20. We first looked at Mrs R’s complaint the rheumatology team failed to offer her support or monitoring of her ciclosporin medication.
21. The consultant rheumatologist prescribed Mrs R ciclosporin in March 2021 for her complex connective tissue disorder. The Trust provided Mrs R with a copy of the patient information leaflet for ciclosporin and referred her appropriately for a drug counselling appointment. In April 2021 Mrs R attended the appointment with a rheumatology specialist nurse.
22. Our adviser said the nurse referred to a checklist used for drug counselling, all the appropriate pre-counselling checks, and the blood tests required for Mrs R to monitor safety.
23. This is in line with BSR guidelines on monitoring patients on non-biological disease modifying drugs which says:
‘The decision to initiate DAMARDs [disease modifying anti-rheumatic drugs] should be made in conjunction with the patient/carer and be supervised by an expert in the management of rheumatic diseases.
Patients should be provided with education about their treatment to promote self-management…
Baseline assessment should include height, weight, blood pressure and laboratory evaluation full blood count (FBC)’.
24. The Trust has provided a record of Mrs R’s appointments offered by the rheumatology department from her first referral to the service on 18 August 2017 until 14 June 2021.
25. We can see from the records, Mrs R had access to the Trust’s rheumatology telephone helpline. In addition to this she had two other appointments with the rheumatology team on the 3 June and with a rheumatology nurse on the 14 June 2021.
26. It appears Mrs R was provided with the necessary support to start new medication through appropriate counselling clinics, and offered support through the rheumatism telephone helpline, and clinic appointments shortly after starting her new treatment. This is in line with national guidance from the BSR, as above. As the Trust acted in line with relevant guidance, we have seen no indications of failings.
27. We next looked at Mrs R’s concerns the rheumatology nurse failed to offer Mrs R support regarding her symptoms and side effects.
28. On 14 May Mrs R contacted the rheumatism helpline, regarding symptoms of diarrhoea, incontinence, and a swollen tongue since starting the new medication.
29. The rheumatology specialist nurse returned the call the same day and advised Mrs R to contact her after the nurse had discussed her symptoms with the rheumatology consultant. Mrs R called the helpline again on 15 May, and this call was returned on 17 May and 18 May. It appears Mrs R did not answer these calls.
30. The relevant guidance here is the information leaflet ‘Drug information ciclosporin 2020, Possible risks and side effects’ which says:
• diarrhoea • nausea (feeling sick) • headaches • any problems or changes to your eyesight • enlargement of the gums in the mouth • tiredness • excess hair growth • any other new symptoms or anything else that concerns you.
31. It also says contact your doctor immediately if any of these symptoms are severe. As ciclosporin can increase your risk of infection, you should report any new symptoms such as a sore throat, flu-like symptoms, or high temperature to your GP as soon as possible.
32. Records show the speciality registrar in rheumatology then saw Mrs R face-to-face at an appointment on 3 June. This was within three weeks of the call and was followed up with a telephone consultation on 14 June where her concerns were noted and ciclosporin stopped with a plan for alternative treatments.
33. We can see the Trust did offer suitable support to Mrs R. It addressed the symptoms she reported and looked at alternative treatments. As the Trust has acted in line with guidance, we do not see any signs of a failing here.
34. We next looked at Mrs R’s concern the doctor was dismissive of her symptoms.
35. Records indicate the Trust’s contact with Mrs R was maintained through the helpline and the consultant was involved in providing support at each stage. The speciality registrar in rheumatology saw Mrs R in clinic on 3 June 2021. In a letter to Mrs R’s GP dated 8 June, the registrar noted Mrs R’s symptoms of swelling of the hands, feet, lips, tongue and gums, along with generalised aches and pains and feeling feverish, caused by ciclosporin.
36. Our adviser said the medication was discontinued and the doctor discussed alternative medication with Mrs R. The face-to-face appointments appear to be prompt and in keeping with Mrs R’s complex connective tissue disorder. This is in line with the GMC guidance, which states:
‘You 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’.
37. We do not agree the Trust was dismissive of Mrs R’s symptoms. This is shown by the Trust’s actions, the support it offered her, and its looking at alternative treatment. It acted in line with the guidance. We have seen no signs of the Trust doing anything wrong.
38. Finally, we considered Mrs R’s complaint the Trust took a long time to respond to her complaint.
39. On 17 May 2021 Mrs R complained to the Trust by email. It noted receipt of her complaint, provided a summary of the complaint, and gave an estimated date for its response of 22 June. It explained it would advise Mrs R if it seemed its investigation was going to take longer. It also directed her to advocacy services. It provided its response to Mrs R on 21 June and directed her to us.
40. We have considered the time taken for the Trust to respond to Mrs R’s complaint. We can see it updated and explained to Mrs R there may be a delay. The Trust offered Mrs R a local resolution meeting to try to resolve her complaint. This is in line with our principles which say:
• Deal with complaints promptly, avoiding unnecessary delay, and in line with published service standards where appropriate. Resolving problems and complaints as soon as possible is best for both complainants and public bodies.
• Acknowledge the complaint and tell the complainant how long they can expect to wait to receive a reply. Public bodies should keep the complainant regularly informed about progress and the reasons for any delays and provide a point of contact throughout the course of the complaint.
• Treat complainants sensitively and in a way that takes account of their needs.
41. The Trust responded to Mrs R’s complaint in a timely manner. Therefore, we have not seen anything wrong in the time the Trust took to respond to the complaint.
Summary
42. We understand Mrs R’s distress, and it is clear she is concerned about her care. We do not wish to diminish the impact she says events had on her. We have seen no indications the Trust did anything wrong and will be taking no further action. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reason for this.