A practice in the Croydon area

4. On 25 July 2023, Ms O asked the Practice for a referral to another endocrinology team for her thyroid. She complains this was not sent to the correct hospital which resulted in her waiting for this referral for 10 months.

5. This has caused Ms O distress and exhaustion, given her heart palpitations, and has impacted her mental health. She only recently started to feel better after getting some cooperation. She also says the delay has now caused her to be diagnosed with an underactive thyroid.

6. As an outcome she wants an explanation of the delay and what should have happened. She also wants service improvements to prevent this happening to others and to minimize any unnecessary delays.

7. On 25 July 2023, Miss O asked the practice to refer her to another endocrinology team.

8. On 8 August 2023, the Practice made a further endocrine referral. The Practice liaised with Croydon University hospital to redirect the referral to Royal London Hospital, as this hospital was not visible on NHS e-Referral system (ERS) search criteria.

9. On 15 August 2023, the Royal free London Hospital wrote to the Practice to say after reviewing information it felt it would be more appropriate if this patient were referred to Royal London Hospital for integrated medicine. It believed the Practice had the hospital confused and explained the Royal London Hospital was a part of University College London Hospital not the Royal Free Hospital.

10. On 17 October 2023, the Practice sent a new referral to Croydon University Hospital asking it to redirect the referral to the Royal London Hospital as it was still not showing on its system.

11. On 20 October 2023, we can see an email suggesting Croydon University Hospital agreed to redirect the referral. Once picked up, the Practice chased the referral for an update and a new referral was sent and was confirmed as received by the Royal London.

12. On 24 October 2023 a text message was sent to Ms O by the Practice informing her the referral was sent to triage service and gave phone number for her to chase if she had not heard anything by 15 December 2023.

13. On 30 October 2023, during an appointment at the Practice, Ms O said the referral had gone to the wrong hospital and it needed to go to the endocrine team, Royal London, Whitechapel, at St Barts hospital.

14. On 21 December 2023, we can see from the medical records the Practice explained to Miss O it did not send referral to the wrong place. It referred to the local hospital for it to direct to a chosen hospital, as this is the Practice’s policy.

15. On 23 February 2024, following a telephone consultation with Ms O the Practice agreed to chase the endocrine referral and advised against a new referral to a new hospital.

16. On 19 March 2024, the Practice sent an endocrine referral to St Barts.

17. On 9 April 2024, the Practice received correspondence from St Barts saying Miss O was out of area and to refer to local services as it does not currently offer outside of its catchment area.

18. On 28 June 2024, Ms O was then referred to St George’s hospital, but on 29 June 2024 was rejected saying ‘Inappropriate Service Referral rejected by hospital consultant as ‘unable to support through NHS, this is not a part of standard practice for thyroid cancer’.

22. Ms O says the Practice did not make her endocrine referral to the correct hospital and this caused her to wait to be seen for over 10 months.

23. On 25 July 2023, Ms O asked the Practice to refer her to another endocrinology team as she wanted specialist tests (Graves antibody test).

24. The Practice says the GP communicated their concern that another referral would not be accepted, however, Ms O wished to try and see the Integrated Medicine team at Royal London Hospital, a partner of University College London Hospital.

25. Ms O’s medical records show the GP informed her of their concerns in taking over her care while she was being looked after at University College London Hospital for her cancer but agreed to send the referral.

26. On 8 August 2023, the Practice made the endocrine referral to Croydon University Hospital asking it to redirect the referral to Royal London Hospital as it was not showing up on the Practice’s system.

27. The Practice says as Royal London Hospital is outside of the Croydon area it is contractually obliged to send the referral to Croydon in the first instance for approval. If approved, it would send the referral to the hospital the Practice had requested.

28. The GMC guidance says doctors ‘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’.

29. And ‘In providing clinical care you must: • adequately assess a patient’s condition(s), taking account of their history, including symptoms and the patient’s views, needs, and values • promptly provide (or arrange) suitable advice, investigation, or treatment where necessary • consult colleagues or seek advice from your supervising clinician, where appropriate • refer a patient to another suitably qualified practitioner when this serves their needs.’

30. Our adviser clarified each geographical area will have different processes and protocols on referring out of area. In this case the process was to refer to the local hospital who could then refer onwards if needed.

31. Our adviser says the Practice would not normally know the status of a referral unless it has been rejected. It is usually the patient who would chase up the referral or contact the Practice if there are any worsening symptoms, especially in the case of a routine referral.

32. Since April 2024, the records show the Practice had monthly consultations with Ms O, mainly around blood tests to monitor her thyroid function. The Practice say it feels it has done their best to support Ms O referring her to numerous specialists across London.

33. Our adviser highlighted that the Practice acted appropriately in relation to the thyroid referrals and in accepting to do specialist blood tests and numerous referrals on a regular basis. We consider the actions of the Practice were in line with the GMC guidance as the Practice provided suitable investigations and referrals when Mrs O requested them.

34. The Practice were unable to send referrals directly, so appropriately sent them all via the local Trust for it to triage. Ultimately the hospital’s all rejected the referrals because they were out of area, which is out of the Practice’s control. We therefore see no indications of failings or delay in the Practice actions in sending referrals for Miss O.

35. We understand this has been a stressful time for Ms O and hope that our investigation puts her mind at ease that nothing went wrong in the referral process and the Practice sent the referral to the correct hospital.

36. We appreciate Ms O may not have yet been seen by a specialist of her choice, we are pleased to see the Practice have referred Ms O to her requested hospitals for opinion in line with the local procedure and guidance. It is unfortunate the referrals have been an unsuccessful so far. From reviewing all information, medical records, and advice we feel this is not due to any error of the Practice.

37. We hope she manages to get the help and support she requires with the continued support of her GP for the future and thank her for bringing her concerns to us.

1. We have carefully considered Ms O’s complaint about the Practice.

2. We are satisfied that we have not seen any indication that anything went wrong with how the Practice handled Ms O’s referral.

3. We recognise this has been a difficult time for Ms O as she has told us about how this has been impacting her daily life and her mental health.