Request for analgesia
18. Miss R raises concerns the Practice ignored her requests for analgesia after she complained about severe burning pain in both her legs. She tells us she had to contact the Practice about this regularly.
19. NHS England says Miss R contacted the Practice many times with complaints about different issues. For the pain in her leg Miss R requested pregabalin. Because she had not had this before it asked for her to speak to a doctor first.
20. Pregabalin is a drug used for the treatment of ‘peripheral or central neuropathic’ (nerve) pain in adults.
21. We got clinical advice about this.
22. Having reviewed the records, we can see Miss R contacted the Practice with ‘left femur bone pain’ on 29 April 2021. She explained she wanted to query if an urgent X-ray was needed. As she was away on holiday, the GP arranged for an urgent X-ray the next week when she returned but advised her to attend her local emergency department (ED) if she still had symptoms. She was advised to contact the Practice if she had any issues.
23. We can see she attended an ED on the same day, 29 April. An X-ray was completed and she was prescribed analgesia. The records show she attended the ED again the next day, on 30 April, with the same symptoms.
24. After this the records show she contacted the Practice on 4 and 9 May, but this related to a complaint of hip pain. She also contacted the Practice on 12 May to discuss gynaecological pain. We do not think these consultations link with her concerns about her leg pain so we have not reviewed them further.
25. The records show Miss R contacted the Practice on 20 May with a complaint of pain and weakness in her legs. The notes detail that she was seeing a private neurologist and she wanted painkillers because the co-codamol she was taking at the time was ‘not touching’ the shooting pain and nerve pain in her leg. During the consultation the GP asked, ‘what seems to help’ and Miss R replied, ‘meloxicam has helped a little bit’.
26. We can see the GP prescribed both ‘meloxicam and amitriptyline’ (medications for pain).
27. We think the GP’s action after the 29 April phone consultation was in line with GMC guidance that states:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: • adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs’.
28. As Miss R was away on holiday, it was in line with GMC guidance for the GP to advise her to attend an ED if her symptoms got worse. It was also in line with the guidance for an urgent X-ray to be arranged upon her return, for further investigations.
29. Having reviewed the records, we have seen no evidence to suggest the GP ‘ignored’ Miss R’s request for analgesia when she complained about pain in her legs. The pain that Miss R described was ‘shooting’, which would be consistent with ‘neuropathic pain’.
30. NICE guidance for nerve pain says: ‘Neuropathic pain is a symptom that develops as a result of damage to, or dysfunction of, the somatosensory system.
The pain may be constant or intermittent, and it is typically described as shooting, stabbing, burning, tingling, numb, prickling, or itching’.
31. It adds, ‘a person with neuropathic pain (except trigeminal neuralgia) should be offered a choice of amitriptyline, duloxetine, gabapentin, or pregabalin’. We think the GP acted in line with this when they prescribed Miss R amitriptyline to manage her leg pain.
32. We think the GP took appropriate action to treat and manage her presenting symptoms and we have not seen any signs of failings.
Referrals
33. Miss R says she made requests to be referred to a neurologist but the Practice failed to action this. She explains that because of this she had to contact a neurologist privately. NHS England says she would not have met the criteria for these referrals. We can see that after this a referral was made to a neurologist on 9 June.
34. We are sorry to hear about these concerns and understand how important it is for a person to be referred to a specialist when necessary.
35. We got clinical advice to look at this concern.
36. Having reviewed the records, we can see no evidence of Miss R asking the GP to refer her to a neurologist before 9 June. During her consultation on 20 May, she told the GP she had made an appointment to see a private neurologist.
37. The records show that on 7 June Miss R requested to be referred to neurology and this was completed on 9 June by the GP. There are no entries after this, as Miss R left the Practice on 17 June.
38. Our adviser has found that there was no referral criteria for neurology, as stated by NHS England. Rather, in practice a person is referred and it is up to the neurology department to triage the urgency based on the clinical need of a person.
39. Based on the information we have seen, there is no evidence to suggest the Practice failed to action a request to be referred to neurology. After Miss R’s request, the Practice made the referral within a few days. We think these actions are in line with GMC guidance that says: ‘refer a patient to another practitioner when this serves the patient’s needs’.
40. We do not think the Practice did anything wrong.
The MRI scan
41. Miss R says after being seen by the private neurologist, they wrote to the Practice to request an MRI. Miss R says the Practice failed to action this in good time.
42. The Practice states the request for a full MRI was received on 7 June. The Practice tried to contact Miss R about this but was unsuccessful. It says she confirmed her phone had been playing up. The Practice says a request for an MRI scan was made and a referral to the neurologist was completed on 9 June.
43. Having reviewed the records, we can see a note on 7 June that says, ‘patient wanting referral for MRI scan full spine’. After this, attempts were made to contact Miss R and she confirmed her internet connection was ‘playing up’. We can see the referral for an MRI was completed on 9 June.
44. Our adviser explains there is no guidance to say how quickly a referral should be submitted. GMC guidance states doctors should, ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’.
45. We think the GP’s actions in completing the referral within two days is in line with GMC guidance. We are pleased to hear the results were reported back on 22 June and they said, ‘entirely normal’.
46. We have not seen any signs of failings.
Consultation on 14 May 2021
47. Miss R raises concerns that during the consultation, the GP relied on previous notes of an examination completed by the physiotherapist, rather than completing their own examination.
48. From NHS England’s review of the complaint we can see it acknowledged that Miss R’s clinical history was not taken, but it concluded it was clinically appropriate to rely on a previous consultation. The consultation notes show that Miss R said, ‘been to hospital, no one looked at back. Went to physio yesterday who suspects bulging disc with brisk patella tendon reflexes-increased hyperreflexia in the left leg. Please do a referral so I can book private MRI at St Hughs’.
49. GMC guidance says a doctor should, ‘adequately assess the patients conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; and where necessary, examine the patient’.
50. Our adviser explains that the history forms part of a patient's assessment. It allows continuity of care and also helps form the basis of history of the presenting symptoms of a patient.
51. Having reviewed the records, it was in line with GMC guidance for the GP to have reviewed the examination from the physiotherapist, which was completed the day before. This is because her complaints were of a bulging disc, which was suspected by the physiotherapist. Her request was for an MRI scan, which was completed. We think the doctor acted in line with GMC guidance in considering Miss R’s views and values and there was no clinical need to examine Miss R again.
52. We do not think the Practice got anything wrong.
Managing the UTI
53. Miss R says that during a consultation on 26 April, she reported a UTI but the GP failed to action treatment for this in a good time. Miss R tells us the UTI was not treated for ten days.
54. NHS England says, ‘this relates to a consultation on 26 April 2021 when the patient had evidence of +1 blood on a urine dipstick and later was identified on microscopy as a UTI. It is unclear when a prescription was done, but in a well person with a lower UTI, a delay would not be significant’.
55. We can see Miss R attended the Practice on 26 April with a complaint of urine in her blood. A dipstick sample was taken, which did not indicate infection. The sample was sent to the laboratory for further testing.
56. The records show that on 28 April the GP arranged for an urgent renal and bladder ultrasound and bloods.
57. We can see Miss R attended the Practice on 4 May with complaints of ongoing hip pain. During this consultation the GP noted that her urine sample had returned the same day confirming she had an infection. It is noted a course of antibiotics, namely nitrofurantoin, were prescribed.
58. Based on the evidence we have seen, there are no signs of delays in Miss R’s UTI being treated. The GP was made aware of the infection when the results returned on 4 May. This was communicated to Miss R on the same day and antibiotics were started. This is in line with GMC guidance on ‘providing good clinical care’. It says:
‘You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must work in partnership with them to assess their needs and priorities. The investigation or treatment you propose, provide or arrange must be based on this assessment, and on your clinical judgement about the likely effectiveness of the treatment options.’
59. NICE guidance for UTIs recognises nitrofurantoin as a suitable antibiotic to be prescribed for non-pregnant women aged 16 and older.
60. Overall, we do not think there were delays in managing Miss R’s UTI.
61. In summary, we appreciate the time Miss R has taken to bring her complaint to us and we understand why this is so important to her. We hope Miss R is assured that the Practice acted in line with national guidance.