A practice in the Teignbridge area

3. Mr I complains that on 16 December and 28 December 2022 the Practice took a functional approach to his rib pain, so did not order appropriate investigations into the cause.

4. Mr I says that because of this he lost the opportunity to have a diagnosis, prognosis or treatment plan. He has experienced ongoing rib pain since and has symptoms of his chronic illness which he believes is connected. He has to use mobility aids or he cannot move around the house sometimes. He sleeps between 12 and 16 hours a night and is reliant on aids to help him sleep. He says the amount he sleeps makes him isolated. He has lost faith in the medical profession. He says he is not able to work, his wife is not able to work full time because she needs to look after him and this has caused a large financial loss.

5. Mr I would like £10,000 but will accept any amount we think is appropriate. He would also like an apology and service improvements to make sure this does not happen again.

6. Mr I has been unwell for over a decade and has seen several specialists and different GPs to try and find the cause. Mr I had rib pain for many years before these appointments in December 2022.

7. Before these appointments Mr I had many magnetic resonance imaging scans (MRI scans take detailed images of the body) of his chest, vascular (relating to circulation) and inflammatory (swelling) investigations, electromyography and nerve conduction studies (tests that check nerve responses and the response of muscles to nerve stimulation), creatine kinase (tests to check for muscle damage), computerised tomography (CT) scan of the thorax and extensive heart and blood tests. Specialists had not been able to find a diagnosis based on the results and he had not been given a specific diagnosis for his rib pain.

8. Mr I went to the Practice with his symptoms on 16 December. It says he wanted a diagnosis and his most troubling symptom was aching ribs. It noted this pain was never in the day time and was on the underside of his lower anterior ribs (bottom ribs at the front of the body) and intercostal (muscles between ribs). It examined him and noted symmetrical tenderness on both sides. It noted he thought the symptoms were rooted in an initial infection which then affected his autoimmune response. It documented that they agreed a trial of ibuprofen gel for the rib pain.

9. He attended the Practice again on 28 December. It noted some information about other symptoms. For rib pain it noted, ‘rib pain has improved, did not need to use gel’. It provided a private referral letter for neurology (nervous system specialists) at Mr I’s request.

13. GMC guidance advises doctors should:

• ‘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.’

14. The NICE guidance explains potential causes for chest pain. These fall broadly into the categories of gastrointestinal (digestive), pulmonary (lungs), cardiac (heart) or musculoskeletal (related to connective tissues, bones and muscles).

15. Our adviser said the gastrointestinal, pulmonary and cardiac conditions and symptoms listed do not fit Mr I’s symptoms. Some of the musculoskeletal symptoms described do mention aching pain which would fit with Mr I’s description of aching lower ribs.

16. NICE guidance does not recommend specific investigations for musculoskeletal rib pain, so this is down to clinical judgement. It recommends doctors consider prescribing analgesia (pain relief) such as paracetamol or a non-steroidal anti-inflammatory (NSAID).

17. The Practice did this by prescribing ibuprofen gel for Mr I to try. Ibuprofen is an NSAID. This was in line with both GMC and NICE guidance.

18. NICE guidance explains doctors should consider referring to a consultant if the person has suspected stable angina (chest pain caused by reduced blood flow to the heart), chest pain where the cause is unclear, or where chest pain persists despite management in primary care.

19. We have not seen any sign that Mr I met the criteria for the Practice to refer him to a consultant. He did not have suspected angina. The Practice identified a working diagnosis of a musculoskeletal cause for his rib pain, even if it had not diagnosed his underlying chronic illness. This was the first appointment with this Practice and by the second appointment it noted Mr I told them his rib pain had improved without him using the ibuprofen gel. It was therefore in line with NICE and GMC guidance for the Practice to not refer him to a consultant.

20. NICE guidance does say that if doctors are unsure of the suspected cause of chest pain to consider these tests - electrocardiography (if there is an indication of cardiac issues), a variety of blood tests, thyroid function tests, liver function tests, c-reactive protein test (to check for infection) and chest X-Ray.

21. We can see that since these events Mr I has gone back to the Practice as the rib pain has continued. The Practice has since done various blood tests, checked his kidney and liver function, thyroid function, a c-reactive protein test and done a bone profile. He had an abdominal ultrasound around the area that was painful and private allergy tests. None of these have suggested a specific diagnosis which we understand is frustrating for Mr I. We cannot see any sign that there were more investigations the Practice should have ordered in December 2022 that would have provided Mr I with more answers.

22. Our adviser suggested we look at the RACGP journal article. This article suggests that for musculoskeletal chest wall pain further investigations are often unnecessary and should only be used when the provisional diagnosis suggests they are needed.

23. We can see that the Practice acted in line with GMC guidance by taking a history, examining and providing treatment to Mr I for his rib pain. NICE guidance does not recommend any specific investigations and we have seen no sign that there is anything more the Practice should have done. We have also not seen that any future investigations have led to a diagnosis for Mr I’s rib pain.

24. We understand Mr I complains the GP treated him ‘functionally’. Functional symptoms are those with no known physical cause. It seems a specialist suggested before that Mr I had a functional nature to his symptoms. Mr I disagrees with this and feels this was said due to a process of elimination rather than clear clinical features. In its complaint responses, the Practice explained that in cases where many specialists have done investigations and not found a root cause, they use a functional approach. It explained this approach treats symptoms as very real and not purely psychological. It aims to treat the symptoms to relieve pain so the individual can try to regain normal function. It apologised that this approach had upset him and reassured him that this does not prevent assessment or investigation of any ongoing symptoms.

25. As we have said, we have seen no sign that the Practice did not follow NICE and GMC guidance when considering Mr I’s rib pain. We have not seen any suggestion that taking a functional approach to Mr I’s overall chronic illness affected its decisions to assess, investigate or treat his rib pain.

26. We appreciate Mr I has very real and significant symptoms and we are sorry to hear how these continue to affect his life.

1. We have carefully considered Mr I’s complaint about a GP Practice in the Teignbridge area (the Practice). We recognise how significantly Mr I’s pain has affected his daily life.

2. We have not seen any sign the Practice did anything wrong when investigating Mr I’s rib pain. We explain our decision in detail below.