A practice in the Teignbridge area

4. Ms R complains about the care and treatment the Practice provided between June 2020 and January 2021. Specifically, that it did not respond appropriately to her blood test results. She believes the Practice should have referred her to a nephrologist during this time, which may have prevented a stroke in January 2021.

5. Ms R has been suffering with a brain injury since the stroke. She experiences confusion and struggles to process information. She is no longer able to live independently and relies upon family for support. This has been immensely stressful for her and her family.

6. In bringing the complaint to us Ms R would like the Practice to acknowledge what went wrong, make service improvements and pay her a financial remedy.

7. What follows is a summary of events. We have not included all details as both parties are aware of this.

8. On 24 June 2020 Ms R contacted the Practice with an eight-week history of ankle swelling. She was also feeling fatigued, had occasional dizzy spells and was light headed. A GP had a virtual consultation with her the following day where they discussed her symptoms and requested a range of blood tests.

9. On 30 June Ms R had blood tests. A GP reviewed the results and noted Ms R had oedema (swelling due to a build-up of fluid) on both of her feet and low protein levels. The GP felt the oedema was likely linked to decreased movement due to the Covid-19 lock down and asked Ms R to go in for a cholesterol test.

10. Ms R had blood tests again on 9 July. The GP reviewed the results and considered these were satisfactory and required no further action.

11. On 12 November Ms R contacted the Practice again as she had an episode of post rectal bleeding (bleeding from the bottom) with no weight loss or change in bowel habit. A GP noted her previously high levels of: • haemoglobin (a key protein in red blood cells) • mean corpuscular volume (the average size of red blood cells) • ferritin (iron) • cholesterol (a type of fat that helps the body perform important functions).

12. Between 13 and 14 November Ms R had repeat blood tests. The GP reviewed the results and felt these were satisfactory and required no further action.

13. On 23 January 2021 Ms R was admitted to hospital with aphasia (inability to understand or produce speech, because of brain damage) which was found to be because of an arterial ischemic stroke (a stroke caused by a blockage in an artery to the brain).

14. On 26 January 2022 Mrs R had a liver scan in hospital. This led to her being referred to a nephrologist.

15. On 21 April Mrs R had an appointment with a nephrologist and underwent a kidney biopsy (a medical procedure that involves taking a small sample of body tissue for examination) on 9 May. This led to her being diagnosed with membranous nephropathy (a kidney disease where the immune system attacks kidney filters) on 19 May.

Evidence we are considering

16. What follows is a list of evidence we have considered in our investigation of this complaint: • Ms R’s complaint form and her account of what happened • Ms R’s complaint to the Practice • Ms R’s Practice records from June 2020 to January 2021 • Ms R’s hospital records from January 2021 to May 2022 • the Practice’s full complaints file and its response regarding events.

17. We obtained independent clinical advice from a general practitioner (our GP adviser) with over 20 years of experience in the NHS. We also got advice from a consultant nephrologist (our nephrologist adviser) with over 30 years of experience working in nephrology. Clinical advice goes onto assist us in reaching a decision as material evidence we have relied upon. Clinical advisers provide advice but do not reach decisions on the complaints we look at.

18. We use relevant law, policy, guidance and standards to inform our thinking. This allows us to consider what should have happened. We have referred to the following standards:

• General Medical Council (GMC): ‘Good medical practice’, 25 March 2013 • Our Principles for Remedy, 10 February 2009.

19. Ms R complains about the way the Practice responded to her blood test results during the period of complaint. She considers these should have led the Practice to refer her to a nephrologist.

20. Ms R’s blood test results from June and November 2020 show she had low albumin levels (albumin is a protein the liver makes). Our GP adviser explained low albumin levels can suggest kidney or liver disease. They can reflect diseases in which the kidneys cannot prevent albumin from leaking from the blood into the urine and being lost.

21. Our GP adviser said there are no national standards or guidance for doctors to follow when investigating low albumin levels. In lieu of specific guidance we refer to GMC’s Good medical practice. This says if doctors assess patients they must promptly arrange or provide suitable treatment and investigations.

22. Our GP adviser said Ms R’s low albumin levels should have led GPs to arrange urine protein testing in July and November. Given what we know about Ms R’s albumin levels and her later diagnosis of membranous nephropathy, it is likely that this testing would have shown protein in Ms R’s urine. They said the Practice should have referred Ms R to nephrology for further investigation after this. The Practice has accepted this and apologised that it did not do this.

23. We understand that this would have been a routine referral not an urgent one. Given that the issues Ms R raises occurred during the COVID-19 pandemic, when the NHS paused many non-urgent investigations, it is not possible to say with any certainty whether Ms R would have seen a nephrologist before she had her stroke if the Practice had referred her in 2020.

24. Good medical practice makes it clear that doctors must promptly arrange suitable investigations. Clinical records show the Practice did not carry out urine testing in July or November 2020. Nor did they refer Ms R to nephrology during this time. The evidence suggests that the Practice should have referred Ms R to nephrology after carrying out urine tests further to her July results. There appears to have been a further missed opportunity to have referred Ms R after her November results. We have found a failing in this aspect of the complaint.

Impact

25. Ms R had a liver scan in hospital in January 2022. This led to her seeing a consultant nephrologist in April and undergoing a kidney biopsy in May. She received a diagnosis of membranous nephropathy on 19 May. She says her consultant queried her pre-stroke symptoms and said the stroke was likely due to undiagnosed membranous nephropathy.

26. Ms R considers an earlier referral to nephrology would have led to her receiving treatment that could have prevented her stroke.

27. Our nephrologist adviser agreed it was likely Ms R would have received a membranous nephropathy diagnosis if the Practice had referred her in 2020. They said there are no specific standards or guidelines on the treatment of membranous nephropathy. Specific treatment for membranous nephropathy depends on kidney function, severity and progression. They explained membranous nephropathy can spontaneously resolve or remain stable and not require any aggressive treatment.

28. Normal albumin levels are between 35 and 50. Ms R’s clinical records from July 2020 show her albumin levels were 31 and her kidney function was normal. Our nephrologist adviser said that whilst clinicians can treat low albumin levels with oral blood thinning medication, there is no specific guidance on this. Typically, clinicians would prescribe this to someone with low albumin levels and abnormal kidney function. They said it is not possible to say whether Ms R’s slightly low albumin levels and normal kidney function would have prompted a nephrologist to prescribe oral blood thinning medication as this would not be in line with normal clinical practice.

29. Our nephrologist adviser said for some patients with high cholesterol and membranous nephropathy clinicians will prescribe a statin (medication to lower cholesterol). They clarified Ms R’s cholesterol levels in 2020 were not high enough to require medical intervention. Meaning we cannot say an earlier referral would have led to her receiving this medication.

30. We note Ms R has a history of high blood pressure. Our nephrologist adviser explained this is a stroke risk factor, meaning Ms R would have remained at risk of future stroke even if she received specific nephrology treatment in 2020.

31. Ms R began receiving nephrology treatment in 2022 because her kidney function was lower at this time.

32. We recognise Ms R considers an earlier referral to nephrology would have led to her receiving treatment that could have prevented her stroke. Based on the evidence we have seen, we cannot say Ms R would have received any specific treatment if the Practice had referred her to nephrology in 2020. As we explain in an earlier section of this report, it is not possible for us to say with any certainty that Ms R would have seen a nephrologist prior to her stroke if the failings had not occurred. Meaning we cannot say the lack of referral contributed to her stroke.

33. Ms R has been suffering with a brain injury since her stroke. She is no longer able to live independently and relies upon family for support. It is clear from her account of events that having a stroke has had far reaching consequences and her life is no longer the same. We understand that this has been a source of significant distress for her and her family.

34. We acknowledge her consultant’s view that her membranous nephropathy may have caused her stroke. We do not dismiss this. There is not enough evidence for us to say with any certainty that Ms R would have received treatment from nephrology if the Practice had made a referral in 2020. We also do not know if she had received treatment, that it would have impacted her changes of having a stroke. Meaning we cannot say the impact she has experienced was because of any mistake on the Practice’s part.

35. In its response to the complaint dated 17 May 2024 the Practice acknowledged the medical issues Ms R has experienced and the impact these have had for her and her family. It noted membranous nephropathy is a rare condition and the GP involved in the complaint had reflected on this and modified their working practice. This acknowledgement of what went wrong and apology are in line with our Principles for Remedy.

36. In bringing the complaint to us, Ms R wanted the Practice to acknowledge what went wrong. It is clear from her account of events she would like the Practice to acknowledge that a lack of referral in 2020 meant she missed out on treatment that may have prevented her stroke. We have not seen evidence that this was the case. We do not consider the Practice needs to do anything further. We do not uphold this complaint.

1. We have carefully considered Ms R’s complaint about the Practice. We are sorry to hear about the distress she has experienced because of the issues she complains about. We understand she had a challenging recovery after her stroke and recognise this continues to affect her life.

2. We have found a failing in the way the Practice responded to Ms R’s blood test results between July and November 2020. We consider it should have referred her to a nephrologist (a kidney specialist) during this time.

3. We have been unable to link this lack of referral with any negative clinical impact. This is because we have not seen evidence that Ms R would have received specific treatment from a nephrologist had the referral taken place sooner. It is our view this lack of referral did not mean her stroke was preventable. For this reason, we do not uphold the complaint.