The Trust did not recommend a PPI for Mrs B from 2006 to 2018 to line her stomach and reduce the side effects of the anti-inflammatory medication she was taking for her arthritis 23. Mrs B complains the Trust failed to recommend the correct digestive medication (medication to reduce stomach acid production) from 2006 to 2018 to reduce the effects of the NSAID medication she was taking.
24. She says this caused a peptic ulcer to form in February 2018, when she was rushed to hospital, had a laparotomy (a type of open surgery of the abdomen) and was told she had a hole in her stomach and needed surgery.
25. Mrs B has a large scar from the surgery on her stomach. She says this has crushed her confidence. She also says the pain of the ulcer and impact of the surgery on her body means she can no longer live the active life she used to.
26. Mrs B says she had an appointment with the rheumatologist at the Trust who had asked her GP to recommend etodolac on 30 May 2018.
27. Mrs B says, when she asked the rheumatologist why they did not also ask the GP to recommend medication to line her stomach, they replied: ‘well you were a lot younger then and I didn’t think you needed anything to put a lining on your stomach’.
28. Mrs B says the rheumatologist never discussed medication to line her stomach with her before the surgeon told her why the perforated ulcer developed, and she was not aware something like omeprazole (a PPI) existed during the years she was taking etodolac.
29. Mrs B says she also had an appointment with an arthroplasty (replacement surgery for joints done by realigning the joint or replacing it with an artificial one) nurse on 14 August 2019. Mrs B says the nurse was shocked to hear Mrs B was taking etodolac when she had a perforated gastric ulcer and said, ‘you should not have been put onto etodolac without something to put a lining on your stomach’.
30. Mrs B is concerned the rheumatologist who first suggested the medication did not know about this when other professionals in the healthcare industry did.
31. In its response, the Trust said etodolac and some other NSAIDs have a lower risk of gastrointestinal side effects, like ulcers, compared to other, similar drugs.
32. The Trust said it was not normal to recommend a drug to line the stomach at the time Mrs B was recommended etodolac, except in elderly patients or if the patient had indigestion.
33. The Trust said the NICE Guidance recommends using a PPI (such as omeprazole) for patients with rheumatoid arthritis (a long-term condition that causes pain, swelling and stiffness in the joints) and osteoarthritis (a condition that causes joints to become painful and stiff) when they receive any type of NSAID.
34. The Trust also said all prescriptions must be reviewed and modified, if necessary, if a patient’s condition changes. It recommends prescriptions for older patients be reviewed because older patients may be more likely to have side effects.
35. The Trust said GPs and pharmacists usually review medication each year. It apologised to Mrs B that they did not explain this to her.
36. The Trust said the rheumatologist thought the person responsible for recommending the drug would also give her advice about the possible side effects and risks of taking the medication, which is what normally happens. It apologised that Mrs B feels no one explained the possible risks of etodolac to her, and for any additional anxiety this may have caused her.
37. We asked an independent rheumatologist (‘our adviser’) for advice about whether the Trust should have recommended a PPI to Mrs B while she was taking etodolac for over ten years from 2006 to 2018.
38. Our adviser said long-term use of NSAIDs is not recommended; they should be given only for short periods and at the lowest possible dose to have an effect.
39. But our adviser said some patients are on NSAID medication for many years when no other suitable analgesia is available and it is helping them.
40. We can see that, while the rheumatologist first recommended the drug, the GP continued to recommend it for Mrs B.
41. Our adviser said leaflets about NSAID medication mention a risk of gastric side effects and say to seek medical advice if there are any problems.
42. Our adviser said it would make sense to ask patients on long-term NSAID medication about any gastric problems and make sure they are treated if necessary. Our adviser explained that the GP, specialist or even a pharmacist providing the medication could be responsible for asking patients if they were having any problems.
43. Our adviser explained that guidance for using a PPI with NSAIDs has changed and there is evidence to support the Trust’s response that, in 2004, using a PPI with NSAIDs was not recommended for patients under the age of 65 with no history of bleeding (Mrs B was under 60 years old and had no history of bleeding when etodolac was first recommended).
44. The NICE Guidance says if two risk factors are present, staff should consider recommending a PPI. Our adviser said Mrs B may have needed a PPI because she was taking a high dose of an NSAID (etodolac) for a long time, and both of those things are risk factors.
45. However, it is not clear whether older NICE guidelines made the same recommendation during the 12-year period Mrs B was taking etodolac. Also, it is not clear who would have been responsible for recommending a PPI, as this would likely have been a shared responsibility between primary and secondary care.
46. Mrs B has complained about the care and treatment of the Trust only. We have no power to consider the actions of any other organisation and we believe a full investigation of this issue would not produce a satisfactory conclusion.
47. We cannot take this part of the complaint any further because: the period of care Mrs B is complaining about is so long; we cannot say with certainty when the guidance changed about recommending using a PPI with NSAIDs, which means we cannot tell if there is a failing; and the shared responsibility for recommending a PPI with NSAIDs stops us from fully investigating the issue.
48. For those reasons, we have decided not to do a detailed investigation.
49. We are sorry to hear Mrs B developed a stomach ulcer and has a scar on her stomach from the surgery. We recognise this decision may be frustrating for her, but we hope the points above show we have considered the issue carefully.
The Trust delayed providing appropriate treatment for the arthritis in her left hand from 2007 to 2018 50. Section 9(4) of the Health Service Commissioner’s Act 1993 says the person complaining must complain to us within one year from the day they first became aware they had reason to complain. If they do not, the law says we cannot investigate their complaint unless we consider it reasonable to do so.
51. Mrs B complains the Trust delayed providing appropriate treatment for the arthritis in her left hand from 2007 to 2018. She says this caused her to be in constant pain, with swelling and reduced function in her hand.
52. She feels this would have been avoided if the Trust had correctly referred and treated her when she reported the symptoms.
53. Mrs B says she became aware of this issue when a different rheumatologist assessed her in December 2018, saying she should have been referred for treatment for the arthritis in her left hand much earlier.
54. Mrs B had a trapeziectomy (a procedure to remove the trapezium, a small bone in your wrist, which can help to relieve pain and enable the thumb joint to work as it should) in May 2019, and she feels this could and should have happened much earlier if she had been referred.
55. We recognise Mrs B feels it was December 2018 when she found out she could have had a trapeziectomy in her left hand earlier.
56. We have considered this carefully, but we feel it is likely Mrs B was aware of the pain in her left hand (and was unhappy that treatment was not helping it) before December 2018. She says she had been reporting pain in her left hand since 2007, and likely had concerns throughout this period that she was not being referred or receiving the appropriate care and treatment.
57. For example, during this period of care, Mrs B says she had an injection of hydrocortistab (a medicine which reduces pain, itching and swelling) in one of the fingers on her right hand during a clinic appointment at the Trust in June 2010. Yet she says her medical notes say she also has marked swelling on one of the fingers on her left hand.
58. In her complaint letter to the Trust, Mrs B said the joints in her hands were becoming more and more painful and she said the middle finger of her left hand was injected only once in 2010: ‘it would have then been seven years later before it was ever attempted again, when the rheumatologist eventually, after being prompted by me took the time to try the steroid injection in my left middle finger for only the second time, but by this time it was already too late.’
59. This suggests Mrs B was aware and unhappy before 2018 that she was not being treated for the pain she was experiencing in her left hand, and that she was unhappy she had not got any injections since 2010.
60. Our usual approach would be to review the person’s medical records to look for an exact date when the person first knew about this part of their complaint.
61. However, in line with our ‘Principles of proportionality’, we do not think it would be proportionate to review medical records for an 11-year period to find out exactly when Mrs B first knew about this part of her complaint. We believe it would be extremely difficult to say exactly when she became aware of the Trust not treating her left hand.
62. Overall, we think it likely Mrs B had concerns about the pain in her left hand during this period, and we think she could have asked why she was not getting any treatment or complained earlier than she did.
63. Mrs B said she did not bring the complaint to us earlier because she was diagnosed with cancer in June 2017 and was concentrating on her health. We understand her reasoning.
64. We can see the local complaints process took approximately one year and seven months in total (Mrs B first complained to the Trust on 12 November 2019, and the Trust confirmed on 10 May 2021 it had given her its final response and recommended she contact us if she was still unhappy).
65. We can see the Trust took around three months to respond to the first complaint letter, five months to respond to her second complaint letter and two more months to respond to Mrs B’s letter outlining her remaining concerns and containing images of the scars on her stomach. In total, the Trust was responsible for a ten-month delay.
66. We consider the complaint to be over our time limit, because Mrs B would have been concerned she was not receiving treatment for the pain in her left hand between 2010 and 2018.
67. While the Trust was responsible for a ten-month delay, we can see the main reason for delay appears to be Mrs B not raising a complaint earlier than she did.
68. While we have decided to disregard our time limit for the other parts of Mrs B’s complaint because of her cancer diagnosis in June 2017, we see no strong reason to justify her delay in making a complaint for the period before this. We have decided not to disregard our time limit for this part of the complaint.
69. We are very sorry Mrs B has unresolved concerns about her care. We appreciate why she brought the complaint to us. Unfortunately, we are unable to take this part of Mrs B’s complaint any further because it goes over our time limit.