Referral to a physiotherapist
15. We first considered Ms X’s complaint the Practice arranged for Ms Z to speak to a physiotherapist when they believed Ms Z needed to see a GP.
16. The Practice said Ms Z agreed to speak to the first available practitioner. It said in these situations a patient could speak to a GP, nurse or physiotherapist, but it added Ms Z could have chosen to speak to a GP if she had wanted to.
17. The DHSC’s NHS constitution says patients have a right to receive care and treatment appropriate to them which meets their needs and reflects their preferences. Applied to this case, that means the Practice should have referred Ms Z to a GP if that was what she asked for and the appropriate person for her to see.
18. We can see from the records a physiotherapist spoke to Ms Z first but a GP did speak to her later.
19. We cannot see from the records whether Ms Z asked for a GP but was instead referred to a physiotherapist. What is clear from both accounts is the Practice arranged for Ms Z to see a GP when she asked to see one.
20. We cannot see a gap between what should have happened and what did happen. It is unclear what Ms Z said when she initially called the Practice. Ms X says they both wanted to speak to a GP. The Practice says Ms Z agreed to speak to any available practitioner, which the Practice says was a physiotherapist at the time. As such, there is a conflicting view of what happened when Ms Z initially called the Practice.
21. It is important to note the Practice did refer Ms Z to a GP when she asked to see one. It preserved her rights as an NHS patient by doing this, as she told them her preference and they agreed to accommodate it.
22. It does not seem the effect Ms X described is linked to this complaint. Although we can appreciate both Ms Z and Ms X were anxious to speak to someone who could help them, it seems possible there was a miscommunication between them and the Practice that led to Ms Z speaking to a physiotherapist rather than a GP.
23. We are not considering this aspect of the complaint further, as there are no signs anything went wrong.
Ms Z’s symptoms
24. We next considered Ms X’s complaint the Practice did not identify that Ms Z’s symptoms were signs of a heart attack or investigate her pain. She feels it should have investigated Ms Z’s pain more given she had gone to A&E the night before. She thinks Ms Z had symptoms of a heart attack.
25. The Practice said Ms Z had a history of bilateral carpal tunnel syndrome (CTS) and no other relevant past medical history. Bilateral CTS is a condition where there is pressure on a nerve in the wrist which causes tingling and numbness in a person’s hands and fingers. The Practice felt her symptoms were consistent with musculoskeletal pain, which is pain affecting the bones, muscles, ligaments, tendons or nerves. It told Ms X any symptoms of chest pain would have resulted in reception referring Ms Z to casualty, but Ms Z did not report this symptom.
26. The Practice said it was fine for its GP to have carried out Ms Z’s appointment over the phone.
27. Overall, it believes her symptoms at the time did not mean it should have taken a different approach and her outcome would not have changed.
28. The GMC Guidance section 15 says a GP must provide a good standard of practice and care. If they assess, diagnose or treat patients, they must:
• 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, and, where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary.
29. Applied to this case, the GP should have assessed Ms Z’s symptoms and considered both her history and her perspective. They should have provided suitable advice or treatment based on their assessment. If it was clinically appropriate, they should have arranged to examine Ms Z.
30. There is no standard that links wrist pain to a heart attack.
31. Ms X says Ms Z was experiencing pain in her left hand and arm.
32. On 9 August 2021, Ms Z went to A&E with pain in her left hand and arm. The Practice said Ms Z’s case was streamed to a practitioner at an out-of-hours service instead of A&E. They told Ms Z her pain was musculoskeletal, took a blood pressure reading and advised her to take pain relief. They advised her to seek help from a GP practice if her symptoms did not improve within six weeks.
33. On 10 August 2021, Ms Z spoke to a GP at the Practice who insisted her pain was muscular, specifically left-side dorsal wrist pain. They prescribed her co-codamol. Ms X says Ms Z told the GP the pain relief treatment was not reducing the pain she was experiencing. The Practice said both parties concluded pain relief was appropriate based on Ms Z’s presentation. It also said it arranged for her to have an urgent steroid injection to help her with her symptoms.
34. The GP did not bring Ms Z into the Practice for a physical examination.
35. Later the same day, it appears Ms Z developed chest pain and had a heart attack. She was taken to hospital, where she sadly died in August 2021.
36. It is clear from the records Ms Z was not well, as she went to A&E regarding her wrist pain, then to her GP the next day due to her ongoing pain.
37. Unfortunately, based on the symptoms Ms Z presented with to her GP – pain in the wrist and arm –there is no evidence her symptoms were linked to a heart attack. If she had any other symptoms, they were not communicated to the GP. The GP had no reason to conclude Ms Z was having a heart attack, so we cannot say they failed to assess Ms Z properly due to her having a heart attack later that day.
38. It was ultimately the GP’s decision not to see Ms Z at the Practice. The GMC Guidance says GPs should only arrange an examination if it is clinically appropriate. It seems from the guidance the GP was able to assess Ms Z based on what she told them over the phone, so they did not see the benefit of bringing her into the Practice.
39. Our GP adviser said it would most likely not have made a difference to Ms Z’s outcome if she had gone into the Practice for an examination, as she had not mentioned chest pain as one of her symptoms. The NHS webpage on chest pain says if a person has chest pain that spreads to their arms, they should go to A&E. If Ms Z had mentioned chest pain, the Practice would have immediately referred her to A&E.
40. This is understandably very distressing for Ms X, and we can appreciate why she has brought this complaint to us. We can understand it was a very difficult time for her. The evidence we have seen shows the Practice assessed Ms Z’s symptoms appropriately at the time. There is no sign in the available evidence that the Practice is responsible for failing to identify Ms Z was about to have a heart attack.
41. We will not consider this complaint any further, but we hope we have offered some reassurance the Practice provided appropriate care in the circumstances.