left calf. His GP diagnosed post viral vasculitis (inflammation of the blood vessels) and blood tests were requested. At this stage no further treatment was given.

10. Mr D says his blisters ruptured into open wounds and he returned to his GP on 3 December. His GP was concerned and took photographs of his wounds, advising him that there was evidence of necrosis (death of body tissue). A referral was sent on 5 December (including photographs) to the dermatology clinic at the healthcare provider requesting an urgent appointment.

11. The referral was reviewed by a consultant and an email request was sent to clinic staff informing them to offer Mr D an appointment within one week. However, a two week appointment was sent by post to Mr D.

12. During this time, Mr D’s condition worsened, and he saw his GP again on 7 December. His GP contacted the dermatology department at the healthcare provider and spoke to an on-call consultant. The consultant advised Mr D’s GP to prescribe Betnovate cream and this was then prescribed.

13. On 10 December, Mr D’s leg had deteriorated further, and he had necrosis inside his wounds. His GP contacted the healthcare provider and asked if Mr D should be hospitalised. Mr D says by this time he was under a lot of stress and anxiety as he thought he was going to lose his leg. Mr D says his blood pressure was extremely high.

14. Mr D’s appointment was brought forward to 12 December and his GP was advised to prescribe prednisolone 5mg tablets by the healthcare provider, and this was then prescribed. Mr D then had further appointments with the healthcare provider on 19 December and 7 January. Mr D says it took around three months for his leg to fully heal.

Mr D’s appointment at the healthcare provider

18. Mr D says he was not seen by the dermatology clinic within a reasonable amount of time from when the urgent referral was made on 3 December up until he was seen at the dermatology clinic on 12 December.

19. Mr D first attended his GP Practice on 28 November with blisters on his left calf and his GP made a working diagnosis of vasculitis. Mr D next attended his GP Practice on 3 December. Mr D’s GP was concerned at the sight of his leg and sent photos of it to the dermatology clinic at the healthcare provider. It was noted in the clinical records that Mr D had a vasculitis like rash with some central necrosis on his lower legs and mild swelling on his left ankle. The GP records show that an urgent referral to the healthcare provider was made on 5 December for Mr D.

20. Mr D was contacted by his GP Practice on 7 December, and he said he felt his rash was worse. It was noted Mr D had an appointment at the healthcare provider on 18 December for a biopsy to be taken. Mr D attended his GP Practice again on 10 December, as his wounds had deteriorated further. His GP contacted the healthcare provider again and was informed that the dermatology clinic at the healthcare provider would see Mr D on 12 December. Mr D’s records from the healthcare provider show he was seen on 12 December, and he had a biopsy taken from his left lower leg.

21. In its response to Mr D, the healthcare provider stated it is standard practice for an urgent appointment to be made within two weeks of the request being received. When the request was received, the healthcare provider had asked for Mr D to be seen within one week. The healthcare provider explained Mr D’s appointment was not made within one week as requested and it apologised for this error. It explained the administration team booked the nearest available appointment within the two week time frame, which was 18 December, but they failed to notice the additional information stating a one week timeframe was needed. The healthcare provider stated at no point was it confirmed Mr D would be seen within 48 hours of the referral being made by his GP.

22. Mr D’s GP records show his GP made an urgent referral to the dermatology clinic at the healthcare provider on 4 December and pictures of Mr D’s leg were emailed to them. The healthcare provider’s access policy shows the standard waiting time for an urgent referral is two weeks.

23. To determine if Mr D was seen by the healthcare provider in a clinically appropriate amount of time, we have received clinical advice on this and we have looked at national guidance in relation to the management of cutaneous vasculitis.

24. The Therapy in Practice guidelines for the clinical approach to cutaneous vasculitis outline that the optimal time for a skin biopsy is within the first 48 hours after the appearance of a vasculitic lesion. If the biopsy is poorly timed, the pathologic features (the signs that are indicative of the condition) of vasculitis may be absent, and the guidance says this must be considered when interpreting a negative biopsy from a patient whose clinical findings suggest vasculitis.

25. It is clear the healthcare provider was aware there was a suspicion of vasculitis on 3 December, as Mr D’s GP had arrived at a working diagnosis of vasculitis. His GP had also emailed pictures of Mr D’s leg to the dermatology clinic at the healthcare provider and requested an urgent referral. The referral letter from Mr D’s GP to the healthcare provider, dated 4 December, described the rash on Mr D’s leg as vasculitic in nature with some central necrosis.

26. Our clinical adviser has informed us they do not consider Mr D was seen by the healthcare provider within a clinically reasonable amount of time for a presenting complaint of vasculitis. Our adviser outlined that given the potential for renal or other systemic involvement, Mr D should have been ideally seen within 24 hours, and at most 48 hours, following the suggestion of a diagnosis of cutaneous vasculitis. A diagnosis of cutaneous vasculitis should be made by skin biopsy and the optimum time for a skin biopsy is within the first 48 hours of the appearance of the lesion, as outlined in the guidance above.

27. Our clinical adviser also explained that after 48 hours, the chances of detecting cutaneous vasculitis through a biopsy diminish, which is why Mr D should have been seen within 48 hours of the urgent referral on 5 December.

28. Based on the clinical advice we have received, and after having carefully considered the Therapy in Practice guidelines, we have found it was not clinically appropriate for Mr D to have waited from 5 December until 12 December to be seen by a dermatologist at the healthcare provider.

29. We have found Mr D should have been seen within 48 hours of the urgent referral that was made on 5 December. As this did not happen, we have identified this to be a failing. We will discuss the impact we have found this had on Mr D in the impact section of our report, below.

Betnovate and prednisolone prescriptions

30. Mr D says the consultant dermatologist from the healthcare provider should not have prescribed Betnovate cream (treatment for itching, swollen or irritated skin) or prednisolone 5mg tablets (a medicine used to treat a wide range of health problems including allergies, blood disorders, skin diseases, inflammation, infections, and certain cancers and to prevent organ rejection after a transplant) without having first examined him face to face. Mr D considers it was inappropriate for him to have been prescribed medication without first being physically examined at the dermatology clinic. Mr D says the prescribing of Betnovate cream was inappropriate, as he had open blisters on his leg.

31. In its response, the healthcare provider stated to Mr D that the prescribing of topical steroids, such as Betnovate, is common practice for patients with vasculitic lesions. The healthcare provider said this is much safer than a course of oral steroids, which is the alternative. The healthcare provider said the prescription was made based on the information provided by his GP, which was a full medical history and relevant clinical information. The healthcare provider stated the prescribing of Betnovate cream was clinically appropriate.

32. To consider if it was appropriate for the healthcare provider to have prescribed Betnovate and prednisolone, without first having assessed Mr D face to face, we have looked at the relevant guidance and standards and we have received clinical advice on this from our independent clinical adviser.

33. Our clinical adviser has told us it was not appropriate for the healthcare provider to have prescribed any treatment (topical or oral) without having reviewed Mr D in person first. Our clinical adviser explained a clinical diagnosis should have been established by the specialist and this should have been confirmed by a skin biopsy.

34. Our adviser added that as blisters were present. This suggested a more aggressive form of vasculitis which should have prompted consideration of systemic therapy, and it should have alerted the healthcare provider to a more serious form of vasculitis with systemic involvement.

35. The Therapy in Practice guidelines stated that, in patients who show significant symptomatic disease, more aggressive therapy will be required.

36. The GMC guidance says to prescribe medicine or treatment, including repeat prescriptions, only when they have adequate knowledge of the patient’s health, and are satisfied the medicine or treatment the patient’s needs. The guidance also says to provide effective treatments based on the best available evidence.

37. Based on the guidance and the clinical advice we have received, we have found it would have been appropriate for the healthcare provider to have reviewed Mr D face-to-face before prescribing him either Betnovate or prednisolone. Based on the clinical advice we have received, and the clinical guidance we have referred to, we have found a failing with the healthcare provider’s decision to prescribe Mr D Betnovate and prednisolone without first reviewing Mr D in a face-to-face setting.

Our findings in relation to impact

Mr D’s appointment at the healthcare provider

38. We have identified a failing with the length of time that Mr D had to wait to be seen by the dermatology clinic at the healthcare provider. Mr D was seen by the healthcare provider on 12 December where he had a skin biopsy. Mr D started compression treatment on 19 December.

39. Our clinical adviser has outlined that as Mr D was not seen within the 48 hour time he should have been seen in, this led to Mr D’s rash deteriorating and him having a more protracted illness, without adequate treatment from 5 December to 12 December. During this time Mr D was not reviewed by the healthcare provider. Our adviser has informed us that the delay would be unlikely to have made any difference to Mr D’s overall clinical outcome.

40. However, we have found that Mr D was caused added stress, worry and anxiety, between the date he should have been seen by, 7 December, to the date when he was first seen by the healthcare provider on 12 December.

The prescribing of Betnovate and prednisolone

41. We have identified a failing with the healthcare provider prescribing Betnovate and prednisolone to Mr D without having reviewed him face to face.

42. We have found that Mr D was caused added concern and anxiety at being prescribed medication without being reviewed by a specialist first. The GP records show on 7 December it was noted that Mr D should avoid applying the cream to broken skin, however, he had blisters on his leg. Mr D says he went back to his GP surgery on 10 December with high levels of stress and anxiety, as his wounds had deteriorated further.

43. It was noted on 10 December in the GP records that the steroid cream had been of no help and his rash was red with central dark necrosis.

44. Based on the evidence we have considered, we have found this would have caused Mr D added concern and anxiety at what was already a very worrying and concerning time for him.

45. While Mr D says he had to take time off work to recover from his illness, we are unable to say his recovery would have been quicker without the delay of five days he experienced, or that he would not have needed to take time off work.

46. It is understandable that Mr D was concerned at the blisters that formed on his leg and the deterioration of his condition after he started treatment. The delays and lack of face-to-face consultation will have added to the worry he experienced.

1. We have identified three failings with the standard of care and treatment that was provided to Mr D by a healthcare provider in the Nottingham area (the healthcare provider). We have found that Mr D was not seen by the healthcare provider within an appropriate timeframe for a presenting complaint of vasculitis. This caused Mr D added distress and concern at what was already a worrying time. We have found the delay in Mr D being seen by the healthcare provider led to him having a more protracted course of illness from 5 December to 12 December.

2. We have found it was inappropriate for Mr D to have been prescribed Betnovate cream and 5mg prednisolone tablets without having been assessed in a face-to-face setting, and without a skin biopsy being done to confirm the diagnosis. We have found this caused Mr D added worry and anxiety, as his condition worsened after applying the Betnovate cream.

3. We have also found that Mr D’s urgent appointment was wrongly offered within a two week timeframe. We have found this caused Mr D added anxiety and concern between 5 December and 12 December at what was already a worrying time. Therefore, we will be partly upholding Mr D’s complaint.

4. We recommend that the healthcare provider writes to Mr D to apologise for the impact of, and implement service improvements for, the failings we have identified. We are also recommending that the healthcare provider provides Mr D with a financial remedy to put right the impact we have identified.

5. We understand the worry that Mr D experienced during this time and that he remains concerned that a worse outcome could have occurred, because of the healthcare provider’s failings. We appreciate why Mr D remains concerned and hope the explanations we have given will provide some reassurance.

47. 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.

48. 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.

49. Our principles say that public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service. In line with this, we recommend that the healthcare provider writes to Mr D to apologise for the impact the failings had on Mr D. We also recommend that the healthcare provider produces an action plan that specifically addresses the failings we have identified and explain the actions it will take to reduce the chances of failings like this occurring in the future.

50. 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.

51. 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. We have looked at our guidance on financial remedy. Our scale allows us to ensure the recommendations we make are consistent and transparent for everyone who uses our service. The figures included in the scale represent the Ombudsman’s judgement about the sort of sums that are both appropriate and proportionate for us to recommend.

52. Level two of our scale of injustice refers to amounts from £100 - £450. This is where we consider that an apology on its own is not an adequate remedy. Typically, the injustice will arise from a relatively low impact failing, often resulting in a degree of distress, inconvenience, or minor pain, but the duration of the injustice will tend to be longer than in cases with level one injustice.

53. Level two impacts in relation to distress is described as distress, worry, annoyance and similar injustice of the sort which a healthy adult would be expected to deal with on a regular basis, without external support, and which does not impact on the affected person’s day to day functioning, or their ability to live a normal life: for a period from one to two weeks to about six months. We would reasonably expect any impact to diminish completely in the fullness of time.

54. Level two in relation to physiological impact is described as minor pain lasting from a few days to a month, or severe pain lasting for no more than a week.

55. After carefully considering our scale of injustice, and cases we have previously closed where similar impacts we experienced, we consider the impact caused to Mr D falls within level two on our scale. This is because his treatment was delayed, which meant he was in discomfort and pain, as evidenced by his GP records on 10 December that state Mr D’s left ankle slightly swollen and painful, but not too bad. Mr D was also caused worry and concern due to the delay with him seeing a specialist at the dermatology clinic.

56. Following this review, we recommend the healthcare provider should pay Mr D £300 in recognition of the stress, worry and anxiety that was caused to him because of the failings we have identified.

57. We are very sorry to learn of the concerns Mr D has brought to us and we appreciate he went through a very difficult and worrying time. We are pleased to learn Mr D has fully recovered from his condition and we consider the recommendations we have made address the impact caused to Mr D.