A practice in the Hertfordshire area

2. Ms C complains about the lack of care and treatment she had from the Practice between April and May 2022. She complains the Practice: • diagnosed her symptoms incorrectly • did not do the right referrals • sent unwanted mental health referrals • sent unwanted text messages.

3. Ms C says she experienced unnecessary pain and suffering, leaving her distressed. She says the Practice discriminated against her because of a mental health diagnosis in the past. She explains she has lost faith in all medical professions.

4. Ms C wants the Practice to make changes to improve its service.

5. In April 2022 Ms C wrote to the Practice because she had not seen a doctor for 18 months. An appointment was arranged for 25 April 2022.

6. Ms C says the doctor misdiagnosed two problems. They said the pain in her right foot was due to a lack of exercise, but she told them she walks daily, and the doctor did not make a referral for her foot to be assessed.

7. Ms C also says that during the appointment the doctor tried to refer her to mental health services, but she did not need this.

8. Ms C had a phone appointment with the doctor on 3 May and she told him she was feeling very anxious, had a lump in her throat and had problems swallowing. She says the doctor did not make a referral to another clinician but referred her to mental health services.

9. Two weeks later Ms C saw the doctor again because she was still unwell and a referral was made for her lungs to be checked. Ms C says at no time did the doctor look at her throat and they did not make a referral to the ear, nose and throat team (ENT).

10. Ms C says the doctor suggested she was struggling after the COVID-19 lockdown and she was living in the middle of nowhere with no public transport. She explained she was living in and around farmland where the farmers were spraying toxic chemicals. She felt this affected how she was feeling and she showed him pictures of the spray and chemicals.

11. Since leaving the Practice Ms C has been diagnosed with osteoarthritis (a condition that causes joints to become painful and stiff) and needs a cartilage replacement. She has also been diagnosed with globus pharyngeus (the painless sensation of a lump in the throat and may be described as a tightening or choking feeling).

12. Ms C is now in extreme pain and needs a referral for her foot, back and arthritis.

13. Her current practice referred her to hospital. She feels if the Practice had referred her, she would have had help sooner and found out what was wrong.

14. Ms C also complains that in May 2022 she had unnecessary and unwanted text messages from the Practice about contraception.

The Practice did not diagnose her symptoms or refer her and it sent unwanted mental health referrals

17. GMC guidance says:

‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: • adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.’

18. It adds:

‘In providing clinical care you must: • prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs • provide effective treatments based on the best available evidence’.

19. Ms C told us she went to the Practice with a physical problem but the doctor said she had an emergency mental health need. Ms C does have anxiety but that was not her reason for having an appointment. We can see Ms C wrote to the Practice on 4 April and explained she had spinal problems and pain in her left hip at the joint of the coccyx and hip. She explained this made it difficult to walk and move. Ms C asked the Practice to call her or refer her to hospital for a scan.

20. The Practice notes from 4 April say, ‘Problem: Osteoarthritis, History: Coccyx pain, L, 8 weeks, ? trigger. Fractured coccyx - many years ago. Has PMH hypermobility. Pain in left hip, reduces mobility, First thing in the mornings, finds it hard to get going, stiff++. Does yoga exercises to get going in the morning. Tested 3rd for covid this am. Plan: 1, Xray.’

21. The same day the Practice made a referral for Ms C to go to hospital for an X-ray.

22. We cannot see that Ms C mentioned problems with her foot. The Practice assessed and referred Ms C based on what it discussed with her.

23. The Practice records confirm Ms C had a follow up phone call with the Practice on 22 April. The records say, ‘patient suffering from physical symptoms which occur every year when the farmer is spraying the field very close to her house from March to October - doesn't know what the chemical is but believes its a pesticide - this week a large volume was discharged near her house and she has again developed boils on her face, worsening migraines and severe pains in her lung. Distressed and requested testing for poisons/pesticides. I explained it doesn't work like that need to know chemical- then can call poisons units and ask for advice - they may recommend testing for specific agents they may not. recommend that if she has problems with her lungs she go to A+E. Patient reports that she would want a report. I explained that what we could write would be limited and cost money to produce. She request continuity of care explained not possible at present as not enough doctors you get who you get at present.’

24. Ms C next had a face-to-face appointment at the Practice on 25 April.

25. The detailed Practice notes reflect on the concerns Ms C had about pesticide exposure and how this was affecting her.

26. The Practice explained, ‘we are not able to test blood individually for whole long list of chemicals she has listed, she feels Manganese is the most important of these- we will need to get advice from lab’.

27. The notes confirm it completed a physical examination of Ms C’s heart rate, oxygen, ears and eyes and all were normal. The notes also confirm Ms C was tearful and in a low mood.

28. The Practice referred Ms C for a chest X-Ray, gave her details to self-refer for mental health services and arranged for blood tests.

29. Ms C wrote to the Practice on 27 April saying, ‘To all whom have helped me since Monday of this week the 25th April 2022. I am so utterly grateful to all who have answered my emails since Monday and [Dr A] for his kind and thorough examination of me and my symptoms. To [B] the practice manager/ nursing staff who went over and above to help me on Tuesday the 26th April Via the telephone. I understand the unbelievable pressures you must be under and I cannot thank you enough for my care. All the very best to all of you!’.

30. The Practice did a phone assessment with Ms C on 3 May.

31. The notes confirm the blood test results were normal, but Ms C explained she was still unwell. The notes record what Ms C told it about the pesticide and how it made her feel. They say, ‘over the weekend at the evening, a spray mist/halo over the house. Says mist being absorbed into her skin. Says afterwards started to have pus coming from breasts and breasts painful. Associated dry retching, says had episode coughed up blood. Says going to hospital A&E as requires bone marrow sample and tissue sample to see if manganese in system. Says manganese not detectable in blood and requires these tests to prove being poisoned.’

32. In the call on 3 May Ms C confirmed she did a self-referral to mental health services but it rejected her referral saying, ‘her case is too complex’.

33. The same day the Practice referred her to a different agency for mental health support.

34. From what we have seen, Ms C did not talk about a problem with her foot in April or mention a lump in her throat in May. The records confirm Ms C’s focus was the pesticide exposure.

35. The Practice made referrals for her problems to be investigated when she asked for these and Ms C’s email confirmed she was pleased with the care. We also know the Practice sent a letter to Ms C to try and help her with her housing issues and find alternative accommodation.

36. Ms C did a self-referral to mental health services and when the Practice knew it was unsuccessful, it referred her to another service. We appreciate what Ms C says about being sure she discussed her foot problem and lump in her throat. The records do not show this.

37. If Ms C had discussed the foot pain and the lump in her throat with the Practice, we think it is likely that it would have referred her to another service or investigated these concerns further.

38. We think the Practice acted in line with GMC guidance and there is no sign that it did anything wrong.

The Practice sent unwanted text messages

39. Ms C complains the text messages about contraception were very distressing because she has no womb, has never been prescribed contraception and very sadly her partner died in 2017.

40. After she got the text messages she told the Practice through its online portal and feels it should have sent an apology as soon as it knew about the error.

41. Ms C said the doctor should have known she did not need contraception and she felt as though the Practice was ‘pushing for the medication to be prescribed’.

42. The Practice records from 14 May confirm it sent a text to Ms C saying, ‘Please find attached some important information regarding one of your tablets and pregnancy risks. I cannot find any evidence of contraception use in your records. Please respond to this message advising me if you do require contraception, so that I can either arrange an appointment or update your notes accordingly.’

43. The same day Ms C replied to the Practice saying she did not need contraception.

44. On 16 May the Practice sent another text. It said, ‘Thank you for your response, I can confirm your appointment with [name] at 11.40 on the 17th May. Regarding contraception, thank you for responding. If you are sexually active you do require contraception until age 55. I will update your records, saying contraception is not required, if however that is not the case please let me know.’

45. Ms C replied by text, ‘Thank you for the text confirming my appointment. Regarding the contraception matter, if you are looking through my notes then surely the fact that I had a full hysterectomy in 2009 and have navigated the menopause without HRT purely because I have Factor 5 Leiden should of been available within these notes?

I do not appreciate the repeated text back n forth about such matters. Given that I attempted to be clear this morning with you regarding contraception measures. Given my factor 5 Leiden, I have never taken the pill, again my notes should of illustrated that.

In closing, given all of the above & that my partner [died] almost 4 years ago and the fact I have no womb, I am more than surprised by your repeated attempts to get me on contraception!’

46. We have seen the Practice’s complaint response and the letter from the doctor who sent the text messages.

47. The letter says, ‘I am very sorry that the message brought back sad feelings regarding the death of your partner, this was not our intention.

The messages are sent out based on searches on records looking for specific issues, in your case it was: 48. Age – under 55; 49. Specific medication (Pregabalin in your case) and 50. Presence or absence of contraception.

Unfortunately, it does not include a history of having had a hysterectomy. This is a major omission and I will feedback to the team responsible for setting up the searches. We send these out in bulk, hence we don’t get to review each patient’s notes. On reflection I regret not reviewing your notes and sending the message to you. I apologise for causing you distress.

I have looked through your records and can only find evidence of one message being sent to you on the 14th May 2022, to which you responded. I sent a response to your response… I will need to feedback to the company and would be grateful if you could you provide me with the dates and times and number of messages you received so I can use that as evidence when I feedback to them. I appreciate that receiving multiple messages would be annoying and potentially upsetting. I am sorry that this caused you distress.’

51. Our Principles of Good Complaint handling say that organisations should, ‘Be open and honest when accounting for their decisions and actions. They should give clear, evidence-based explanations, and reasons for their decisions. When things have gone wrong, public bodies should explain fully and say what they will do to put matters right as quickly as possible’.

52. They also say, ‘There is a wide range of appropriate responses to a complaint that has been upheld. These include: • an apology, explanation and acknowledgement of responsibility • remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures, policies or guidance to prevent the same thing happening again; training or supervising staff; or any combination of these’.

53. Our Principles for Remedy say, ‘The public body should ensure that the complainant receives: • an assurance that lessons have been learnt • an explanation of changes made to prevent maladministration or poor service being repeated.’

54. Ms C wants the Practice to make service improvements. We think the Practice has taken learning from Ms C’s complaint and done what we would expect it to in line with our Principles.

55. We recognise the negative experience Ms C had and we are sorry hear about her difficulties.

1. We have carefully considered Ms C’s complaint about a GP practice in the Hertfordshire area (the Practice). We have decided not to consider Ms C’s complaint further because we have not seen anything wrong with the service the Practice gave her. We are sorry to hear about her experience and how distressing she found it. We explain our decision below.