Investigation and treatment of pain symptoms
13. 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 in Mr F’s case and have not found any indications that something has gone wrong.
14. Mr F complains that the practice failed to investigate, and treat, his symptoms of recurring pain appropriately and in a timely manner. He told us he approached the practice on a number of occasions over the course of several years between 2017 and 2023 reporting symptoms of pain in several areas, including his back and shoulder.
15. He says the practice did not take appropriate action, particularly when it was clear this pain was recurring rather than isolated. Mr F was diagnosed with Fibromyalgia in February 2024 following a referral to rheumatology in September 2023. He says the practice should have made this referral sooner so that he could have received the diagnosis, and treatment earlier.
16. In the responses of 14 November 2022 and 28 August 2024, the practice explained it carried out investigations when Mr F presented with back and shoulder pain. It outlined a number of occasions and consultations in which Mr F raised concerns and the steps it took in response each time.
17. We have reviewed the relevant medical records available from the period in question. We also sought input from our GP clinical adviser. Our adviser referred to NICE guidelines NG59 on low back pain in sciatica in over 16s: assessment and management (NG59) and NG193 on chronic pain in over 16s: assessment of all chronic pain and management of chronic primary pain (NG193).
18. From the records, we can see Mr F presented with recurring issues relating to pain in his back and shoulder on a number of occasions from March 2017 onwards. He also presented with pain in other areas of his body on occasion, for example in his foot and wrist. However, we can see there were clear explanatory factors for these such as a sprain or tendon injury.
19. The records also show that on each of the occasions Mr F approached the practice reporting back or shoulder pain, the practice took steps relating to this. We can see the practice offered to carry out blood tests for Mr F on several occasions. From our advice and consideration of the medical notes for the period, we understand this would be to investigate possible alternative causes of his pain, such as inflammatory conditions, and that doing so would be an appropriate step to take.
20. We can also see the practice involved a physiotherapist in Mr F’s care at several points and gave him advice on exercise and remaining active. Section 1.2.2 of NICE NG59 explains clinicians should consider exercise for people with low back pain. Section 1.2.1 and 1.2.2 of NICE NG193 also explain clinicians should encourage those with pain to remain active. We consider the above actions the practice took are in line with this guidance.
21. We have also not seen any evidence to indicate the physiotherapy service suspected fibromyalgia as a diagnosis for Mr F. Our adviser suggested that this would have been done if there were significant symptoms indicating it as a possibility.
22. Section 1.2.15 of NICE NG59 also explains clinicians should promote returning to work for those living with low back pain. In the records, we can see Mr F suggested his pain may be related to stress at work on several occasions. Where this was the case, we can see the practice signposted him appropriately, including to legal advice or involving his union. We consider this was reasonable and appropriate.
23. From the records, we can also see the practice prescribed Mr F sertraline (an anti-depressant) on a number of occasions. We understand this would also have been an appropriate intervention to offer, given Mr F’s suggestion that his pain may be related to stress or impacted by his mental health.
24. We have not seen any indication that the practice should have offered any further or additional interventions or investigations to Mr F during the period in question, that on each occasion the practice responded to the emerging picture accordingly and in line with standards. In particular, he has raised concerns about the practice not referring him for imaging of his back or to rheumatology at an earlier stage.
25. Section 1.1.4 of NICE NG59 explains clinicians should not routinely offer imaging for people with low back pain. Based on this guidance, we consider it was reasonable for the practice not to refer Mr F for further imaging relating to his pain.
26. From our advice, we understand a referral to rheumatology, and subsequent diagnosis of fibromyalgia, would be made following evidence of persistent pain, usually present or recurrent for more than three months. As outlined above, the records document that Mr F’s symptoms did not meet these clinical criteria for most of the period in question.
27. Our adviser also noted there were multiple other factors present for much of the period which indicated against Mr F’s symptoms being caused by fibromyalgia. This included Mr F self-reporting through questionnaires that he had no issues with sleeping which would be a typical reason to suspect fibromyalgia. The fact that Mr F also suggested alternative reasons for his pain levels such as stress at work also indicated causes other than fibromyalgia.
28. We can see the first documented mention of fibromyalgia as a possible diagnosis was during an appointment on 27 September 2023. We understand that the symptoms and circumstances at this point were more likely to meet the criteria outlined above. This is because
29. Based on the above, we consider it was reasonable for the practice not to have suspected a diagnosis of fibromyalgia or made a referral to rheumatology at an earlier stage than it did.
30. Although we have seen no indication of failings in the practice’s treatment and investigation of Mr F, we consider it is also worthwhile noting that an earlier diagnosis is unlikely to have changed the overall clinical outcome. This is to be transparent and open with Mr F in the interest of giving him clarity around the circumstances of his complaint.
31. From our advice we understand most of the interventions that would be offered following a diagnosis of fibromyalgia were already in place for a significant amount of the period in question. This includes advice on activity and exercise, referral to a physiotherapist and medication to manage pain and mood.
32. In his correspondence to the practice and ourselves, Mr F has stated he has since been prescribed pregabalin (an anticonvulsant often used to treat fibromyalgia) and told us this has made a difference to his symptoms. Our adviser referred to both NG59 and NG193. Both of these sets of guidance make it clear that antiepileptics, such as pregabalin, should not be prescribed to manage chronic pain or low back pain.
33. Taking the above into account, we have not seen any indications that the practice failed to act appropriately when Mr F presented with back and shoulder pain symptoms. We have also seen no indication that the practice should have referred him to rheumatology or diagnosed Mr F with fibromyalgia at an earlier stage. We are therefore not intending to look into his case further.
34. We acknowledge this may be disappointing to Mr F, particularly as he has experienced such difficult symptoms over a significant period of time. By making the decision, we are not intending to diminish his experience, and hope he is reassured that we have looked into his case thoroughly.
Complaint handling
35. Mr F has raised concerns about the practice’s complaint handling. In particular he told us he was unhappy with the practice not issuing a final full complaint response about the investigating or treating his pain until April 2025.
36. Mr F told us this was several months after he was expecting to receive a final response and that this added to his distress during an already difficult period.
37. We note the NHS Feedback and Complaints guidance which is relevant here (https://www.england.nhs.uk/contact-us/feedback-and-complaints/complaint/) and notes there’s no set timeframe for responding, and this will depend on the nature of the complaint raised and if delays are incurred the complainant should be kept informed of the reasons for delay
38. We understand each complaint to the NHS is different and can involve layers of complexity such as how many departments are involved with the response, the complexity of care or other factors which may make a complaint response slower.
39. We also note additional guidance in the NHS Complaint Regulations 2009. The complaint regulations explain that organisations should send complainants a response within six months of the date the complaint was received. If it is not able to do so, the organisation should notify the complainant to explain why this is the case and send the response as soon as reasonably practicable.
40. We would normally take a delay beyond this six-months to indicate a complaint response was potentially becoming old, but again, depending on the nature of the response on a case-by-case basis recognise there can be justification for this.
41. The practice told us it had indeed prepared a response to the issues Mr F raised but was minded issuing this owing to some legal action which was ongoing at the time.
42. We also recognise this covered a period of several years of care.
43. We have reviewed the relevant complaint documentation from the period in question. We can see Mr F received a response to his initial complaint in November 2022 and approached us in December 2022 when he remained unsatisfied. We made an initial decision on the complaint in November 2023, and reopened the case after Mr F challenged the decision.
44. After determining that the practice had not issued a final response covering all the issues Mr F had raised, we asked it to consider issuing a final response covering the more recent issues in the first complaint component. This was in April 2024.
45. The practice informed us it was willing to provide a further response. However, in May 2024 and June 2024 it received documentation relating to legal action Mr F had initiated.
46. The practice expressed concern about providing the final response to Mr F whilst this legal action was being initiated or ongoing as the two were entwined. The practice explained it had concerns that the issues covered in the response may be related to the issues being considered in the legal action. We acknowledge that Mr F disagrees with this opinion and felt that the issues were unrelated.
47. We have seen the practice also sought input from solicitors and the medical defence union on the issue. After doing so, it did not provide the response directly to Mr F until the legal action was discontinued.
48. Here, we are not looking at the legal matter in our investigation but considering if factors that caused delays were justified.
49. It is clear the practice did not issue the final complaint response to Mr F within six months. The overall time limit between us requesting a further response, and Mr F receiving a copy of this was around 12 months. As outlined above, there are no timescales to a complaint response, and this is on an individual basis. Here we note the practice was handling a complaint response and within it initiated legal proceedings and covering a significant period of care.
50. During this period, the practice was in regular contact with us to explain its position. We, in turn, updated Mr F regularly to inform him of the reasons no response had been issued, and the practice’s thinking at the time.
51. We have not seen any evidence the practice contacted Mr F directly to explain that it was not intending to provide a response within six months, or the reasons for this. However, it did check with the caseworker that Mr F was aware of this.
52. We acknowledge that it would have been a frustrating time for Mr F and he was waiting up to a year for a response.
53. When we consider failings we must consider if they fell so far short of a standard that we can call them maladministration. Recognising that in the circumstances of this complaint a legal matter was also running concurrent to the complaint response we have not indicated a failing that fell so far short to be maladministration. We also note Mr F was in contact with the Ombudsman providing updates and owing to the complexity of the legal matter, once the organisation was in a position to provide a complaint response it did.
54. Therefore we have not identified a failing in this aspect. We are therefore not intending to look into this part of Mr F’ complaint further.