Referrals to specialists (secondary care) 18. Miss B says her mother was under the care of psychiatric services for her mental health, neurology for Parkinson’s disease and physiotherapists, before she moved to Devon. Miss B says her mother’s new GP should have referred Mrs B to these specialists as soon as they first assessed her.
19. Miss B tells us because this did not happen, she was left worried that her mother’s health got worse. We are really sorry to hear what happened caused her such worry.
20. In their complaint response at the beginning of March, the Practice GP said they agreed to refer Mrs B to the Parkinson’s and physiotherapy teams following their telephone call with Miss B in January. In relation to a referral to psychiatry, the GP said they wanted to assess Mrs B’s mental health before deciding on a course of action.
21. Our adviser said there are no specific guidelines which say exactly what a GP should do when a new patient comes under their care. They said when the patient is in a nursing home, there is usually a designated GP who does a weekly care round of the patients.
22. They said accepted good practice would be for the new GP to look at the circumstances of the patient entering the home and identify any immediate needs. They said GPs would usually review the last few months of notes to get an overall picture of the patient and identify any outstanding requirements.
23. Whilst there are no guidelines which specifically address what a doctor should do when they start seeing a new patient, GMC’s Good medical practice is applicable to all doctor/patient relationships and says doctors: ‘must provide a good standard of practice and care. If [doctors] assess, diagnose or treat patients, [they] 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.’
24. It goes on to say doctors must provide ‘effective treatments based on the best available evidence’ and ‘consult colleagues where appropriate’.
25. Primary care is the first point of contact for patients. With Mrs B, this was the GP at the Practice. Secondary care involves specialists who provide more advanced or specialised care. Our adviser explained that a patient may be under secondary care but this may not be recorded in GP notes. They said if a patient is under a specialist and their medication is keeping them stable, the specialists are unlikely to update a GP of this.
26. The Practice’s clinical notes indicate Mrs B was under secondary care for Parkinson’s disease before she relocated to Devon. These notes do not indicate if mental health or physiotherapy specialists were providing her with ongoing secondary care.
27. Our adviser said the notes indicate Mrs B was stable at the point she moved to the nursing home in Devon and came under the care of the Practice. The evidence does not indicate that Mrs B had any immediate needs which required further referral at this time. They said, for example, people with Parkinson’s are at risk of falls. However, Mrs B was bedbound and was in a care home so she was not vulnerable to a fall.
28. In a telephone call with the GP in January 2023, Miss B explained the care that specialists had been providing, and that she believed her mother needed ongoing specialist support. Miss B asked for referrals to mental health, neurology and physiotherapy secondary care.
29. Following the conversation, the GP agreed to refer Mrs B to neurology and physiotherapy and the Practice made these referrals the next day.
30. Our adviser said, whilst there had been no immediate need for these referrals previously, it was appropriate for the GP to do this after the conversation with Miss B. We think this shows the GP considered the information Miss B discussed with them and referred Mrs B to these specialists in line with GMC guidance.
31. Mrs B arrived at the nursing home on at the end of December 2023. The Practice’s notes show what reviews the Practice and other clinicians did prior to the call with Miss B.
32. Following the new year bank holiday weekend, Mrs B’s new Practice GP reviewed her three times in early January. During these reviews, the GP requested a flu vaccine and blood tests. The GP reviewed Mrs B and the blood test results in the middle of January. A pharmacist also regularly reviewed Mrs B, and prescribed further pain medication when needed. We hope Miss B is reassured that the GP assessed her mother’s immediate needs in her first few weeks at the new nursing home.
33. The Practice made the neurology and physiotherapy referrals just under four weeks after Mrs B came under its care. Our adviser said this was timely and would not have been detrimental to Mrs B’s condition. We hope Miss B is reassured by this.
34. In the call with Miss B, the GP said they wanted to monitor Mrs B’s mental health and assess if a referral was needed.
35. The GP reviewed Mrs B two days after the phone call with Miss B and spoke with Mrs B and nursing home staff. The notes say that Mrs B seemed settled and indicate there were no concerns about her mental health.
36. An occupational therapist (OT) in a Community Mental Health Team (CMHT) who had previously supported Mrs B wrote to the Practice. The letter is undated, however the Practice informed us it received this three days after the phone call with Miss B. The OT wrote that CMHT had discharged Mrs B and that she did not ‘present with any mental health needs requiring ongoing support at this time.’
37. Our adviser said the there was no need for the GP to refer Mrs B for secondary mental health care at that time. Mrs B was not under specialist care for her mental health and there was nothing to indicate any issues or that her mental health had recently got worse. She was also in a nursing home with 24 hour care which provided extra support.
38. The notes indicate the GP monitored Mrs B’s mental health regularly after the conversation with Miss B. The first indication of a deterioration in Mrs B’s mental health was at the beginning of March, when nursing staff raised concerns. The GP arranged for a referral to mental health services at this point which our adviser said was appropriate and in line with accepted good practice.
39. We consider the GP acted in line with GMC guidance and accepted good practice when assessing Mrs B and arranging referrals to secondary care when they did.
Phone call with GP 40. Miss B says, in a call in January her mother’s GP was unprofessional. She says she was trying to explain her mother's needs but the GP was disrespectful, rude, aggressive in tone and continually interrupted her.
41. We are sorry to hear that this call caused Miss B upset and distress at a time when she was concerned about her mother.
42. In the GP’s complaint response, at the beginning of March 2024, they said that Mrs B’s best care was their only concern. They apologised that there has been a breakdown in communication. They said, however they had listened to the call recording, they had not once interrupted Miss B and had allowed her to voice her concerns. They said they did not jump to conclusions and did not speak to her with ‘disrespect, agitation or aggression’ in the call. The GP said they did not ‘dogmatically insist [they] had the highest levels of expertise in [her] mother’s care’ or have ‘delusions of grandeur’ as Miss B had said in her complaint to the Practice.
43. The GP said some of Miss B’s complaint was offensive and they felt Miss B’s tone was threatening and made them feel uncomfortable. They said they were sorry if they came across as ‘uncollaborative and resistive’ and they were trying to be candid, pragmatic and to explain they need time to assess Mrs B’s needs.
44. GMC guidance says doctors ‘must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.’
45. Our Principles of Good Administration say public organisations should deal with people ‘helpfully, promptly and sensitively, bearing in mind their individual circumstances.’
46. The Practice provided us with a copy of the call recording. At the beginning of the call, Miss B said she wanted to check that all her mother’s records had been transferred from and that she had been referred to the specialists she needed.
47. The GP confirmed the records had been transferred and asked Miss B to clarify which referrals she meant. Miss B explained which specialists her mother had previously been under. The GP said they would refer Mrs B to the Parkinson’s team.
48. The GP then asked if Miss B lived locally. She said she did and saw her mother twice a week. The GP said they did not think a physiotherapist would help and said it was Miss B that can do the most for her mum in relation to keeping her mobile.
49. The GP interrupted Miss B twice whilst she was trying to explain her mother’s mobility. On the second interruption the GP said, ‘[Miss B], it’s you. I know it’s nice if it’s someone else, but it’s you. If you really, really care about your mum and you want to maintain her dexterity, mobility and strength, it’s going to be you doing that.’
50. We consider the GP lacked empathy and was not sensitive towards Miss B when they said this. We think it is clear from the call that Miss B cared about her mother’s health and we think the GP could have said this in a more supportive way. We also think the tone in which they said this came across as insensitive.
51. The GP interrupted Miss B twice when she was explaining the previous physiotherapy support. The GP spoke over Miss B and said, ‘I’ll do what I feel is appropriate, leave it with me’, in what we consider was a dismissive tone. We think this suggests the GP was not willing to work collaboratively with Miss B.
52. Miss B asked about a referral to psychiatrists and began to explain the mental health care her mother had previously received. The GP interrupted Miss B and said they would monitor Mrs B’s mental health as they have a lot of experience of this. The GP interrupted Miss B again when she started to explain that her mother’s case is complex.
53. Miss B said her enquiries were not anything personal with the GP. She explained she had a good understanding of her mother’s health and care. She said there was a previous episode when her mother’s mental health was not monitored properly, before she had moved to the area. The GP explained they would like time to assess Mrs B to see if she needed psychiatric support.
54. Miss B started to explain her mother’s medication and the GP interrupted her. They said they understand the medication and that they have been doing the job a while ‘so I’m aware of that, thank you’. We think the GP said this in a dismissive tone.
55. Miss B said she was concerned that the GP was not taking her seriously. The GP interrupted Miss B again and said they were taking her seriously but it is important to assess if referrals are necessary.
56. The GP had interrupted and talked over Miss B seven times up to this point.
57. Miss B then asked how she could get an update on the referrals. The GP paused and said, ‘Gosh, you’re quite abrupt aren’t you, [Miss B]. I am finding you very hostile and aggressive actually. I’m finding your manner very upsetting. I’m feeling threatened, I’m feeling intimidated and I’m finding it really unpleasant actually.’
58. Miss B said she was not being threatening. The GP interrupted her and said, ‘That’s how I’m feeling. You might want to tell me I’m not and that would fit with the rest of the conversation, if you’re going to tell me how I’m feeling’.
59. Whilst we do not dispute how the GP felt at that time, we do not consider that Miss B said anything threatening and she did not comment on how the GP was feeling. We think Miss B came across as polite and respectful throughout the call, and she did not raise her voice at any point. We consider she was very patient despite the interruptions from the GP, and the tone in which they spoke to her.
60. Miss B calmly said she was looking to get the best care for her mother. The GP interrupted her and said they felt bullied. The GP and Miss B tried to speak at the same time at this point. Miss B said she did not feel the GP was listening to her and the GP said they were.
61. Miss B then said, ‘Can I request that you stop interrupting me so I can get my point across and then maybe you can understand the perspective I’m coming from. I need to be able to finish my sentence…’. Before Miss B finished, the GP said ‘I’ve let you finish many sentences. I have not interrupted you and listened to everything you said fully.’
62. The GP then agreed to make referrals to physiotherapy and the Parkinson’s team and to keep Mrs B under assessment for a psychiatry referral. Miss B asked how she could be updated regarding the referrals and the GP said she could do this through the nursing home.
63. As we outlined in the previous section, we consider the GP made the right decisions regarding specialist referrals. However, the GP interrupted Miss B numerous times during the call. We consider they spoke to her in a dismissive tone on several occasions, when she asked questions which we consider were reasonable for a caring relative to ask. We think the GP came across as rude and lacked empathy towards Miss B during this conversation.
64. For these reasons, we do not think the GP was considerate or sensitive when speaking to Miss B and, as such did not act in line with GMC guidance or our Principles. This is a failing.
Impact 65. Miss B told us she felt upset, angry and distressed because of the way the GP spoke to her in the call.
66. We can understand why Miss B felt this way. We can also understand why she thought the GP was rude for interrupting her throughout the call when she was trying to explain her mother’s medical and care history.
67. During the call, Miss B said she was concerned that the GP was not taking her seriously. When considering the GP’s dismissive tone, we can understand why Miss B felt like this.
68. We appreciate this was a period of change for Miss B and her mother and we can see Miss B was trying to ensure her mother had the care she felt she needed. We think the way the GP communicated with her in the phone call caused the upset she has told us about.
Complaint handling 69. Miss B says the Practice made no attempt at mediation in relation to her complaint. She says the Practice’s review of her complaint was not independent as it did not arrange for anyone to review it, other than the GP she complained about.
70. NHS Complaint Standards say, ‘An effective complaint handling system makes sure staff take a thorough, proportionate and balanced look into the issues’. They say staff should ‘make sure everyone involved in a complaint (including those specifically complained about) know how they will look into the issues. This includes…who will be responsible for providing the final response and how they will communicate their findings.’
71. The standards go on to say that organisations should give everyone involved in a complaint the opportunity to give their views and respond to the issues, where appropriate. The standards say, ‘Where possible, staff who have not been involved in the issues complained about should look at the complaint’.
72. The Practice’s Complaints Procedure says the complaints manager is the practice manager. It says investigations should be thorough and, where appropriate obtain independent evidence and opinion.
73. It says the organisation should ensure ‘both the complainant and those complained about are responded to adequately.’ It says the Practice will issue a final formal response and should inform the complainant that they may complain to us if they remain dissatisfied.
74. The procedure references our Principles of Good Complaint Handling. These say organisations should act fairly and proportionately, including ‘Ensuring that complaints are reviewed by someone not involved in the events leading up to the complaint.’
75. Miss B emailed her complaint to the practice manager in the middle of February. The practice manager acknowledged the complaint, said they would need to speak to the GP and would reply as soon as possible. They also said they would listen to the call recording.
76. At the beginning of March, the practice manager emailed Miss B, explained they are waiting for a written response from the GP and would be meeting with them to discuss this. Later the same day, they said the GP would provide a written response and the practice manager would contact Miss B again once they have this.
77. The practice manager emailed Miss B three days later and attached a letter from the GP. The email said, ‘Should you need any further feedback or would like to discuss the attached any further please do feel free to contact myself or [the GP].’
78. In the letter, the GP addressed Miss B’s points about referrals to specialists and, as we outlined in paragraph 42, disputed that they were disrespectful in the call.
79. Miss B replied to the practice manager just over a week later, said she was unhappy with the GP’s response and asked how to escalate her complaint. She also raised a further issue about a mental health referral the GP made at a later date. The Practice manager responded the following day and directed Miss B to us.
80. The only response the Practice provided to Miss B’s complaint was from the GP she had complained about, and who disputed her account. We think this was a further missed opportunity for someone independent to review Miss B’s complaint.
81. We consider that the Practice acted in line with NHS standards when it sought the views of the GP. However, there is no evidence that anyone independent considered the issues which Miss B raised. We do not think the Practice’s investigation was thorough and balanced because of this. This is not in line with NHS standards, Practice policy or our Principles. This is a failing.
Impact 82. We are sorry to hear that the Practice’s response to her complaint caused her further upset.
83. We can understand why Miss B felt further dismissed when the Practice did not provide an independent review or investigation of her complaint. We think this was upsetting for Miss B at a time when she already felt the GP had not listened to her.
84. For these reasons, we go on to make recommendations for the Practice to put this right and to ensure the same failings do not happen again.