A practice in the Barnet area

2. Mrs H complains about the following parts of the Practice’s treatment:

• blood pressure management: Mrs H complains the Practice overprescribed her blood pressure medication, it did not review the medication and did not arrange for annual monitoring

• failure to arrange cardiac monitoring: Mrs H says the Practice refused to arrange ambulatory blood pressure monitoring (ABPM). She says this is a breach of its duty as responsible medical professionals

• fitness to work certificate: She complains the Practice did not supply a fitness to work certificate as it said it was the hospital’s responsibility.

3. Mrs H feels she collapsed because the Practice overprescribed and failed to monitor her blood pressure medication. She says her fall led to a fractured ankle.

4. Mrs H wants a written apology from the Practice and financial compensation.

5. Mrs H has been diagnosed with high blood pressure for some time. She has been taking blood pressure medication for over twenty years and does home blood pressure readings to monitor it.

6. Mrs H has had several changes to her medication over the years to reduce the risks associated with high blood pressure. The Practice said these changes have been in response to her blood pressure readings measuring above targets set by the National Institute for Health Care and Excellence (NICE).

7. Mrs H had been experiencing dizziness in August 2021. Her records do not show she discussed this with the Practice. On 24 August Mrs H collapsed and fractured her ankle.

8. She went to the emergency department (ED) at a local hospital and her blood pressure readings were raised.

9. On 10 September 2021, Mrs H had a telephone consultation and the GP discussed her blood pressure average since she had stopped taking bendroflumethiazide (a drug to treat high blood pressure).

10. They also discussed her systolic blood pressure (pressure between arteries when the heart is beating).

11. The GP advised Mrs H to stop taking doxazocin because of the lower systolic blood pressure, and to take losartan in the evening which would be more effective (both drugs are used to treat high blood pressure).

12. On 22 October 2021 Mrs H had another telephone consultation. The GP agreed with Mrs H that she should stay on losartan alone rather than adding in other blood pressure medication.

Blood pressure management

16. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any signs that something has gone wrong.

17. The Practice said the last increase in medication was in February 2019, when home blood pressure readings were around 150/85mmHg. The Practice increased the dosage of doxazocin from 4mg twice a day to 8mg.

18. They said home blood pressure readings are used to assess blood pressure control, as clinic-based blood pressure readings are often falsely raised.

19. The Practice said the home blood pressure target for patients of Mrs H’s age is 135/85mmHg or below. As Mrs H’s result was raised, the dose of doxazocin was increased to 4mg twice daily, in keeping with clinical guidelines to aim for blood pressure control of 135/85mmHg or less. The Practice said this is the right-treatment to improve blood pressure control and reduce health risks.

20. As a general guide to blood pressure readings, most doctors use 140/90mmHg as the cut off for point for diagnosing high blood pressure. A high reading is anything above this figure, and this is when the risk of serious health problems increase.

21. Pre-high blood pressure is between 120/80mmHg and 140/90mmHg, and means a patient can develop high blood pressure if this is not managed.

22. NICE guidelines say:

‘Reduce clinic blood pressure to below 140/90 mmHg and maintain that level in adults with hypertension aged under 80… Provide an annual review of care for adults with hypertension to monitor blood pressure, provide people with support, and discuss their lifestyle, symptoms and medication’.

23. Our adviser said the Practice monitored Mrs H’s blood pressure in line with these guidelines. A patient’s blood pressure can be monitored either in a clinic or at home depending on the patient’s preference and it should be monitored annually.

24. The records show Mrs H had been monitoring her blood pressure at home. She had a review in February 2019 and the Practice increased her medication in line with the guidelines, because her blood pressure was above the target.

25. The next review was in August 2020. This was more than a year since the last review, but it was during the first COVID-19 lockdown when face to face appointments were restricted. The records show the Practice did a phone consultation in May 2020 and Mrs H did not report any problems.

26. The review in August 2020 showed Mrs H’s blood pressure from her home readings was slightly closer to the target than before, but still below 140/90mmHg. Our adviser said this was not a cause for alarm and the guidelines clearly say that clinical judgement can be used. The Practice chose to continue with the medication Mrs H was taking.

27. Mrs H’s records show she had a history of having side effects to some medications. This explains why she was on this combination of tablets.

28. Our adviser said while all medication can have side effects, the medication she was taking before her fall was appropriate and there was no suggestion from the records that it was having a negative effect on Mrs H until her fall.

29. We have reviewed all the available evidence and have not seen anything to suggest the Practice failed to act in line with national guidance.

Failure to arrange ABPM

30. ABPM is a simple recording of a patient’s blood pressure that requires them to wear a cuff on their arm and a small box on a belt around their waist. The patient wears this at home and returns it the next day. It is a non-invasive test to monitor blood pressure over a 24-hour period.

31. NICE guidelines say doctors should: ‘Consider ABPM in addition to clinic blood pressure measurements, for people with hypertension identified as having a white-coat effect (A discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis) or masked hypertension (in which clinic and non-clinic blood pressure results are conflicting). Be aware that the corresponding measurements for ABPM and HBPM are 5 mmHg lower than for clinic measurement’.

32. Our adviser said based on the guidelines, Mrs H did not meet the criteria for the Practice to consider ABPM. The records show she had not complained of irregular dizziness before the fall. If she had, the Practice could have looked at this and considered ABPM.

33. The Practice arranged ABPM in the weeks after her fall.

Fitness to work certificate

34. In their complaint response, the Practice said the hospital had a responsibility to issue the certificate as part of the care they provided.

35. The DWP guidance was produced in April 2022 and replaced the guidance from 2017.

We do not have access to the guidance that existed in August 2021 when Mrs H requested the fitness to work certificate, but the guidance clearly says the only changes to the 2022 version were the removal of the need to sign the form and the ability to pre-populate the form with the name and profession of the issuing doctor.

36. The DWP guidance says, ‘Hospital doctors may need to provide all certification for social security and Statutory Sick Pay purposes for patients who are either incapable of work or who may be fit for work with support from their employer. The duty to provide a Med 3 (certificate) rests with the doctor who at the time has clinical responsibility for the patient.’

37. It also includes examples where hospital doctors should consider issuing a Med 3: • ‘when a patient has received treatment in Accident and Emergency and the treating doctor believes that the patient will be unable to work for over 7 calendar days, it would be appropriate to issue a Med 3 for a period consistent with the anticipated incapacity • when a patient is receiving treatment at a fracture clinic and so does not need to see their GP for any clinical reason.’

38. Our adviser confirmed that in Mrs H’s situation it was the fracture clinic doctor or the emergency department doctor who should have issued the certificate, not the Practice.

39. We understand this issue caused more stress and anxiety for Mrs H at a time when she was experiencing health problems. We find the Practice acted in line with guidance in advising her to request the certificate from the hospital.

40. We hope our explanation gives Mrs H and Ms H some reassurance that the Practice did not do anything wrong.

1. The Parliamentary and Health Service Ombudsman has carefully considered Mrs H’s complaint about a practice in the Barnet area (the Practice). We recognise this was a difficult experience for Mrs H and she has faced ongoing uncertainty with her health. We appreciate this caused her daughter, Ms H, anxiety and concern. We have not seen signs that the Practice did anything wrong. We explain the reasons for this decision below.