Medication, GP support, referrals, accessibility, treatment other than those components of the complaint listed below
14. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so. We discussed this with Ms U to understand the reasons why she could not make her complaint earlier.
15. The events Ms U complains about took place over a number of years. After considering Ms U’s clinical records, her complaint correspondence and by talking to her, we have identified events which happened during the following time periods:
July 2020 complaint
• mental health: from childhood • ongoing childhood illnesses: before 2016 • nerve damage: 2015 • invitations to appointments at the Practice: 2015 • medication: unknown, Ms U says ‘many years before 2020’
May 2021 complaint
• transport: 2018 • ingrown toenail: 2012 • medication: from childhood
16. We consider Ms U’s date of knowledge to be when the events happened, except in relation to the concerns which started during her childhood. Ms U told us she took responsibility for her healthcare when she was 16, and this is when she became aware and was able to speak up for her own health and concerns. We therefore consider this to be her date of knowledge for these earlier events.
17. Ms U made her first complaint to NHS England on 20 July 2020, and to the Practice on 24 and 29 July. This is at least five years after the date of the latest event detailed in the first complaint letter.
18. The Practice replied to the complaint on 21 August 2020. At this time, the Practice signposted Ms U to us. NHS England provided its final response on 15 September 2020.
19. Ms U raised her second complaint to the Practice on 25 May 2021. This is at least four years after the date of the latest event. We chased the Practice for a response on 15 June, and it identified Ms U had sent her email to an unmonitored inbox. It provided a formal response on 1 July (the letter is incorrectly dated 30 July). This is after Ms U submitted her complaint form to us.
20. Ms U made her complaint to us on 7 May 2021. The law says we cannot look at any complaints brought to us over one year after the date of knowledge, except in exceptional circumstances. In light of the above timeline of events, we can see her complaint is at least two years out of time for the date of the latest event or date of knowledge.
21. Ms U told us she has been complaining to the Practice for many years. She said she has complained to the GPs repeatedly, and she put her complaint in writing when she felt the issues had become more important. She said, at this point, she had had enough of the Practice and the way it treated her, and this is why she then pursued her complaint. We appreciate Ms U’s continued frustration with ongoing issues at the Practice, and we are sorry to hear of her problems.
22. Ms U also explained she has struggles with reading and writing. This has always been the case and has become worse since her stroke in March 2020. This is why she got help to pursue her complaint with the Practice.
23. The law is clear the date of knowledge is the date the complainant became aware they had a reason to complain, not when they knew the exact details or significance of this. Ms U told us she has not been satisfied with the Practice and has raised these issues for a number of years. We understand Ms U made her formal complaints in 2020 and 2021, as she felt this is when she had had enough of the Practice. As a result, we consider Ms U was aware of her need to complain a long time before she brought her complaint to us.
24. We recognise Ms U finds making a written complaint a difficult process, and this is why she contacted an advocate to help her. Ms U does not say this process caused any delays in her making a complaint, or that she was unable to get an advocate sooner.
25. In summary, we conclude Ms U’s complaint is at least two years out of time, and we have not seen reason enough to set aside the time limit in the circumstances.
Blood tests and medication from the hospital
26. Ms U complains the Practice did not arrange for her to have blood tests to check her immunity to COVID–19, which her asthma specialist wanted her to have.
27. She also says the GP would not prescribe the medication the hospital said she needed, once she was discharged after suffering a stroke in early 2020.
28. We spoke with Ms U at length about these events over a number of telephone calls. We have sought to identify what medication her complaint relates to, and when she was supposed to have the blood tests. Ms U told us she could not recall what these points of her complaint were relating to. She also said she did not recall why she complained about them or told us about these issues.
29. We also got Ms U’s medical records to see if they could shed any further light on these events or help to provide any further context which would aid Ms U or ourselves in identifying this information.
30. After consideration of Ms U’s medical records, we cannot find any reference to blood tests relating to Ms U’s asthma and testing for COVID-19 immunity.
31. We have seen in early 2020, Ms U, the Practice and other medical professionals had discussions after her stroke about prescribing gabapentin medication (an anticonvulsive medication to treat seizures and nerve pain). However, Ms U’s complaint is regarding the Practice’s refusal to prescribe medication, and the record entries show the Practice identifying the most appropriate dosage of medication and prescribing this. So we cannot say, with enough degree of certainty, Ms U’s complaint is about this medication.
32. We looked at the Practice’s response to Ms U’s complaint. Regarding medication, it provided a general response as to how it can work with Ms U and the pharmacist to meet her medication needs. The Practice said it could not identify a specific incident where it refused to provide Ms U with medication the hospital had prescribed.
33. Regarding the blood tests, in its complaint response the Practice said it had arranged these tests now they were due. It said it provided Ms U with the forms to go for the tests and it would inform her of the results.
34. We appreciate, due to Ms U’s memory and communication difficulties, recalling these details is more difficult, and so we took extra steps to ensure these limitations did not disadvantage Ms U.
35. However, despite these attempts, we were unable to identify the information needed to conduct a proper and detailed investigation. As a result, we have decided to close these parts of the complaint.
36. We trust Ms U understands our efforts to try to identify these issues, and we are sorry we are unable to look into these parts of the complaint any further.
Referrals after stroke
37. Ms U says she needed the input of a number of specialists to aid her recovery from a stroke in March 2020. She complains the Practice did not make the referrals to mental health, physiotherapy and social care services when she needed this care.
38. The Practice said it tried its best to provide the best care possible. It explained it made many referrals and spent a lot of time liaising with different teams to get Ms U the help she needed to aid her recovery. The Practice accepted Ms U wanted more than this, and it said it would continue to do its best to address this issue.
39. We reviewed Ms U’s relevant clinical records to determine what happened at this time.
40. Ms U suffered a stroke on 2 March 2020, for which she received hospital treatment. The hospital discharged her shortly afterwards, and referred her to the care of the Early Supported Discharge Unit (ESDU) medical staff, who identified which specialists she required for her rehabilitation needs.
41. Ms U was admitted to the ESDU for recovery support on 9 March, and she remained there until 12 March when she discharged herself. She continued to be under the care of the ESDU as an outpatient until it discharged her on 16 April.
42. During this time, Ms U and the ESDU kept in contact with the Practice. On 9 March, Ms U contacted the Practice to voice her concerns about the lack of follow-up care after her stroke. The GP advised Ms U they were awaiting information about this from the hospital trust.
43. On 11 March, Ms U rang the Practice to ask for her new medications to be added to her repeat prescriptions. She did not know the names of the new medications, so the GP sent Ms U the list of her current medications for her to review.
44. A GP contacted Ms U on 13 March. They discussed the treatment the psychology and occupational therapy services were providing to her. The GP told Ms U someone from a stroke support charity would visit her to help her understand what had happened and provide support. Ms U expressed concerns her housing benefits might be stopped, but said at the present time things were fine. The GP offered to refer Ms U to mental health services, but she declined as she was unsure about how they could help her at the time.
45. The ESDU continued to arrange for psychology, physiotherapy and occupational therapy services to attend to Ms U. On 20 March, the Practice contacted the ESDU, which confirmed the services providing help to Ms U (occupational therapy, psychology and physiotherapy, and the stroke charity for social care).
46. On 25 March, a local authority made a referral for a community navigator to help Ms U with her mental health and social needs.
47. The psychology team contacted the Practice on 27 March, and they agreed the GP would refer Ms U to the community mental health services. The GP spoke with the stroke charity about the care it was providing Ms U on 31 March.
48. On the same day, Ms U had an appointment with the GP and mentioned the psychology team’s recent comments about her medication. The GP said they would be happy to add the medications to her prescription once they heard from the psychology team. There is no recorded evidence the psychology team contacted the Practice about Ms U’s medication needs at this time.
49. Ms U contacted the Practice on 2 April, as she was concerned about the lack of communication from the treatment providers. The GP said they would contact the treatment providers for an update. The GP contacted a local community mental health service, which provided contact details for Ms U to get further mental health support. The GP passed on this information to Ms U, added her to the vulnerable call list at the Practice, and arranged to speak with her again in a week.
50. Ms U was discharged from physiology services on 8 April, the psychology team on 15 April, the ESDU on 16 April and occupational therapy services on 21 April. The ESDU noted she required ongoing mental health support and physiotherapy, and her GP would need to liaise with these services. The ESDU explained it had already referred her to local authority welfare services, housing association services and the stroke charity was providing her with help.
51. On 27 and 28 April and 11 May, the local authority support service reviewed Ms U’s mental health needs. On 11 May, the GP confirmed the mental health team had seen Ms U on 1 May, and they had prescribed her sertraline (an antidepressant medication) and confirmed she was seeking help from the mental health charity.
52. During a consultation with Ms U on 13 May, the GP reassured Ms U they would provide the council with any reports she needed to help with her housing benefits.
53. On 15 May and 8 June, the local authority called Ms U to check in on her. She confirmed a number of services were providing her with support, including the mental health team. On 10 June, the local authority also referred Ms U to a specialist befriending call list for additional social support.
54. Ms U attended the Practice on 16 June and saw a GP. During the consultation, they discussed her ongoing sciatica (pain caused by pressure on the sciatic nerve). Ms U explained she did not think the physiotherapy service had discharged her, as she had been attending until lockdown, and then she had her stroke. The GP had a long conversation with Ms U about managing her symptoms with medication and movement. The GP followed this up with an email to Ms U, enclosing some exercises for her to do and a link for her to self-refer for physiotherapy treatment.
55. The local authority discharged Ms U on 23 July. On 24 July, Ms U’s stroke co-ordinator arranged for her to receive more physiotherapy.
56. On 24 July, Ms U contacted the Practice, as she felt she was getting very little mental health and social care from the community services. The GP provided Ms U with the details to seek further social support and agreed to follow up with her in a couple of weeks.
57. Ms U returned to the Practice on 28 July to explain she had contacted social services, but she felt this was a circular process. The GP suggested to Ms U the services she wanted may not exist. They agreed to contact the mental health services to see where she was in the system. Ms U said she thought she had replied to the pain team so it could provide her with treatment.
58. Paragraphs 15(b) and 15(c) of the GMC’s ‘Good Medical Practice’ says doctors should ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’ and ‘refer a patient to another practitioner when this serves the patient’s needs’. It also says, at paragraph 35, doctors should ‘work collaboratively with colleagues, respecting their skills and contributions’.
59. We can see from 9 March to 16 April, Ms U was under the care of ESDU, and it was responsible for arranging physiotherapy, occupational therapy, mental health and social care services. From 25 March to 23 July, the local authority took responsibility for arranging Ms U’s mental health and social needs in the community. So we can see, in the first instance, the Practice was not primarily responsible for Ms U’s care immediately following her stroke.
60. As a result, it was appropriate for the Practice to allow the ESDU and the local authority to co-ordinate her care, as they did. This is in line with paragraph 35 of ‘Good Medical Practice’, as the Practice was respecting the other organisations’ role in her treatment and their decisions regarding her care.
61. During this time, the Practice kept in touch with the ESDU and the local authority to ascertain the treatments Ms U was receiving and whether she needed any further help. This is in line with paragraph 35 of the GMC’s ‘Good Medical Practice’, insofar as the Practice made sure it got enough information about Ms U’s ongoing care.
62. When Ms U contacted the Practice during this time, she sometimes told the Practice about actions the other care providers wanted the Practice to take. The Practice said it would speak with the care provider or await correspondence from them.
63. Given the number of agencies involved in Ms U’s care, and the fact it identified instances of referrals being duplicated due to miscommunication, we consider the Practice’s actions during this time to be appropriate. This is because there was a real risk of further confusion, which could have caused delays, and so we consider the Practice’s actions were in line with paragraph 15(c) of ‘Good Medical Practice’, as the Practice was first making sure its involvement would best serve Ms U’s medical needs.
64. Once Ms U was discharged from ESDU and the local authority, the Practice took over her day-to-day care. It provided her with the website link to make a self-referral to physiotherapy and social support. It also contacted a local hub to get information about the mental health services available to Ms U and passed on this information to her. When Ms U returned to the Practice after contacting these services, it agreed to contact the mental health team to see where she was in its system. So we can see the Practice appropriately took over Ms U’s care once ESDU and the local authority had discharged her.
65. We see from Ms U’s records she was receiving contact and treatment from a number of specialist teams, all within a very short period of time (from March to July). We appreciate this will have been a lot of information for Ms U to take in, at the same time as coming to terms with suffering a stroke and the recovery process.
66. We also understand Ms U struggles with her memory, and can sometimes be confused when interacting with a number of care providers. So we appreciate why this was a difficult period for Ms U, and how this may have impacted her view of the Practice’s actions during this time.
67. To conclude, we can see no evidence from the records to show the Practice did not do what it should have done to make sure Ms U received the correct care after her stroke. It kept itself informed of Ms U’s treatment while she remained under the care of the ESDU and the local authority, and provided the relevant contact details or referrals to other service providers once they discharged her from their care.
Brain scan
68. Ms U says she was due to have a brain scan in 2020, but this was cancelled as she was self-isolating during the COVID-19 pandemic. She complains the Practice refused to rearrange the scan once she was able to attend again.
69. The Practice said it was not aware of a referral for a scan or who requested it. It also said it did not think she needed the scan rearranging, as she had recently been in hospital and had scans completed during this time. The Practice said it contacted the neurologist (a doctor specialising in conditions affecting the brain and spinal cord) in response to her request, to see if further imaging would be helpful.
70. In Ms U’s complaint dated July 2021, she mentioned the scan as being due to take place last year. We have reviewed Ms U’s medical records from 2020 to the date of her complaint, and we cannot see any reference to a referral for a scan or when this was meant to take place. There is also no evidence in Ms U’s records of a discussion taking place with the GP about it.
71. However, on 5 October 2020, the Practice referred Ms U to the neurology department, and in this referral it specifically asked, ‘are further neurological investigations or interventions needed following her stroke?’ We can see the Practice sent this referral again on 15 March 2021.
72. Paragraph 16(a) of the GMC’s ‘Good Medical Practice’ says doctors must ‘prescribe drugs or treatment, including repeat prescriptions, only when [they] have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs’.
73. We appreciate the lack of evidence around this discussion limits the degree to which we can examine the Practice’s actions in the circumstances. In this instance, we do not know the full timeline of events.
74. However, Ms U’s complaint is not about the Practice making the referral within a certain timeframe, but that it did not make the referral at all.
75. We can see the Practice did make a referral to the neurologist, but it did not specifically ask them to perform a scan. Rather, the Practice asked the neurologist if this would be appropriate.
76. We consider the Practice’s actions to be in line with what we expect to see in the circumstances. This is because the Practice was unaware of any previous plan to perform a scan or the purpose for this. As it was unaware of the medical need to perform a scan, the alternative solution was to seek the opinion of a professional who was better informed to make this decision.
77. As a result, the Practice’s actions were in line with paragraph 16(a) of ‘Good Medical Practice’, which says doctors should only prescribe treatment when they have enough knowledge it serves the patient’s needs.
Designated GP
78. Ms U complains the Practice will only let her see a specific GP, and this means she experiences long waiting times before they are available. She complains this restricts how easily she can access medical treatment when needed.
79. The Practice said it is normal practice for a patient, in particular those with complex needs, to see a specific GP for continuity of care. It said, even when patients have a designated GP, they can still have appointments with other GPs, in particular in emergency situations. The Practice said this arrangement had never prevented Ms U waiting longer than two weeks for an appointment.
80. We considered Ms U’s Practice records from 2020 onwards. Ms U’s records show she saw a number of different GPs and nurses. One GP, Dr P, communicated with other care providers about Ms U after she suffered a stroke in early 2020. On 27 March, another GP noted they would arrange for Ms U to see her ‘usual’ GP to discuss her medication queries the following week.
81. The GMC’s ‘Good Medical Practice’ says doctors must work together (paragraphs 16(d) and 35) to provide treatment, make sure the patient sees the most appropriate practitioner to meet their needs and knows about their treatment (paragraphs 15(c) and 16(f)), and encourages safe collaboration and continuity of care (section 44).
82. In this instance, we can see a number of different medical professionals at the Practice reviewed Ms U, although Dr P was primarily co-ordinating and taking responsibility for Ms U’s longer term care needs. We consider this to be in line with the above GMC guidance. This is because medical professionals were able to respond to Ms U’s needs during individual appointments, but the Practice also provided overall, consistent care, as one GP was responsible for Ms U’s longer term needs.
83. Regarding the consultation on 27 March, the GP’s decision to refer Ms U to a colleague to review her medication needs was in line with paragraphs 15(c) and 16(f) of the GMC guidance, as they did this to make sure the GP most informed about Ms U’s medical needs could make the best informed decision.
84. So, we consider there are no signs of a failing for this part of the complaint.
Summary
85. In summary, we have decided we will not take further action on the majority of Ms U’s complaint, as the complaint is out of time. We understand this will be disappointing for Ms U, and we hope we have explained our consideration of this in detail.
86. Regarding the blood tests and issues with medication prescribed by the hospital, we are unable to consider these complaints any further, as we cannot identify enough information or evidence to carry out an investigation. We understand Ms U has tried to aid our enquiries as much as possible, and we appreciate her efforts to try and remember this information.
87. Regarding the remaining parts of the complaint, we have considered all the available evidence and conclude there are no signs of a failing.
88. We are thankful to Ms U for her help in this matter, and we hope we have explained the reasons for our decision.