3. Miss A complains about the care and treatment she received from the Practice between 26 October 2022 and 15 November 2022. She specifically complains the Practice should have:
• assessed her condition in person (26 October 2023) • referred her for scans • identified her hip fracture.
4. As a result of the failings, Miss A says her recovery was delayed by three weeks and she was left in pain for three weeks.
5. Miss A seeks financial remedy, an apology and service improvements.
6. Miss A (aged 33 at the time) says she had a fall at home around September 2022 which did not cause too much pain to start with. She later felt pain but sometimes it went away. She was still able to train in the gym and run.
7. She phoned the Practice on 26 October 2022 with pain in her back and left leg for around five days. The Practice felt the injuries were muscular, related to the gym and running. The Practice prescribed pain killers and referred her for physiotherapy.
8. Miss A attended her Practice on 31 October to get different painkillers and a sick note.
9. On 1 November 2022, she attended a physiotherapy appointment. Her pain had been getting worse but the previous 24 hours had improved. The physiotherapist provided Miss A with a crutch and a follow up appointment was planned for seven days’ time. The assessment was acute hip pathology.
10. On 8 November, Miss A tripped over her crutch and worsened her injury. She phoned 111 the same day. She says she told them she had fallen but this does not appear to be recorded.
11. The 111 service directed her to the Practice who issued Miss A with a new sick note and prescribed co-dydramol (pain relief medication).
12. On 14 November 2022, the Practice gave Miss A another sick note and advised her to keep taking pain killers.
13. On 15 November 2022, the Practice told Miss A to keep taking painkillers again and await her next physiotherapy appointment.
14. On 19 November 2022, Miss A attended Hounslow Urgent Care Centre (A&E). Her pain had worsened and she was unable to walk due to the pain. Whilst in A&E, a scan discovered Miss A had fractured the neck of her femur.
19. 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 have done this and have not found any indications that something has gone wrong.
Lack of in-person assessment (26 October 2023)
20. Miss A’s first contact with the Practice about her injury was a telephone consultation on 26 October 2023. She reported with pain in her back and left leg. Miss A believes the Practice should have asked her to come into the Practice for an in-person assessment.
21. Medical records show, having listened to her symptoms and social history, the Practice suspected the injury was muscular and Miss A agreed. Miss A had experience with muscular injuries previously, as someone who frequently goes to the gym and frequently runs. The Practice referred her to the local physiotherapy and musculoskeletal service (MSK) and prescribed pain killers.
22. Our adviser said there was no need to assess Miss A in person on 26 October 2023. Our adviser said it was appropriate to refer her to the physiotherapy service given her age, symptoms, and history. Importantly, there was no indication of significant trauma (e.g. big fall). A referral to MSK service was the most appropriate action.
23. Our adviser said the actions of the Practice on 26 October 2023 were in line with GMC Good medical practice guidelines, specifically point 15:
‘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.’
24. We conclude the evidence indicates the Practice adequately assessed Miss A’s condition and took account of her history. We think it was able to do this appropriately by telephone at this appointment. It also seems to have taken steps to arrange advice or investigations with the referral to MSK.
25. The Practice’s actions therefore seem to have been within relevant guidelines on 26 October 2023 when it did not assess Miss A’s condition in person. We have not seen indications of a failing with this appointment.
Identifying the hip fracture
26. Miss A believes the Practice should have identified her hip fracture. The Practice believed the injury was a muscle tear and noted no direct trauma to the hip. From our discussion with our adviser, we understand the same GMC guidance is relevant to this part of the complaint.
27. Miss A first reported the issue to the Practice on 26 October 2022. Urgent care centre (UCC) staff finally identified the fracture on 19 November 2022 after they took an X-ray. Between these dates, Miss A had contact with medical staff (in person and via telephone) eight times. These include staff from the Practice, MSK and NHS 111.
28. Unfortunately, nobody identified the hip fracture. Miss A also said she had private physiotherapy during this time. However, it appears they did not suspect a fracture either.
29. During this period, Miss A had four consultations with her Practice.
30. Notes from the call on 26 October show Miss A had been exercising recently but began getting pain in her back and left leg for five days. The notes contain no record of a fall or trauma.
31. Notes from the consultation on 31 October say Miss A thought she may have done something at the gym to cause the injury. They also say pain was worst when walking but it had got better. The notes contain no record of a fall or trauma.
32. Notes from 14 November, show the Practice’s working diagnosis was still a muscle injury. Miss A requested a scan, but the clinician told her they are unable to perform a scan. They noted she had an upcoming appointment with MSK. The notes contain no record of a fall or trauma.
33. Notes from 15 November show the pain had been present for three weeks but had got worse in the last week. The clinician advised Miss A to go to A&E if there were any red flags or back pain and seek medical attention if there were any concerns. The notes contain no record of a fall or trauma.
34. We also have some notes from the MSK service from consultations on 31 October and 1 November, but these do not mention a fall or trauma.
35. Miss A told us that she had told the Practice about her falls, but this is not recorded in the notes. The Practice response suggests that it believes it was not told about a fall. Our adviser said there is some shared responsibility between patient and clinician to ask about or mention any possible falls.
36. It is difficult to say for certain if Miss A reported falls to the Practice because there is a difference between her and the Practice’s accounts. We have considered Miss A’s account as part of the evidence. It is difficult for us to say the Practice’s records, which do not document any falls, are inaccurate. We therefore conclude, on balance of probability, it is more likely than not the records are accurate.
37. Our adviser confirmed there was no missed sign of a hip fracture according to the notes from the Practice consultations. They said it is very unusual for someone of Miss A’s age to have fractured their hip without a history significant trauma or fall without a bone condition such as osteoporosis.
38. In the absence of evidence to confidently say Miss A reported a fall to the Practice, we consider it acted in line with the GMC guidance. It seems it assessed Miss A’s symptoms and took account of her history (including no recent history of falls) as part of its diagnosis. As we explained above, it also referred her to MSK, which could have done further investigations if needed.
39. We do not believe the Practice missed an opportunity to identify the hip fracture sooner. We have not seen indications of failings with this part of the complaint.
Referrals
40. Miss A believes the Practice should have referred her for a scan.
41. After the first consultation, the Practice referred Miss A to MSK, a specialist physiotherapy and musculoskeletal service. At no point did the Practice specifically refer her for any type of scan.
42. Our adviser said a scan did not appear necessary from her first two consultations. The injury and history did not suggest the injury was as serious as a hip fracture and they were right to refer her to the MSK service.
43. By the Practice consultations on 14 November and 15 November, Miss A’s pain had worsened. Our adviser said at this point there could be some variation in practice between GPs. Some may have referred her for a scan, some may not have, as was the case here. There is no specific guidance, other than GMC good medical practice, mentioned previously.
44. Our adviser said although the GP did not refer the patient for a scan, she was already under the care of the specialist MSK which was the most appropriate referral for someone of Miss A’s injury. We consider the Practice’s action to refer Miss A to that service was in line with GMC good medical practice point 15, mentioned previously.
45. This is because it seems, based on the evidence, MSK was appropriate to serve Miss A’s needs. We do not consider the evidence indicates the Practice needed to make any another referral specifically for a scan. We also note that the specialist MSK service could have referred Miss A for a scan but did not.
46. Therefore, we believe the Practice did not act outside of the relevant guidelines on the issue of whether the Practice should have referred Miss A for a scan. We have not seen indications of a failing with this issue.
Conclusion
47. We have concluded that the service Miss A received from the Practice did not fall below the relevant standard we would expect, and we have no indication of failings.
48. We appreciate this will not be the outcome Miss A had hoped for, but we hope it can provide some reassurances. The injury has clearly had an incredibly significant impact on Miss A’s life, and she has been hugely unfortunate to have sustained this injury.
49. When we spoke on the phone in March, we were very pleased to hear she was recovering, slowly but surely. We hope this continues, and we wish her all the best for the future.
1. We have carefully considered Miss A’s complaint about a practice in the Ealing area (the Practice). We were sorry to hear about her hip fracture and the serious impact it is has had on her day-to-day life.
2. We carefully considered all available evidence and discussed Miss A’s complaint with one of our independent clinical advisers. We have seen no indication that anything went wrong in the service the GP provided. Therefore, we have decided not to consider this complaint further. We have explained our reasons in this statement.