Downgrade of referral
15.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.
16.Mr H complained to the Trust that the referral from his GP was downgraded from urgent to routine without any notice given or consultation with himself. He adds that he had been told by his GP and a specialist musco-skeletal team to look out for red flags regarding his back issues. He therefore believes his referral should have stayed as urgent.
17.The Trust, in the complaint response state that the referral was triaged by a neurosurgeon at the Trust. The Trust added that the referral was downgraded to routine as it did not mention any red flag symptoms being present or list concerns of leg pain. Symptoms of lower back pain were noted on the referral and the neurosurgeon had access to the scan report, but the Trust stated that the downgrade in referral was appropriate.
18.Our clinical adviser detailed that from their own clinical experience, it is very common for a referral to be downgraded from urgent to routine after a specialist review. They added that the decision to downgrade was appropriate and given their own experience, that they would have made the same decision. This would be line with GMC good medical practice as a clinician must adequately assess a patient’s condition and promptly provide or arrange suitable advice or investigation. The neurosurgeon did this when reviewing Mr H’s referral.
19.NICE guidelines state that imaging should not be routinely offered in a non-specialist setting for people with low back pain with or without sciatica. From clinical advice obtained we note that that Mr H’s GP therefore did not need to request imaging, but this does not affect how Mr H was managed clinically.
20.From the clinical advice we note that an urgent referral would be indicated for a patient with a significant spinal disease that threatened an injury to the nerves of the spine. From the referral letter and medical records, Mr H did not fit the criteria for an urgent referral. As the Trust detailed in the complaint response, there is no mention in the referral from the GP of there being any red flag symptoms or concerns of lower leg pain. The decision to downgrade the referral from urgent to routine was therefore clinically appropriate.
21.Mr H complained that he had not been told of the downgrade in referral. There are no guidelines that state a patient should be made aware of a downgrade in referral. GMC good medical practice states that patients should be given the information they want or need to know in a way they can understand. However, the referral was sent by the GP and therefore it would have been the GP that would have been able to check the referral system to see it had been downgraded. Our clinical adviser confirmed that a patient is not routinely made aware of any change in urgency of a referral.
22.From the clinical advice received we also note that whilst the NHS target for referrals for treatment is eighteen weeks, pressure in the NHS is meaning patients are waiting much longer to be seen in an outpatient clinic. Delays of up to a year are not uncommon and therefore the time waited by Mr H from referral from his GP to seeing a consultant of around six months is not unusual.
23.There are therefore no indications of a service failure in Mr H’s referral being downgraded and him not being made aware of this. As detailed, it was a clinically appropriate decision to downgrade the referral (by a specialist) from urgent to routine due to the absence of red flag symptoms. Mr H states he had been told to watch out for red flag symptoms previously. But that does not mean he presented with red flag symptoms and thus they were not detailed on the referral sent by the GP.
24.There are no specific guidelines that state a patient should be made aware of a downgrade in referral. However, Mr H could have enquired about the referral with his GP or with the neurology team at the Trust. Whilst I understand the delay caused worry for Mr H, it is standard practice for referrals to be triaged to ensure the most urgent cases are seen first.
25.The GP sent the referral and therefore any notification of a change in urgency for a referral would be able to be seen by the GP. There are therefore no indications of maladministration that the Trust did not tell Mr H about the downgrade in his referral from urgent to routine.
Consultant unable to see scan result during an appointment on 8 January 2024
26.Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have found the Trust has already done enough to put right the impact of these events.
27.Mr H complained that the consultant was unable to see his scan results during the appointment he had on 8 January 2024. This meant that they could not discuss his condition. The Trust replied to this in the complaint response. They apologised that the consultant was unable to see the scan results during the appointment. It was added that the scans should have been imported prior to the appointment but this did not happen. The consultant had since written to Mr H following his review of the scans.
28.The consultant detailed in his letter to the GP dated the day of the appointment (8 January 2024) that he had been unable to view the scans. He subsequently wrote to Mr H on 23 January 2024 having been able to review the MRI scan which took place in May 2023. It was decided that they would continue to monitor his symptoms and to get in touch if his mobility worsens significantly or if his bladder or bowel function deteriorated.
29.Mr H queried how his referral could be downgraded if the consultant had not been able to see the scan results. However, the Trust clarified that the scan report is sufficient for the purpose of triage. It was the scan images that would be used in a consultation for a more in-depth discussion. However, there is no information available to suggest the consultant could not see the scan report at the time of triaging Mr H’s referral. As detailed above, the decision to downgrade the referral from urgent to routine was clinically appropriate.
30.Mr H explained in a call that he felt disappointment and a loss of trust in the doctors at the Trust as a result of his scan images not being viewable during the appointment on 8 January 2024. This would likely fit into level one on our severity of injustice scale. Level one is detailed as ‘a single (one-off) incidence of maladministration or service failure, where the effect on the individual is of short duration, and where there are no other adverse effects or ongoing wider impact.’
31.The consultant wrote to Mr H on 23 January 2024, 15 days after the appointment. The impact on Mr H was a loss of trust and disappointment. This would fit into level one on our severity of injustice scale as:
‘Distress, worry, annoyance and similar emotional impacts, injustice of the sort which a healthy adult would be expect to deal with on a regular basis, without external support, and which does not impact on the affected person’s day to day functioning, or their ability to live a normal life; for a period of up to two weeks. One-off clinical or administrative failures causing minor worry or annoyance.’
32.For a level one injustice, we would generally consider an apology to be an appropriate remedy. The Trust have already apologised to Mr H as detailed in the complaint response from the Trust. Mr H suffered a further 15-day delay in his scan images being reviewed by the consultant. This did not change the clinical outcome for Mr H.
33.We understand the disappointment and loss of trust Mr H felt in this delay. However, the Trust apologised which is likely what we would recommend given the listed impact. There is therefore no evidence of an unremedied injustice. We appreciate it has been difficult for Mr H to discuss the matters in this complaint and thank him for doing so.