27. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We do this by using standards and guidance to inform us what should happen and then, in considering all parties accounts we arrive at an understanding of what did happen.
28. Following this, if we identify a failing, we consider if an injustice has been caused by this failing (we refer to this as ‘flowing’ from the failing). Next, we consider if there is an impact or negative experience from the injustice and what the organisation has done to put matters right. If we consider more could be done, we may make a range of further recommendations.
29. We have done this and have not found any indications that something has gone wrong.
Complaint about incorrect referral on 19 February 2024
30. The National Institute of Health and Care Excellence, (NICE) guideline, on suspected cancer: recognition and referral, tells doctors to offer urgent, direct access upper gastrointestinal (UGI) endoscopy, to be done within two weeks to assess for oesophageal cancer in people with dysphagia (difficulty swallowing).
31. Mrs E tells us on 19 February the Practice referred her to the wrong department for tests, as when she attended the hospital for her endoscopy test on Friday 23 February, she was told by a clinician that she should have been referred to the ENT department and they would not inspect her upper tonsil/throat area. Mrs E says she was told to go back to the Practice to request the correct two-week wait referral was made to ENT.
32. The Practice says Mrs E attended an appointment on 19 February complaining of dysphagia and was appropriately referred to the Gastroenterology department for an UGI endoscopy test under the two-week wait pathway. It says the report of the test came back with a recommendation for the GP to prescribe lansoprazole to Mrs E and there were no notes advising for another referral to be made to ENT.
33. The Practice says it received a call from NHS 111 on 26 February to advise Mrs E had contacted it to ask for the referral to ENT be made. The Practice explained to Mrs E that NHS 111 do not provide this service and it advised NHS 111 that a task would be sent to the on-call doctor about this.
34. The Practice decided that an up-to-date assessment was needed, and Mrs E was contacted by email on 27 February at 9.53am to offer her an appointment on 28 February at 8.30am. The Practice says Mrs E accepted this appointment and when she attended she was prescribed with lansoprazole, as recommend following the UGI test at Gastroenterology, and a referral was made to ENT under the two-week wait pathway as Mrs E reported she had a lump on her tonsil for the last six months.
35. We can see from the medical records Mrs E attended the Practice on 19 February complaining of difficulty swallowing food which was getting stuck. She was examined and it was agreed that a two week wait referral was being made for a UGI endoscopy. The record says Mrs E was advised to return to the Practice if she had not received an appointment with two weeks.
36. From clinical advice we are informed it was appropriate for the Practice to make the referral based on the symptoms Mrs E presented with on 19 February 2024 and this was in line with the NICE guideline on suspected cancer that we have outlined in point 30 of the investigation.
37. Mrs E had an appointment arranged at the outpatient’s gastroenterology department (OGD) at 1.30pm on 23 February. The report from this procedure says the endoscopy was carried out and the follow up was for the GP to prescribe 30mg of lansoprazole. There is no mention of a further two-week wait referral to be made to ENT on the report.
38. The records show on 26 February the NHS 111 Service contacted the Practice advising they had received a call from Mrs E regarding a lump on her tonsil which she had for some time and an incorrect referral to gastroenterology had been made. It said Mrs E had advised them the gastroenterology clinic could not examine her tonsils and she needed a two-week wait referral to be made to ENT.
39. We can see from the complaint file; the Practice sent an email to Mrs E on 27 February at 8.41am asking her which consultant she had spoken to at her gastroenterology appointment at it has not received any information to raise a two week wait referral to ENT and it wanted to contact the OGD to confirm this.
40. The Practice sent another email to Mrs E at 9.37am offering her an appointment to attend the Practice the following morning, 28 February at 8.30am, for a face-to-face assessment. Mrs E sent an immediate email back to the Practice accepting this appointment.
41. The records then show Mrs E contacted the NHS 111 Service on 27 February and she was referred to the UCC. The UCC record says Mrs E attended at 1.32pm and left at 3.36pm on 27 February and she was requesting a referral to ENT under the two-week wait pathway. It says this was because she had previously been incorrectly referred to Gastroenterology by her GP and she was unable to speak to her GP.
42. The clinician Mrs E saw at the UCC completed a two-week wait referral to ENT, but this was not sent as the UCC manager contacted the Practice and said the referral needed to come from the GP.
43. Mrs E attended her appointment at the Practice on 28 February at 8.30am and the GP who saw her prescribed the lansoprazole medication as requested by the OGD and sent a two-week wait referral to ENT as she reported she had a lump on her tonsil for several months.
44. From clinical advice we understand Mrs E advised the GP of a lump on her right tonsil for last six months and felt this was impeding her swallowing. The GP carried out an examination including Mrs E’s neck and throat and apart from an enlarged right tonsil with no pus or ulceration no other abnormalities were detected. The GP made the referral to ENT under the two-week wait pathway and notified Mrs E of this the same day in a text message.
45. We asked Mrs E if she received the appointment at ENT under the two-week wait pathway and what the outcome of this was. Mrs E advised she did receive an appointment within two weeks and after examination it was agreed to wait to see if the lump on her tonsil grows, she has another appointment in July 2024, but she does not have a diagnosis of what the problem is.
46. We recognise Mrs E was very anxious about her health at this time and understand she was keen to have the appropriate tests carried out. We are pleased to hear she did have a quick appointment at ENT, and she does not have to have immediate treatment for her problem.
47. Having considered all the evidence available and with independent clinical advice sought we can see Mrs E was appropriately referred by her GP to the gastroenterology service on 19 February and this was in line with NICE guidelines on suspected cancer, based on her reported symptoms of difficulty swallowing at her consultation.
Complaint about deregistration from the Practice on 6 March 2024
48. There are numerous pieces of guidance which inform what should happen here these include: • The General Medical Council (GMC), Professional Standards, ending your professional relationship with a patient.
• The British Medical Association (BMA), Advice and support for GP Practices, guidelines on dealing with abuse of practice staff on social media from patients, • The Practices own policy; Dealing with Unreasonable, Violent and Abusive Patients Policy • The NHS guidance on zero tolerance (NHS)
49. Enshrined within all the guidance it is clear that in rare circumstances, where a breakdown of trust between patient and practitioner occurs and delivery of clinical care compromised then a relationship can be ended immediately. This includes instances where:
• abusive behaviour or threats or a patient acts unreasonable or caused others to fear for their safety (GMC) • Where personal attacks are made on members of the practice or allegations that are clearly unfounded (BMA) • To reduce the risk or of fear of staff being attacked or abused (NHS zero tolerance) • Where activities violate the recipient’s dignity and/or creating an intimidating, hostile, degrading, humiliating or offensive environment and that inappropriate behaviour does not have to be face-to-face and may take other forms including written, telephone or e-mail communications or through social media (Practice policy) • The NHS should not tolerate any form of abuse directed at staff (NHS policy)
50. In conducting our work, it is not the role of the Ombudsman to consider if a practitioner was right to say or make a judgement call on abuse towards them. Our role is to investigate if, administratively, did the organisation or practitioners follow the correct procedure guidance (or not) in doing so when deregistering.
51. Mrs E tells us she received a letter from the Practice on 28 February saying she was being removed from the patient register due to doctor/patient relationship breakdown. Mrs E says she was never violent and never received a warning letter as per the Citizens Advice Bureaux (CAB) and British Medical Association (BMA) advice.
52. Mrs E says the letter said she had until 6 March to find a new GP surgery and she submitted a complaint to the Practice asking it to respond with how it was going to correct its mistake as it must keep her as a patient until she found a new general practice.
53. Mrs E says she could not get a new GP surgery for four weeks due to the high demand of patient registrations and then it would take eight weeks for transfer of records. Mrs E says she told the Practice it had to provide her with urgent care until she registered at a new GP surgery and urgent care included cancer referrals. Mrs E says the Practice responded saying she would not be on its patient register after 6 March.
54. In its complaint response letter to Mrs E the Practice says it decided to remove Mrs E from the patient register as she made a factually incorrect public post about the Practice on the social media platform of Facebook. It also said Mrs E had gone onto disclose the full names of three members of staff and this has raised a concern for safety for the staff. The Practice tells us the staff expressed their individual concerns to the GP partners.
55. The Practice says it was felt that the patient relationship had irrecoverably broken down due to the inconsistencies that Mrs E was using to obtain treatment, and her presentation of incorrect information in the public domain. The naming of three members of staff on the Facebook page in full, had left the staff feeling vulnerable and two members of staff said they were contacted by several members of public outside of the workplace following her actions.
56. On reviewing the records, we can see several derogatory posts were made on a public Facebook page by Mrs E and a family member, about Mrs E’s contact with the Practice, the NHS 111 Service and the UCC. Comments were made about Mrs E’s treatment at the Practice, and this included the full names of three members of staff.
57. We can see from the complaint response letter to Mrs E, the Practice explained she was being removed from the patient register due to a patient/doctor relationship breakdown. It said this was not only because of the posts on a public social media platform but also because of the factually incorrect information that was being posted and provided to the NHS 111 Service and the UCC.
58. The records show the Practice discussed the removal of Mrs E from the patient list at a meeting on 27 February and it sought its own legal advice. The minutes of the meeting refer to impact statements taken from the three members of staff who had been named and exposed publicly on the social media platform.
59. From the records we can see the request for the removal of Mrs E from the patient register was not an immediate removal request due to violence or abuse, it was an eight-day request for relationship breakdown, and it was accepted by Primary Care Support England. The Practice acknowledge to Mrs E it did not send her a warning letter and the reason for this was the decision to remove her was based on the fact it felt this was an irrevocable relationship breakdown and to protect the safety of its staff.
60. We can see from the guidelines we have outlined in this section that it may be reasonable to end a relationship immediately in certain circumstances. The guidelines all allow for the immediate removal of patients from practice lists if a patient has behaved in a way that has caused other people to fear for their safety.
61. We recognise Mrs E did not receive a warning letter and understand it must have been a shock to receive the letter advising her of the removal from the patient register. We are pleased to see Mrs E registered with another general practice on 1 March and was accepted so there was no gap in her care.
62. Having considered all the evidence, we have found the Practice was acting within GMC guidelines, the BMA guidelines, informed of its actions by the NHS approach to zero tolerance and in line with its own Unreasonable Behaviour Policy in its decision to remove Mrs E from its patient register.
63. Although Mrs E was not directly violent or abusive, her behaviour of posting comments on social media and naming individual staff had caused members of staff at the Practice to fear for their safety. As we have found no indications of failings here, we have decided to take no further action with this complaint.