Blood pressure (BP)
14. Mr O complains the Practice wrongly told him in 2016 his BP monitor results were fine when they showed he had stage two hypertension, and did not offer further investigations, treatments or lifestyle advice.
15. The Practice said after Mr O’s consultation on 2 November 2016 it arranged an electrocardiogram (ECG) and 24-hour BP monitor. During this consultation his BP was recorded as 162/104.
16. It explained the GP viewed and actioned the 24-hour BP report. This showed an average waking BP of 140/85 and an asleep average BP of 121/71 over the 24 hours. The GP felt these results were reassuring. This indicated Mr O had an element of ‘white coat hypertension’ (when a person’s BP spikes while a clinician measures it) and the GP did not feel further action was required. The Practice apologised the GP did not communicate this more clearly to Mr O. The Practice said it would have been happy for Mr O to ask to speak to the GP again. The GP marked the BP results as normal, along with a normal ECG result, and took no further action.
17. The Practice said the 2011 NICE guideline on hypertension was in place at the time the GP saw Mr O in 2016. The guideline explains a diagnosis of hypertension should be made if clinic BP is over 140/90 or average home/ambulatory (while walking) BP is 135/85. The GP accepted Mr O’s ambulatory BP at this time was 140/85 and over the specified target. The Practice explained Mr O did not meet the criteria for being hypertensive at the time because his BP dipped at night to 121/71 and his overall cardiovascular risk was low, so treatment was not required.
18. The Practice further explained the NICE guideline defines stage two hypertension as clinic BP 160/100 and subsequent average home/ambulatory BP (BP readings over a 24-hour period) of 150/95 or more. According to the 24-hour BP results in 2016 Mr O did not meet the criteria for stage two hypertension. It said the GP’s management of his care at the time was acceptable and in line with the NICE guideline then in place. It said the GP considered that because Mr O’s overall risk was low, no further action was needed.
19. The Practice explained it tells patients their results once the GP has acted on them and left a comment. This comment is then passed to the patient (for example ‘normal, no action’) when they get their results. Unfortunately the Practice says it does not have the capacity or resource for every GP to contact every patient personally about every result. But it would have booked a follow-up consultation for Mr O if he had asked for one.
20. The relevant guidance covering the 2016 period is NICE CG127. The Practice’s response to Mr O’s complaint states his 24-hour BP average was 140/85. But it should have recorded and acted on Mr O’s average BP when he was awake to confirm whether or not he had hypertension, in line with the NICE guidance. This says:
‘1.2.9 When using ABPM [ambulatory BP monitoring] to confirm a diagnosis of hypertension, ensure that at least two measurements per hour are taken during the person's usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14 measurements taken during the person's usual waking hours to confirm a diagnosis of hypertension. [2011].’
21. Based on Mr O’s medical records his mean (actual) daytime average was 145/89. This is defined in the NICE guidance as stage one (moderate) hypertension. Stage two (severe) hypertension is if the BP daytime average reaches 150/95.
22. The Practice should have diagnosed Mr O in November 2016 as having stage one hypertension but failed to do so.
23. If it had done, the Practice should have then offered to carry out the following investigations in line with the NICE hypertension guidance, which states:
‘1.3.3 For all people with hypertension offer to:
• test for the presence of protein in the urine by sending a urine sample for estimation of the albumin: creatinine ratio [helps to identify kidney disease] and test for haematuria [blood in urine] using a reagent strip • take a blood sample to measure plasma glucose [blood sugar], electrolytes, creatinine, estimated glomerular filtration rate [to show how well the kidneys are working], serum total cholesterol and HDL cholesterol • examine the fundi for the presence of hypertensive retinopathy [damage to retina] • arrange for a 12-lead electrocardiograph to be performed. [2004, amended 2011].’
24. There is no evidence in Mr O’s medical notes the Practice offered to carry out blood and urine tests.
25. Our adviser said the evidence indicates the Practice did not action Mr O’s BP result from his 24-hour BP monitoring in 2016 in line with NICE guidance.
26. The NICE hypertension guidance says the following about treatment:
‘Initiating treatment
1.5.1 Offer antihypertensive drug treatment to people aged under 80 years with stage 1 hypertension who have one or more of the following: • target organ damage • established cardiovascular disease • renal disease • diabetes • a 10-year cardiovascular risk equivalent to 20% or greater.’
27. Although we do not have the results of blood and urine tests for Mr O in 2016 (because the Practice did not do these tests), we do have the results of relevant blood test taken in April 2018. There are no urine tests on record. Based on Mr O’s 2018 blood test results there was no evidence of:
• target organ damage • established cardiovascular disease • renal disease • diabetes or • a 10-year cardiovascular risk equivalent to 20% or greater.
28. It is more than likely this would have been the same result if Mr O had blood tests in 2016, so there would have been no need for the Practice to offer Mr O any relevant drug treatment in 2016.
29. But the NICE guidance says a GP should give a patient diagnosed with stage one hypertension lifestyle advice and arrange for annual reviews to monitor their BP and discuss their lifestyle, symptoms and medication. This did not happen in Mr O’s case.
30. The NICE guidance says:
‘1.4 Lifestyle interventions For NICE guidance on the prevention of obesity and cardiovascular disease see ‘Obesity’ (NICE clinical guideline 43, 2006) and ‘Prevention of cardiovascular disease at population level’ (NICE public health guidance 25, 2010).
1.4.1 Lifestyle advice should be offered initially and then periodically to people undergoing assessment or treatment for hypertension. [2004] 1.4.2 Ascertain people's diet and exercise patterns because a healthy diet and regular exercise can reduce blood pressure. Offer appropriate guidance and written or audiovisual materials to promote lifestyle changes. [2004] 1.4.3 Relaxation therapies can reduce blood pressure and people may wish to pursue these as part of their treatment. However, routine provision by primary care teams is not currently recommended. [2004] 1.4.4 Ascertain people's alcohol consumption and encourage a reduced intake if they drink excessively, because this can reduce blood pressure and has broader health benefits. [2004] 1.4.5 Discourage excessive consumption of coffee and other caffeine-rich products.
[2004] 1.4.6 Encourage people to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure. [2004] 1.4.7 Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure. [2004] 1.4.8 Offer advice and help to smokers to stop smoking. [2004] 1.4.9 A common aspect of studies for motivating lifestyle change is the use of group working. Inform people about local initiatives by, for example, healthcare teams or patient organisations that provide support and promote healthy lifestyle change. [2004]
1.7.3 Provide an annual review of care to monitor blood pressure, provide people with support and discuss their lifestyle, symptoms and medication.’
31. We consider the Practice’s failure to diagnose Mr O with stage one hypertension and offer lifestyle advice and annual reviews is not in line with the relevant clinical standard/guidance as detailed above.
Impact
32. Having seen evidence of a failing, we next looked at whether this had a negative impact on Mr O, and, if so, whether the Practice has put things right. We do not normally uphold complaints where we find appropriate action has been taken to put things right or if we cannot link the impact to the failing.
33. Mr O believes leaving his high BP and cholesterol levels untreated resulted in him being diagnosed at 39 with chronic heart disease and angina and put on medication for life.
34. Our adviser said it is not possible to know what clinical effect the Practice’s failure to advise on lifestyle changes and holding annual reviews would have had on Mr O. It is impossible to quantify the effects. This is because there are too many variables to determine the causes of chronic heart disease and angina. Also, if the Practice had given Mr O lifestyle advice, he may not have acted on it, and if he did, our adviser cannot say whether this would have prevented his chronic heart disease and angina diagnosis.
35. When Mr O next had home BP monitoring in 2021, his BP had risen to the level of stage two hypertension. Our adviser told us it is not possible to know if this could have been diagnosed earlier. We cannot say with any certainty Mr O might have been diagnosed with stage two hypertension sooner if he had been reviewed annually.
36. We are sorry to learn of Mr O’s experiences with the Practice. We have taken into account all the relevant evidence, including Mr O’s account and medical records and clinical advice. Although there was a missed opportunity for the Practice to offer lifestyle advice and annual reviews, it is very unlikely we could quantify the clinical impact this had on Mr O. As a result, we are unable to link the indicated failing to the impact he says he suffered.
Cholesterol
37. Mr O complains the Practice wrongly told him in 2018 his cholesterol was fine when it was high and did not carry out further investigations or treatments or provide lifestyle advice.
38. The Practice states Mr O had a GP consultation on 17 April 2018 about wax in his ears, eczema and chest discomfort. It is recorded his chest pain was sporadic and not related to exertion. The GP arranged some blood tests.
39. Mr O’s cholesterol was documented as 5.9mmol/L with HDL (high density lipoprotein) 1.40mmol/L and non-HDL 4.5mmol/L. A different GP at the Practice from the one Mr O saw on 17 April viewed the results and marked them as satisfactory. The GP calculated Mr O’s QRISK score as 0.89% (extremely low) and so did not take further action. QRISK is a tool to see if a person has a low, moderate or high risk of developing cardiovascular disease (CVD) in the next ten years.
40. The Practice says the GP who looked at Mr O’s cholesterol results in 2018 used the QRISK tool and decided overall his cardiovascular risk was low (QRISK 0.89%). Treatment would normally only be offered for raised cholesterol once the QRISK reaches 10% to 15% (as per NICE guidelines) so the GP felt no action was needed.
41. The relevant guidance is NICE CG181. This guideline covers the assessment and care of adults who are at risk of or already have cardiovascular diseases.
42. Our adviser said the medical records show after Mr O saw the GP in April 2018 the Practice recorded his cholesterol in line with the NICE guideline as 5.9mmol/L with HDL 1.40mmol/L and non-HDL 4.5mmol/L.
43. The NICE guideline says: ‘1.1 Identifying and assessing cardiovascular disease (CVD) risk 1.8 Use the QRISK2 risk assessment tool to assess CVD risk for the primary prevention of CVD in people up to and including age 84 years.’
44. The medical records show the Practice carried out a QRISK risk assessment indicating Mr O was at low risk of CVD (QRISK 0.89%).
45. Based on the NICE guideline, further investigations and treatment would only be considered if the results showed Mr O was at more than 10% risk of CVD. As Mr O’s result was 0.89% there was no requirement for the Practice to consider or carry out any further investigations or treatment.
46. We understand Mr O’s concerns about whether the Practice wrongly told him in 2018 his cholesterol level was fine when it was high. We have carefully considered all the relevant evidence, including Mr O’s account and medical records and independent clinical advice. The evidence shows the Practice recorded Mr O’s cholesterol levels in 2018 in line with relevant clinical guidance. As his QRISK score was recorded as 0.89% there was no requirement for the Practice to consider or carry out any further investigations or treatment. We cannot see indications of failings.
GP involved in Mr O’s care
47. Mr O complains:
• the GP he saw in 2016 and complained about got involved in his current care, without his current doctor’s knowledge or discussing this with him • this same GP wrongly organised an appointment for him at the local hospital cardiology service’s angina clinic, even though he had already been seen at the clinic and discharged • the GP went outside the scope of his complaint by accessing his file beyond the 2016 treatment they provided.
48. Mr O says there is no reason for the GP to access his current medical records or test results or arrange appointments without discussing them with him. He explains this is outside the scope of the complaint he made to the Practice and he does not believe there was a legitimate business need for the GP to access his records beyond 2016.
49. The Practice explained the GP Mr O saw in 2016 had noted the correspondence from the cardiology service and the results of Mr O’s exercise test and computerised tomography (CT) coronary angiogram. It says the GP was concerned Mr O had significant symptoms, being unable to walk his dogs without experiencing chest tightness. The GP wrote to the cardiology consultant in charge of Mr O’s care for an overview of the medical findings.
50. Mr O’s complaint to the Practice (11 November 2021) says his current GP at the Practice told him during a telephone appointment on 9 November they had not asked either the GP he saw in 2016 and complained about or any other doctors at the Practice to look at his exercise test and CT results and provide a second opinion. Mr O says his GP was unaware the GP he saw in 2016 had made a referral back to the cardiology service where he had already been seen and discharged.
51. The Practice’s response to Mr O said GPs discuss medical cases and share knowledge/experience among their colleagues at the Practice, so require full access to medical records and information if needed.
52. Our adviser said because Mr O made a complaint to the Practice about the GP, it was appropriate and in line with good clinical practice for them to access his medical records so they could respond fully to his complaint. It is recorded this same GP also wrote to the cardiology service for more information to help respond to Mr O’s complaint.
53. We recognise Mr O’s concerns about the GP accessing his records and involvement in his care. As Mr O made a complaint to the Practice about this GP it was in line with good clinical practice for it to access his medical records to deal with his complaint.
54. The medical notes show the GP wrote to the relevant cardiologist to get more information to reply to Mr O’s complaint. The GP asked if the cardiologist needed to see Mr O to respond to their request for information and, if so, whether an appointment could be arranged. We consider this was in line with our ‘Principles of Good Complaint Handling’, which says:
‘Ensuring that complaints are investigated thoroughly and fairly to establish the facts of the case.’
55. We have not seen evidence of failings in the actions of the GP.