The Practice would not give H B12 injections
15. We will first address Mrs U’s complaint about the B12 injections.
16. Mrs U says she attended the Practice with H, who was displaying a range of symptoms that can indicate vitamin B12 deficiency. She complains that despite these symptoms and the subsequent results of both NHS and private blood tests the GP refused to prescribe H with B12 injections.
17. The Practice has not provided a response to Mrs U’s complaint. We therefore do not know its position in relation to the events complained about.
18. We obtained H’s medical records from his new GP practice. The records show Mrs U contacted the Practice on 2 October 2020 with concerns about H’s longstanding history of tiredness, lack of concentration and poor sleep, and his more recent nausea, aching and weakness. The GP suspected H had depression and referred him to Child and Adolescent Mental Health Services.
19. The GP also arranged for H to have blood tests, for which the GP received the results on 12 October. The GP recorded that the blood tests (including B12) were normal except for H’s vitamin D levels, which were ‘insufficient but not deficient’. The GP advised Mrs U this could be improved with diet changes and supplements.
20. Mrs U continued to express her concern about H’s condition, so the GP wrote to the haematology department on 19 November to ask for advice about Mrs U’s wanting H to receive B12 injections.
21. The haematology department replied on 24 November 2020 to say there was no clinical justification for B12 injections and, if H’s symptoms continued, it may be worth referring him to the paediatric specialists for further tests.
22. The GP discussed this with Mrs U on 16 December 2020 and agreed to make the referral to the community paediatrics team. The GP did this on 5 February 2021.
23. On 3 March 2021, Mrs U presented the GP with the results of a blood test which H had had done privately. She was concerned he had low methylmalonic acid (MMA) and this meant he needed B12 injections. MMA is a substance used in the processing of food into energy. The GP advised this was not a test they could conduct in primary care and agreed to write to the haematology department again to obtain its advice.
24. The haematology department replied on 17 March 2021 with the advice that H needed to be seen by the paediatric metabolic unit at the children’s hospital before anyone could decide about B12 injections.
25. We considered whether the GP should have provided H with B12 injections at each stage of these interactions. We sought advice from our GP adviser. They helped us to understand what action the GP should have taken in each of the circumstances and the policies applicable at the time.
First interaction – 2 October 2020 (initial presentation of symptoms)
26. The NICE guidance says, to diagnose vitamin B12 deficiency, a doctor must take a detailed medical history, examine the patient, arrange the necessary investigations and consider any other potential causes. It describes the appropriate investigations as: • a full blood count (FBC) to determine mean cell volume (MCV), haematocrit and haemoglobin levels, and a blood film to help to identify megaloblastic anaemia • measurement of serum cobalamin and folate levels to determine the cause of anaemia • additional investigations, such as liver function tests, gamma-glutamyl transpeptidase, and/or thyroid function tests, to identify the underlying cause.
27. The guidance goes on to explain that cyanocobalamin and hydroxocobalamin (the vitamin B12s used to treated deficiency) should not be prescribed before a diagnosis is fully established. Furthermore, paragraph 16a of the GMC guidance says doctors should not provide medication or treatment until they are satisfied it serves the patient’s needs.
28. As a result, because the suspected vitamin B12 deficiency had not been diagnosed with blood tests, the GP’s decision not to prescribe vitamin B12 injections at this point was in line with national guidance.
Second interaction – 12 October 2020 (when blood test results arrived)
29. The test results show H’s vitamin B12 levels were 381 and his FBC was in the normal range.
30. Our GP adviser explained FBC contains the MCV level, which is typically raised in vitamin B12 deficiency, and the haemoglobin level, which, if low, is consistent with anaemia secondary to vitamin B12 deficiency. The MCV shows the average size of red blood cells, and haemoglobin is a protein carried in red blood cells.
31. Furthermore, the NICE guidance explains that in 97% of cases, cobalamin of less than 200 nanograms/L is enough to diagnose vitamin B12 deficiency. Cobalamin is a nutrient contained in vitamin B.
32. As we can see from H’s test results, his B12 levels were not below 200, and his other levels did not suggest any further cause for concern, as his FBC result was in the normal range. Therefore, in the circumstances, we consider there was no definitive indication H required vitamin B12 injections at this time.
33. As a result, the GP’s decision not to prescribe the injections was in line with the GMC guidance about being fully informed and only providing treatment when medically justified.
Third interaction – 3 March 2021 (when private blood test results arrived)
34. Our GP adviser explained tests for MMA are not tests GPs can ask for. Therefore, they are not familiar with them or able to interpret or respond to these results.
35. Paragraph 14 of the GMC guidance says doctors should act only within the limits of their knowledge and training. Paragraph 16a says they should provide treatment only when they are fully informed of and knowledgeable about the situation.
36. In this instance, we consider the GP was not the right person to prescribe vitamin B12 injections as they were not knowledgeable enough about MMA levels to do so. This is in line with the GMC guidance.
37. In each of these circumstances we have identified the GP acted in line with the relevant national guidance in not prescribing vitamin B12 injections. We can see the GP instead kept in regular contact with the local haematology specialists and asked them for advice about H’s symptoms and test results. This is in line with paragraph 16d of the GMC guidance, which says doctors should consult with other medical professionals when this serves the patient’s needs.
38. In conclusion, it was appropriate for the GP not to prescribe vitamin B12 injections and, in seeking further advice from haematology specialists, the GP provided H the most appropriate level of care and investigations in line with the GMC guidance.
The Practice agreed on 16 December to refer H to a paediatrician but did not do this until 5 February, when Mrs U asked for a copy of the referral letter
39. Mrs U complains the GP agreed to make the referral during a consultation in December 2020. At the end of January 2021, she rang the Practice to obtain a copy of the referral letter. This caused the Practice to make the referral in February. She believes if she had not contacted the Practice to get a copy of the letter, the Practice would not have sent it.
40. From H’s medical records, we can see the GP said on 16 December they would refer H to a paediatrician. There is no further mention of this referral until 5 February, when the records show an administrator populated a document entitled ‘Referral to community paediatrician’. This was after Mrs U asked for a copy of the referral on 29 January, as documented in a telephone note in H’s records on this date.
41. Paragraph 15b of the GMC guidance says doctors should ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’.
42. We see the Practice took seven weeks to make the referral to the paediatrician. We do not think this was quick enough. This goes against the GMC guidance and therefore a sign of failing.
Considering the impact this had on Mrs U and H
43. We therefore considered the impact this failing had on Mrs U and H. Mrs U told us H’s symptoms continued to have a substantial effect on his everyday life. She says his tiredness, difficulty concentrating and low mood meant he felt he could not go to school during this time.
44. She also says that, without a formal diagnosis, the school could not provide H with the support he needed and, because of the Practice’s delays, his diagnosis and therefore any help from the school were also delayed.
45. Mrs U says this delay, along with the other parts of her complaint, caused her and H an injustice which is ongoing. As we are not looking further into these parts of the complaint, we cannot link a longer period of injustice to this part of the complaint. This is because the Practice did make the referral as planned, but seven weeks later.
46. Therefore, there appears to be an injustice of a seven-week delay in any treatment for H. We appreciate during this time Mrs U believed the referral was progressing, and she was frustrated and annoyed when she discovered this was not the case.
47. To some extent, the Practice addressed the injustice to Mrs U and H, as it did eventually make the referral to the paediatrician. However, we have not seen any sign the Practice has apologised to Mrs U and H for the impact this had on them in the interim. The Practice has not made service changes to prevent this from happening again.
What the Practice has agreed to do
48. The Practice has not provided any response to Mrs U’s complaint about the referral to the paediatrician. Therefore, we consider the Practice has not done enough to address the injustices to Mrs U and H noted in the complaint.
49. We asked the Practice whether it would be willing to take action to address this impact on Mrs U and H.
50. In considering what action should be taken to provide Mrs U with a suitable outcome, we referred to our Principles for Remedy. These state that where poor service or failings have led to injustice or hardship, the organisation responsible should take steps to put things right. They also say organisations should seek continuous improvement to make sure poor service is not repeated. Moreover, those principles emphasise the importance of being customer-focused, which includes accepting and apologising for failings.
51. Our Principles for Remedy say public organisations should consider various ways to put things right and do so in a way that is appropriate in each case. In this instance, we have considered the outcomes Mrs U wants, the indicated failings and the impact the Practice’s actions had on Mrs U and H.
52. We asked the Practice to apologise to Mrs U and H for the delay in making the referral to the paediatrician and recognise the impact this had on them.
53. We also asked it to review its processes around the provisional failings and create an action plan to show how it will make sure referrals are made promptly.
54. The Practice has agreed to do this. Our Principles for Remedy say an organisation should recognise its failure, show a willingness to accept responsibility and put things right. We believe what the Practice has done is in line with those principles.
The Practice agreed on 3 March 2021 to refer H to haematology but did not do so until 19 July
55. Mrs U says the Practice delayed making H’s referral to the haematology department despite agreeing in March 2021 that he needed its input.
56. The records show the GP told Mrs U on 3 March they would write to the haematology department to discuss H’s symptoms and test results. They did this on 10 March.
57. On 17 March, the haematology department responded to the GP. It advised that H would possibly benefit from being seen by the paediatric metabolic unit at the hospital. It said if H’s MMA levels were raised, vitamin B12 deficiency would be more likely.
58. On 19 March, two GPs at the Practice reviewed this advice and H’s November 2020 results. His MMA levels were 2.91 and 1.5mg/g, with the normal range for such results being anything lower than 3.7. They also noted H had already been referred to the community paediatric team and they would wait for this referral to be completed before considering a referral to the hospital.
59. Mrs U contacted the Practice on 8 July to chase the referrals to both haematology and acute paediatrics at the hospital. At this time, the GP told Mrs U the community paediatric team was making the referral to acute paediatrics and would wait for the outcome of this before making the referral to haematology. On 14 July, the GP reiterated this position and confirmed the community paediatrics team had made the referral to acute paediatrics.
60. On 15 July, Mrs U contacted the Practice to ask it to write a letter to speed up the acute paediatrics referral and make the haematology referral. On 19 July, the Practice made the referral to haematology.
61. The GMC guidance says, in paragraph 15c, doctors should refer patients to other practitioners when this serves the patient’s needs. Paragraphs 16a and 16b say they should only provide treatment based on the best available evidence and when they have adequate knowledge of the patient’s condition to be satisfied the treatment best serves their needs. Paragraph 15b emphasises the importance of providing prompt treatment where appropriate.
62. Our GP adviser helped us to understand the referral processes. They explained the paediatric metabolic unit at the hospital is a tertiary unit. This means it is a highly specialised department. It is usual practice that tertiary units only accept referrals from other specialists or hospital departments and not directly from a GP.
63. They also explained it was not clear exactly what specialism H needed, given that his blood test results were inconclusive, and any further interpretation of the results was beyond the knowledge of a GP. Therefore, it was appropriate to await the community paediatrics team’s decision before proceeding with any further referrals. This is because they were able to conduct further assessments and make the appropriate decisions on any further referrals for H. This is in line with the GMC guidance because the GP was making sure any treatment was the most appropriate course of action based on the information available at the time.
64. Furthermore, multiple referrals, especially when it is not usual practice for them to come from the GP, could have caused delays to H’s treatment. This is because the involvement of multiple specialisms (in this case, the community paediatrician, acute paediatrics, haematology and the metabolic unit) may have caused confusion, communication difficulties and conflicting treatments. Therefore, to reduce the risk of delays to H’s treatment, it was appropriate to wait for the community paediatrician to finish their assessments and complete the referral to acute paediatrics before the GP made any further referrals.
65. This was in line with paragraph 15b of the GMC guidance as, in the bigger picture, the GP’s actions prevented any undue delays and confusion in providing treatment. Given that during this time H was continuing to receive care from appropriate professionals (the community paediatrician then the acute paediatrics department), we consider there was no medical justification for the GP to make this referral any sooner than they did.
66. Consequently, there is no sign the Practice should have done any more than it did in the circumstances.
The Practice did not provide access to H’s medical records online and did not call Mrs U back when she asked for help to resolve this between 20 July and 5 August 2021
67. Mrs U says she wanted to obtain access to H’s medical records so she could form her complaint, investigate his symptoms further and seek help from other medical professionals. She says she spoke to the Practice several times over the telephone as she tried to access H’s records and resolve technical issues. She says the Practice kept saying it would get back to her and resolve the matter, but it did not, and she had to keep chasing it.
68. In H’s medical records, we cannot see any evidence of these repeated communications between Mrs U and the Practice about accessing the medical records. There is an entry on 2 August 2021 that details how Mrs U explained she could not access her or H’s records and asking for this to be resolved. The Practice noted this and its conversation with the IT department about linking the records so Mrs U could access both of them. The receptionist said they passed on the message ‘via task and email and also raised an IT ticket’.
69. In the absence of any further evidence regarding the interactions between Mrs U and the Practice about accessing H’s records, it is difficult for us to reach a conclusion about the Practice’s actions. Therefore, we cannot say much more regarding this part of the complaint.
70. We can also see Mrs U says these difficulties took place over a relatively short period of 16 days. She obtained access to H’s records when she moved him to another practice shortly after. As a result, the new GP has now resolved this part of the complaint.
71. In the interests of proportionality, it would not be productive to investigate further this part of the complaint when we are unlikely to be able to reach a definitive conclusion. This is particularly so in light of the relatively minor impact this had on Mrs U over a short period of time.
The Practice did not acknowledge or reply to Mrs U’s complaint letters dated 29 January, 22 February and 5 March 2021
72. Mrs U complains that despite repeatedly chasing the Practice it did not respond to her formal complaint, which she originally made in January 2021. She explains she sent these letters via Royal Mail tracked delivery and received confirmation the Practice had received them.
73. Mrs U made her formal complaint to the Practice on 29 January 2021. She then resent this to the Practice on 22 February and chased a response on 5 March. She did not receive a response, and she brought her complaint to us on 11 August 2021.
74. We contacted the Practice on 13 August 2021, 14 September 2021 and 28 January 2022. On 28 January 2022, the Practice assured us it would respond to Mrs U. Once we reopened the complaint, we contacted the Practice via email on 5 July 2022. The Practice acknowledged the email on 14 July. We reminded the Practice on 2, 4 and 5 August 2022 to provide its response. The Practice acknowledged the latest email but did not provide any response to the complaint to either Mrs U or us.
75. NHS Resolution’s ‘Responding to complaints’ says GP practices should treat complainants with respect and courtesy, and they should receive a prompt and appropriate response to their complaints. The NHS Constitution also says staff should welcome and listen to feedback and address concerns quickly and in the spirit of co-operation. Furthermore, our Principles of Good Complaint Handling also say that organisations should deal with complaints quickly and sensitively and investigate complaints thoroughly.
76. Given that the Practice was aware of Mrs U’s complaint and there is no evidence it attempted to provide a response despite ample opportunity to do so, there is a sign of failing.
Considering the impact this had on Mrs U
77. Mrs U says she felt frustrated and annoyed because of the Practice’s lack of response to her complaint. She explains this made her feel as though the Practice was not listening to her. We can see why Mrs U feels this, given her multiple attempts to contact the Practice and the fact she has not received any response. We can see how this links directly to the above failing.
What the Practice has agreed to do
78. The Practice has not provided any response whatsoever to Mrs U’s complaint. Consequently, we consider the Practice has not done enough to address the injustices raised in Mrs U’s complaint.
79. We asked the Practice whether it would be willing to take action to address this impact on Mrs U and H.
80. In considering what action should be taken to provide Mrs U with an appropriate outcome, we referred to our Principles for Remedy. These state that organisations should seek continuous improvement to make sure poor service is not repeated. Moreover, the principles emphasise the importance of being customer-focused, which includes recognising and apologising for failings.
81. Our Principles for Remedy say public organisations should consider various ways of putting things right and do the appropriate thing in each case.
82. In this instance, we have considered Mrs U’s desired outcomes, the indicated failings and the impact the Practice’s actions had on Mrs U.
83. We asked the Practice to write to Mrs U to apologise for not acknowledging or responding to her complaint and subsequent correspondence and to recognise the impact this had on her.
84. We asked the Practice to review its processes around the provisional failings in its handling of the complaint. We also asked it to create an action plan to show how it will make sure all complaints are addressed in the future and how it shall comply with NHS policies regarding complaint handling.
85. The Practice has agreed to do this. The principles say an organisation should recognise its failure, show a willingness to accept responsibility and put things right. We believe the above actions are therefore in line with our Principles for Remedy.
Resolutions
86. The Practice has agreed to apologise to Mrs U for the impact to her and H as a result of its indicated failings in delaying the referral to the paediatrician and not replying to Mrs U’s complaint correspondence.
87. It will review and make service changes in relation to its processes around the provisional failings. It will also create an action plan to show how it will make sure it completes referrals promptly and replies to all complaints in compliance with NHS complaint guidelines.
88. We are pleased that we have been able to achieve the outcomes Mrs U wanted, and we consider this resolves the outstanding issues on Mrs U’s complaint.
Summary
89. We understand H has since received a diagnosis for his symptoms, and we are pleased to hear he is receiving treatment for this.
90. We hope we have been able to provide some reassurance, and we consider the resolution addresses the aspects of the complaint where we found indicated failings had caused an impact. We hope we have explained our decision clearly.