13. We look for signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have done this and we have not seen any signs that something has gone wrong.
Diagnosis and treatment
14. Ms E says the Practice incorrectly diagnosed her skin rashes and prescribed inappropriate treatments.
15. The Practice explained skin conditions can be difficult to diagnose and often change over time, meaning different treatments need to be tried and it is often a process of elimination.
16. Our adviser said there is no specific guidance on skin rashes. GMC guidance says doctors 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.’
24 November 2020 appointment
17. The records from this appointment show the Practice noted Ms E’s symptoms as two weeks of blanching rash on her abdomen and legs. A blanching rash is caused by restricted blood flow to an area of the skin, causing it to become paler than the surrounding area.
18. The records show the Practice diagnosed her with folliculitis, a skin condition where hair follicles become inflamed. The Practice advised her to try over the counter hibiscrub, an antimicrobial skin cleanser. If Ms E’s condition was no better or getting worse, she was to let the Practice know.
19. The records show Ms E was unhappy with the diagnosis and treatment. She asked for a face-to-face consultation and the Practice arranged an appointment for 2 December so she could be examined.
20. Our adviser felt the Practice’s actions seemed to be in line with GMC guidance. The Practice noted Ms E’s recent history, reached a diagnosis and prescribed treatment for this. We can also see the Practice arranged for a further in-person appointment in line with Ms E’s wishes.
2 December appointment
21. The records from this appointment show the Practice noted Ms E’s symptoms as multiple small 5mm crusted erythematous patches all over her torso. Erythematous is inflammation of the skin. It also noted three over 1cm ringworm like patches, one on the right of her abdomen, one on her right thigh and one on her left thigh.
22. The records show the plan was to treat Ms E for a fungal infection with hydrocortisone cream to calm the rash and an emollient. Hydrocortisone is a steroid medication and emollient is a moisturising cream. The Practice planned to review Ms E again.
23. Our adviser felt the Practice’s actions were in line with GMC guidance. We can see the Practice noted the appearance of the rash (which was different to the last appointment), reached a diagnosis and gave treatment for this. We can also see the Practice arranged another appointment to review the treatment.
9 December appointment
24. The records from this appointment show the Practice noted Ms E’s symptoms had much improved using the combination of emollient and hydrocortisone, prescribed at the last appointment.
25. The records show the Practice examined Ms E and noted the ringworm on her thighs had nearly gone. The Practice noted there were some crusted spots on her abdomen that were dry and getting better.
26. The plan was to continue using emollient and hydrocortisone for a week and then continue with just emollient. If symptoms continued, the Practice advised a course of fluconazole 50mg capsules. Fluconazole is an antifungal medication. The Practice gave a prescription for this. The Practice agreed to review Ms E again if her symptoms were not improving, or if Ms E was worried.
27. Our adviser felt the Practice’s actions were in line with GMC guidance. We have seen the last treatment the Practice gave seemed to have improved the appearance of Ms E’s rash. We can see the Practice examined Ms E and based its treatment decisions on that examination.
6 April 2021 appointment
28. The records from this appointment show the Practice noted Ms E had rashes under both breasts and ringworm. The records show the Practice prescribed hydrocortisone and miconazole ointment. Miconazole is an antifungal medication. The Practice asked Ms E to let it know if the issue was not settling.
29. Our adviser says the Practice’s actions were in line with GMC guidance. The Practice examined Ms E and prescribed treatment based on that examination.
30 December appointment
30. The records from this appointment show the Practice noted Ms E had a fungal rash under her breasts, which was noted to be a moist itchy rash. It noted she had no fevers, no other symptoms and that Ms E felt well in herself.
31. The records show the Practice explained what red flags to look out for and advised it would review her again if needed. The practice prescribed fluconazole 50mg capsules, hydrocortisone and miconazole cream. The Practice noted Ms E said she was happy with the plan.
32. Our adviser felt the Practice’s actions were in line with GMC guidance. The Practice examined Ms E and noted her history. It prescribed medication based on this review.
14 February 2022 appointment
33. The records from this appointment show the Practice noted Ms E had an ongoing skin rash, which the Practice thought was fungal. The Practice prescribed fluconazole 50mg capsules, hydrocortisone and miconazole cream.
34. The records show the Practice also ordered blood tests. The records show all test results were either normal or satisfactory.
35. Our adviser felt the Practice’s actions were in line with GMC guidance. We can see the Practice again noted Ms E’s ongoing problems and it arranged for investigations. It also prescribed treatment based on Ms E’s presentation.
8 March appointment
36. The records from this appointment show the Practice noted Ms E had a skin rash on and off for eighteen months, which kept coming back. It noted fungal cream or fluconazole helped with the itching but did not completely clear it.
37. The Practice noted Ms E had rashes on her upper thighs and arms but that these were more like dry skin. The Practice felt these areas did not have fungal appearance and looked more like folliculitis.
38. The Practice noted Ms E had individual red papules skin lesions and some pustules skin lesions in the centre of her chest. Papules and pustules are different types of small bumps under the skin. The Practice prescribed a trial of emollient.
39. The records show Ms E was not happy with the length of time her skin condition had been ongoing and the constant testing of treatments. She said she wanted to see a dermatologist, but she was happy to continue to see the GP at the Practice routinely to review the treatment.
40. Our adviser felt the Practice’s actions seemed to be in line with GMC guidance. We can see the Practice noted Ms E’s history and did an examination. It prescribed treatment based on Ms E’s presentation and history.
21 March appointment
41. The records from this appointment show the Practice noted Ms E’s skin looked much better with the emollient treatment. The Practice noted Ms E’s symptoms were consistent with erythematous macules, with no obvious pustules, and some element of a sweat rash. Erythematous macules are fat, distinct, discoloured areas of skin. The Practice noted Ms E had tried treatment with antifungals.
42. The records show the Practice advised Ms E to contact it or NHS 111 if she was no better or had new symptoms. The Practice noted there was no obvious intertrigo, but that Ms E had lots of seborrheic keratoses. Intertrigo is inflammation caused by skin-to-skin friction and seborrheic keratoses are a noncancerous skin growth.
43. The Practice advised Ms E to continue using emollient and to avoid using soap. The Practice prescribed doxycycline and cetirizine. Doxycycline is an antibiotic and cetirizine is an antihistamine.
44. Our adviser says the Practice’s actions seemed to be in line with GMC guidance. The Practice examined Ms E, noted her history and prescribed treatment.
14 June appointment
45. The records from this appointment show the Practice noted Ms E’s symptoms as an ongoing rash to her chest, back of her arms and legs. It noted this was not settling despite antibiotic and antifungal medication. It also noted Ms E had had hydrocortisone but that she had not had stronger steroids.
46. The records show Ms E felt the rash was making her unwell. The Practice noted Ms E had a very itchy and burning sensation that she said had been there for 20 months. The Practice noted Ms E thought it had misdiagnosed her repeatedly and she was considering seeing a private dermatologist.
47. The records show the GP explained the rash was not typical and had features of folliculitis as well as a fungal infection. Ms E explained she was taking regular cetirizine and moisturising as much as she could, but that she was finding it difficult to reach the rash. Ms E asked for oral steroids.
48. The Practice noted no blistering and a dry rash in patches on the back of Ms E’s arms and shoulders, with signs of erythematous. The GP explained rashes are often difficult to diagnose first time and treatments need to be tested.
49. The records show Ms E thought she had pityriasis rosea, a skin condition that causes a temporary rash of raised red scaly patches on the body. The GP explained rosea would not normally last that long.
50. The GP wanted to try stronger steroids and discussed with Ms E how to apply the medication. The Practice prescribed Betnovate ointment. Betnovate is a steroid. Ms E asked for a dermatology referral, which the Practice completed.
51. Our adviser says the Practice’s actions seem to be in line with the GMC guidance. The Practice noted Ms E’s history, did an examination and gave her advice on her condition.
52. Overall, while we understand Ms E’s concerns, we do not think the Practice did anything wrong throughout these appointments.
Dermatology referral
53. Ms E complains the Practice should have completed a dermatology referral sooner.
54. Our adviser said there is no specific guidance on referrals. GMC guidance says doctors should refer a patient to another practitioner when this serves the patient’s needs.
55. The records show that on 16 June the Practice made a referral to dermatology as requested by Ms E. There are no signs in the records that Ms E was to have an urgent (two week wait) referral. We can see Ms E had an appointment with dermatology on 22 August.
56. We have seen no sign that the Practice’s referral to dermatology should have been arranged sooner. It seems the Practice were able to manage Ms E’s condition. When Ms E asked for a second opinion from a specialist, the Practice completed the referral.
57. Based on the evidence we have seen, we have not seen any signs of failings in the Practice’s actions. We hope our work will being some answers to Ms E’s concerns.