A medical practice in the Surrey area

3. Mrs I complains the Practice prescribed 50mg tramadol (a strong painkiller) to her mother, Ms H, on 13 July 2021 without seeing or examining her. Mrs I also says tramadol was inappropriate because of her mother’s medical history.

4. Ms H died later in July 2021, and Mrs I feels her death could have been avoided if a GP had seen and examined her, and had not prescribed tramadol.

5. Mrs I would like a fair investigation into her complaint and for the Practice to improve its care to the elderly population it serves.

6. On 15 May 2018, Ms H experienced severe pain radiating from her lower back down her legs and was frequently breathlessness whenever she walked. She was rushed to the hospital and diagnosed with a Urinary Tract Infection (UTI), pneumonia and sepsis.

7. On 13 July 2021, Ms H contacted her GP because she had severe pain in her buttocks from a fall which occurred four weeks prior. She said it was painful for her to walk or move around. The GP spoke about her pain relief options and if further investigation was needed. The options the GP recorded were available were tramadol, buprenorphine patches and Oramorph. The GP prescribed tramadol as she had taken it in April 2014 and had no side effects.

8. Mrs I says she is shocked that the Practice prescribed such a strong painkiller to her mother, Ms H, without a face-to-face consultation, basic examination by a GP, and having bloods taken.

9. Mrs I says it appears the Practice has ignored her mother’s medical history (polymyalgia, sepsis, pneumonia and UTI). She says that from her understanding of tramadol, and reading information on the drug, it should not be prescribed to individuals who have lung conditions, or their breathing is compromised in any way.

10. She explained her mother’s lungs had been severely compromised from her experience of pneumonia. Ms H could only mobilise short distances before becoming breathless, pale in colour, and needing to sit down. Mrs I believes her mother experienced acute respiratory depression (a breathing disorder characterised by slow and ineffective breathing) and vomiting brought on by the tramadol.

Prescription of 50mg tramadol without a physical examination

14. Before we decide if we should conduct a detailed investigation of 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 have not found any indications that something has gone wrong.

15. GMC guidance outlines the following circumstances in which a face-to-face consultation may be more appropriate than a remote consultation, including:

• ‘you are unsure of a patient’s capacity to decide about treatment • you need to physically examine the patient • you are not the patient’s usual doctor or GP and they have not given you consent to share their information with their regular prescriber; this is particularly important if the treatment needs following up or monitoring, or if you are prescribing medicines where additional safeguards are needed’.

16. Mrs I says the Practice should not have prescribed tramadol to her mother without a face to face consultation and examination.

17. The Practice explained in its response that a recent X-ray did not show any fractures to explain the buttock pain Mrs H was experiencing from her fall. It says this is why it decided to prescribe her pain relief remotely.

18. Ms H’s medical record shows she was already examined with an X-ray which found no fracture. Our clinical adviser gave their view that it was appropriate for the Practice to prescribe tramadol to Ms H remotely because of this.

19. Our adviser explained the GP could not give her codeine because of past side effects and could not give anti-inflammatory painkillers due to the risk of gastric bleeding. The Practice explained the GP prescribed the lowest dose of tramadol (as she had previously taken this without side effects) and advised her to stop immediately if she experienced side effects.

20. Our adviser explained that in view of the history established by the GP, and the knowledge that examination and an X-ray had already been performed and excluded serious pathology (a fracture), there would be nothing to be gained by a face-to-face appointment.

21. We can see no evidence in the records to suggest Ms H met any of the criteria set out in GMC guidance, as no physical examination was needed. Our adviser explained that pain relief (including tramadol) is commonly prescribed remotely.

22. We recognise that Mrs I would’ve preferred for her mother, Ms H, to have undergone a physical examination prior to the prescription of tramadol.

23. There is no evidence to suggest that the Practice did not follow guidelines in prescribing tramadol remotely.

24. To reach this decision, we have considered The GP’s rationale prior to prescribing tramadol, our adviser’s rationale, and information received from Mrs I. Upon review of Ms H’s medical records, we can see that she was suffering with buttock pains and an X-ray was carried out, which ruled out a fracture. The GMC guidance paragraph 22-26 clearly outlines the points in which a patient would need a face-to-face examination and Ms H did not appear to meet any of these. This is why we do not consider the evidence indicates a failing in care.

Prescribing tramadol given Ms H’s medical history

25. Mrs I feels the Practice should not have prescribed tramadol given Ms H’s medical history. She says she understands tramadol should not be prescribed to individuals who have lung conditions, or their breathing is compromised in any way.

26. The Practice explained in its response that other available drugs would not have been adequate to relieve Ms H from her suffering, hence why a proper pain relief was needed. It explained staff could not risk giving her an anti-inflammatory painkiller as she was already taking paracetamol and had experienced severe side effects from taking codeine.

27. The Practice explained the only stronger choice of painkillers were tramadol, buprenorphine patches and Oramorph. The Practice says the GP checked Ms H’s medical history and could see that she had been given tramadol in 2014 without side effects. It says it explained the side effects associated with tramadol to Ms H, and prescribed the lowest dose (50mg). They explained that she must stop taking the medication immediately if it made her unsteady, drowsy, or gave any other side effects.

28. Our clinical adviser explained that after a review of Ms H’s medical and medication records, there was no medical reason (contra-indication) or interactions that would mean tramadol could not be prescribed.

29. We can also see the GP had knowledge of medication prescribed to Ms H, which included a prescription of tramadol in 2014 with no problem, and appropriately prescribed a small quantity at the lowest possible dose for a short period of time with clear advice to stop if there were any issues.

30. It therefore appears the decision to provide the lowest dose of tramadol was appropriate and in line with NICE guidelines which states that ‘lower doses of weak opioids are recommended for elderly and/or debilitated people as they are more susceptible to the adverse effects of weak opioids’.

31. The Prescribing book (BNF) which all doctors use, does not list any of Ms H’s previous medical diagnoses as a reason to not prescribe tramadol. The following outlines the dosage, quantity and period in which tramadol should be given, and a list of medical reasons of when tramadol should not be prescribed:

• Adult – Tramadol

50–100 mg every 4–6 hours, intravenous injection to be given over 2–3 minutes; Usual maximum 400 mg/24 hours.

• Contra-indications For all opioids

Acute respiratory depression; comatose patients; head injury (opioid analgesics interfere with pupillary responses vital for neurological assessment); raised intracranial pressure (opioid analgesics interfere with pupillary responses vital for neurological assessment); risk of paralytic ileus.

• Contra indications for Tramadol specifically Acute alcohol intoxication or hypnotics or opioids, compromised respiratory function in children, uncontrolled epilepsy.

32. Considering all the information presented by Mrs I, the Practice, and our clinical adviser, we can see that the Practice did follow relevant guidelines when prescribing tramadol.

33. Our adviser reviewed Ms H’s medication record and we can see that she was not taking any medication for her lungs or any respiratory medication. We can see no indications in the records she had acute respiratory depression at the time of prescription.

34. The repeat medications she was taking during the time of events (July 2021) were paracetamol (which can be taken with tramadol). Adcal-D3 (for extra calcium and vitamin D), lansoprazole (for indigestion, heartburn and acid reflux) which has no interactions with tramadol, bisoprolol (beta blocker for heart diseases) which has no interactions with tramadol, amitriptyline (pain relief) can increase the risk of seizures when taken with tramadol for those who suffer from seizures (which she did not) and prednisolone which is used to treat a range of health problems none of which list her previous diagnosis as one and has no interactions with tramadol.

35. This shows that she did not have any present contra-indications for all opioids & tramadol listed in the NICE guidelines.

36. Because of this, we are of the view that the Practice’s rationale for prescribing tramadol was in line with the guidance, and Ms H’s medical issues since she was previously prescribed tramadol would not appear to have been a reason to not prescribe it again. We have therefore decided to take no further action on the complaint.

37. We recognise Mrs I has been through a difficult and distressing time. We were sorry to hear about the experience Ms H had and we do not underestimate how challenging it is for Mrs I, her daughter, to revisit the treatment of a loved one.

1. We have carefully considered Mrs I’s complaint about a medical practice in the Surrey area (the Practice). We understand how distressing this experience has been for Mrs I and we are sorry to hear how deeply the loss of her mother has affected her.

2. To reach our decision we reviewed the information provided by the Practice, together with information Mrs I provided over the phone and in writing. We have seen no indication that anything went seriously wrong and have decided not to consider Mrs I’s complaint further.