14. 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 we have not seen any signs that something went wrong.
15. NICE gives national guidance and advice to improve health and social care.
16. At the time Mrs B had the appointment at the Practice (November 2018), there was no relevant NICE guidance in place to say what a health care professional should do when there are concerns of a prolapse. CG171 says a physician should refer women with urinary incontinence who have symptomatic prolapse that is visible.
17. This guidance was updated with NG123 in April 2019. This guidance says the physician should take a history of the patient and do an examination. It also says the physician should discuss the woman’s treatment preference with her and refer her if needed.
18. The medical records include notes of the appointment on 12 November 2018. The notes say a GP offered to examine Mrs B, but she declined this. The plan agreed as detailed in the records is ‘watchful waiting’. The records say the advice given to Mrs B was to return if she experienced ‘pain, bleeding or discharge’ and to come back for an examination. They also say the GP said it was difficult to tell much without examining her.
19. On 2 January 2019, Mrs B went back to the Practice for an appointment. The medical records show this was to discuss her recent hospital blood test results. During the appointment, the GP took a history and noted Mrs B was waiting for a hysterectomy and has a vaginal prolapse. The notes confirm bloods were done as part of a pre-assessment and her thyroid stimulating hormone was raised. The plan noted within the records was for the Practice to increase Mrs B’s medication.
20. On 9 April 2019, Mrs B had a hysterectomy. The discharge notes do not mention a prolapse being treated or discussed.
21. Mrs B told us she does not remember any conversation about a prolapse. She says she did not think she needed to mention it, as the GP told her they had referred her.
22. Based on the evidence we have seen in the Practice’s medical records, there are no signs that the Practice intended to refer Mrs B to gynaecology after her consultation on 12 November 2018.
23. We appreciate Mrs B’s memory of events is different. The records give strong evidence of what happened and it is difficult for us to decide they are incorrect. If the GP had completed an examination and said they were going to make a referral, it is reasonable to expect the GP to have noted this. There would be no reason for the GP not to write this in the notes.
24. The records show the plan of action was for Mrs B to monitor the prolapse and return to the Practice if there were any further problems. There is no record of the GP examining Mrs B, of advising the issue would be resolved by the hysterectomy, or saying they would make a referral to gynaecology for the prolapse. Because we have not seen that the Practice failed to act in line with national guidance or that it failed to keep to its plan, we cannot say it did anything wrong.
25. In line with CG171 because Mrs B did not have urinary incontinence when she raised concerns about the prolapse, the Practice would not have needed to refer her to a specialist. The Practice seems to have acted in line with the NICE guidance.
26. While NICE CG123 had not been published at the time Mrs B went to the Practice, it may have been known that the guidance was to be updated. This is because the draft consultation of this guidance was published in October 2018. But the GP acted in line with the later guidance by taking a history and offering to do an examination. The notes show the GP considered a referral was not needed because Mrs B was going to monitor the prolapse. We would not expect the GP to make a referral without completing an examination first.
27. When Mrs B had the hysterectomy the medical team discussed the planned treatment and had to get Mrs B’s consent. If the planned treatment was to include treating a prolapse, the medical team would have needed to discuss this with her and get her consent for that too, before any surgery to treat the prolapse.
28. When Mrs B had not heard anything from gynaecology about the prolapse and it was not discussed before having the hysterectomy, we think it is reasonable to expect Mrs B to have brought this up with the medical team, or to have contacted the Practice to query it.
29. In summary, we think the Practice acted in line with the relevant guidance at the time. We have not seen evidence to support Mrs B’s view that the Practice made a mistake by not referring her to gynaecology.
30. We recognise Mrs B may be disappointed with this decision and we are sorry for any distress it causes. It is our duty to be fair and clear in explaining our decision. We hope Mrs B understands the reasons for our decision and we thank her for bringing her complaint to us.