Physical examination
15. Mrs A says despite making eleven contacts with the Practice and having two face to face appointments, the Practice failed to carry out a physical examination over a five month period for her ongoing pain condition.
16. We reviewed this issue with the help of our GP adviser, using Mrs A’s medical records.
17. On 13 July 2023, Mrs A contacted the Practice by eConsult request form complaining of back pain radiating down her leg, the Practice offered Mrs A the option to refer to physiotherapy and she declined this.
18. On 14 July 2023 an advanced clinical practitioner assessed Mrs A remotely and prescribed diazepam for 28 days. The advanced clinical practitioner offered safety netting advice to go to the Emergency Department (ED) should Mrs A experience incontinence or numbness in her limbs.
19. On 18 July 2023 Mrs A attended the ED. ED clinicians carried out an MRI scan which showed multilevel degenerative disc disease but no pinched nerve. Multilevel degenerative disc disease is an often age-related condition where degenerative changes affect more than one disc or level of the spine. ED clinicians recommended the Practice refer Mrs A to neurosurgery and the Practice processed the referral on 10 August 2023.
20. On 24 July Mrs A submitted an eConsult request to advise she had a blistering rash which she suspected was shingles and she would like an appointment for treatment. On 25 July the Practice remotely provided a prescription for acyclovir to treat shingles.
21. On 31 July Mrs A contacted 111 complaining of severe pain. The 111 clinician noted she was already taking amitriptyline, codeine, oromorph and paracetamol. The 111 clinician advised Mrs A to stop taking codeine and prescribed tramadol. Mrs A declined a face to face appointment.
22. On 9 August 2023 the Practice assessed Mrs A in a face to face appointment and referred her to neurosurgery. The consultation notes are brief stating ‘assessment, left low back pain radiating down left leg, left foot feels numb, passing urine and bowels opening okay’. The Practice prescribed a further supply of tramadol.
23. On 15 August 2023 the Practice called Mrs A in relation to ongoing left leg pain she was experiencing. The GP noted the pain was from hip to foot and her foot and calf were numb. The GP also noted there was no acute disc or cauda equina seen on the MRI scan on 18 July.
24. The Practice prescribed a further supply of diazepam for 28 days and noted Mrs A had an appointment with neurosurgery in September.
25. The Practice also increased Amitriptyline to three times daily. The Practice recorded a diagnosis of left leg pain and numbness which sounded like sciatica and noted the MRI scan carried out on 18 July was satisfactory.
26. On 23 August Mrs A submitted an eConsult request for another MRI scan. On 24 August the Practice replied to Mrs A saying they didn’t think she needed a further MRI scan at present as she had been referred to neurosurgery and it was best to wait for assessment by neurosurgery in September.
27. On 21 September Mrs A was seen by a consultant neurosurgeon who carried out an MRI scan and referred her on to a consultant neurologist in November 2023.
28. Our GP adviser said there was no need for the Practice to have carried out a physical examination as ED clinicians had examined her and performed an MRI scan on 18 July 2023. Following this, the Practice did assess Mrs A in a face to face appointment on 9 August and referred her to neurosurgery and subsequently neurology. A further physical examination by the Practice would not have changed Mrs A’s management.
29. We have seen evidence the Practice worked in conjunction with other health care professionals to provide an appropriate level of care. This is in accordance with GMC’s Good Medical Practice which says, ‘in providing good clinical care, doctors must consult colleagues where appropriate.’ We have seen no indications of failings here and will take no further action on this complaint part.
Pain medication
30. Mrs A says an ED clinician recommended the Practice carry out an urgent medication review after her attendance at the ED on 18 July 2023. She told us the recommendation was written in the discharge letter from the ED and additionally the ED clinician had told her verbally she needed a medication review. She says the Practice refused to do this.
31. On 18 July Mrs A attended the ED complaining of back pain radiating down her left leg. Mrs A told the ED clinician she suffered with chronic sciatica and for the past week she had started with terrible pain, moreso than usual. An MRI test was carried out as mentioned earlier in this report.
32. The discharge letter recommended analgesia and a referral to neurosurgery. We saw nothing in the discharge letter to suggest the ED clinician requested an urgent medication review by the Practice.
33. We have carefully considered Mrs A’s medical records. We are faced with different accounts of what happened and no clear contemporaneous record to confirm Mrs A’s account. It is not our intention to dismiss Mrs A’s account. We make evidence-based decisions. We have studied the discharge letter which Mrs A says instructed the Practice to carry out an urgent medication review and cannot see it says this.
34. Mrs A told us the Practice refused to prescribe pain relief on 24 July, 13 and 23 August and 28 September.
35. In its complaint response the Practice explained it was more than willing to discuss pain relief needs with Mrs A but wished to do this face to face so they could have a proper back and forth discussion. It said it did not believe diazepam was the right medication to help Mrs A and wished her to see a GP to discuss the best way forward for her.
36. We reviewed this issue with the help of our GP adviser, using Mrs A’s medical records.
37. GMC managing medicines guidelines state, ‘you should only propose, prescribe or provide medicines if you have adequate knowledge of the patients health, and you are satisfied the medicines serves the patient’s needs. A clinician must consider,
• Whether they can establish two way dialogue, make an adequate assessment of the patient’s needs and obtain consent.’
38. Mrs A had long-standing chronic sciatica, and she had started to experience more intense pain in July 2023. She was already being prescribed slow-release morphine, pregabalin and amitriptyline for her chronic pain.
39. On 13 July 2023, Mrs A submitted an eConsult request form reporting lower back spasm and severe pain radiating down her left leg. Under what treatment would you like to request she wrote ‘diazepam 5mg is the only treatment that has helped for previous spasms.’
40. On 14 July Mrs A had a telephone consultation with the Practice, she said she had spasms and felt she needed diazepam. The Practice prescribed diazepam and gave Mrs A safety netting advice to attend ED should her symptoms become worse.
41. On 18 July Mrs A attended the ED with back pain. The ED clinician prescribed three days’ supply of diazepam and recommended a referral to neurosurgery.
42. On 24 July Mrs A submitted an eConsult request to advise she had a blistering rash which she suspected was shingles and she would like an appointment for treatment. The Practice called Mrs A and booked a face to face appointment.
43. The staff member who took the call also noted Mrs A had requested a prescription for diazepam. As the request for diazepam is not showing on the eConsult form it seems this was requested verbally on the telephone. Following this entry, there are no consultation notes and so it appears Mrs A did not attend the Practice for a face to face appointment on that day.
44. On 31 July Mrs A contacted 111 and complained of severe pain in her toe and numbness in her foot. The 111 clinician noted she was already taking amitriptyline, codeine, oromorph and paracetamol. The 111 clinician advised Mrs A to stop taking codeine and prescribed tramadol. Mrs A declined a face to face appointment.
45. On 9 August Mrs A had a face to face appointment at the Practice. The records show the GP assessed Mrs A noting she was passing urine and her opened her bowels. The Practice prescribed further tramadol and referred Mrs A to neurosurgery.
46. On 14 August Mrs A contacted 111 to report she had requested diazepam from the Practice earlier that day but had not heard back. Mrs A told the clinician she had tried tramadol, but it had made her sick and dizzy, so she had reverted back to diazepam which she had now run out of. The 111 clinician recommended increasing the dose of amitriptyline as this was preferable to becoming dependent on diazepam.
47. On 15 August the Practice spoke to Mrs A during a telephone consultation and prescribed 7 days’ supply of diazepam and an increase in amitriptyline.
48. On 23 August Mrs A submitted an eConsult request form reporting continuing pain and numbness in her left foot and queried whether she needed another MRI scan. Under the heading ‘what have you tried?’ Mrs A wrote diazepam helped the most and she was also using amitriptyline and heat therapy. Under the heading what help would you like Mrs A wrote, ‘MRI scan to see why my foot is dead and something done about it.’
49. On 24 August the Practice responded to Mrs A saying they didn’t feel she needed a further MRI scan at the present time as they had referred her to neurosurgery, and it was felt best to wait for an opinion from them. We saw nothing to suggest Mrs A requested pain relief in this eConsult form.
50. Mrs A submitted an eConsult request form on 28 September to say she was expecting to be referred as soon as possible to neurology. Mrs A also described having excruciating nerve pain with zero effect from the current analgesics she was taking.
51. On 29 September, the Practice responded to Mrs A’s eConsult request advising the neurology referral had been actioned and it was more than happy to discuss pain relief in person, but they were not happy to do this remotely.
52. On 17 October Mrs A had a face to face appointment at the Practice. The GP noted the shingles rash was setting using amitriptyline and pregabalin with diazepam as needed. The GP prescribed a further supply of diazepam to be taken one to three times per day.
53. We have seen nothing to suggest the Practice refused to provide pain relief to Mrs A in July and August 2023. On 29 September, the Practice wanted to see Mrs A in person to discuss her pain relief needs. We consider this was reasonable and in accordance with GMC guidance for managing medicines.
Referral letter
54. Mrs A told us The Practice failed to include crucial clinical information in its referral letter to neurosurgery. She told us due to this, she was put on a non-urgent referral list. She says this also meant the team did not have the correct information to make the right diagnosis.
55. We reviewed this issue with the help of our GP adviser, using Mrs A’s medical records.
56. The Practice referred Mrs A to neurosurgery on 9 August 2023 on the recommendation of ED clinicians who had carried out an MRI scan on 18 July. The recommendation from the ED clinicians was not for an urgent referral. We can see the referral from the Practice does not mention a shingles diagnosis.
57. Our GP adviser told us had the Practice included the shingles diagnosis in the initial referral it would not have meant Mrs A would have been seen urgently. They told us the MRI scan in July 2023 had shown no concerning features therefore there was no indication for an urgent referral.
58. Mrs A was seen by neurosurgery on 21 September 2023. An MRI scan was carried out which showed nothing of concern. The consultant neurosurgeon recommended Mrs A be referred to a consultant neurologist. This was not recommended as an urgent referral. The Practice referred Mrs A to neurology on 27 September 2023. The Practice provided information to neurology about Mrs A’s shingles diagnosis on 27 November 2023.
59. Mrs A was seen by a consultant neurologist on 23 April 2024. The consultant neurologist noted Mrs A’s shingles diagnosis when taking a medical history from her. We saw nothing to suggest the consultant neurologist was unaware of the shingles diagnosis when assessing Mrs A.
60. The consultant neurologist’s initial impression on 23 April 2024 was of postherpetic neuralgia which is another term for shingles pain. The consultant neurologist requested a series of blood tests and imaging to rule out an alternative cause.
61. Despite being aware of the shingles diagnosis, the neurology team still carried out further tests to rule out potential other causes of the pain. We do not consider Mrs A’s journey would have been any different had the shingles diagnosis been included on the initial referral.
62. Mrs A claimed she was not seen urgently, and the team did not have the correct information to make the correct diagnosis. We have been unable to link this claimed impact to the shingles diagnosis not being included on the initial referral letter.
63. We are sorry to hear how Mrs A has struggled with chronic pain and how this was exacerbated by shingles. We recognise from conversations we have had with Mrs A how difficult this has been for her. We have not identified anything went wrong in Mrs A’s care and therefore we are not taking further action on her complaints. We hope our decision provides some reassurance to Mrs A about the care and treatment she received.