A practice in the Ribble Valley area

6. Ms X complains about the care the Practice provided to her between December 2023 and July 2024. She says:

• The Practice provided inadequate care and a lack of essential treatment following consultations with her, leading to a failure to diagnose Ms X with Irritable Bowel Syndrome (IBS), or Cryptosporidiosis or Giardiasis at the earliest opportunity.

• The Practice failed to accurately complete Ms X’s medical records following consultations with her, contributing to the delay in diagnosing Ms X’s IBS, Cryptosporidiosis and Giardiasis.

7. Ms X says that, as a result of the inadequate care and treatment provided by the Practice, there was a delay in diagnosing her with IBS, Cryptosporidiosis and Giardiasis which led to ongoing avoidable pain, discomfort and distress. Ms X also now fears booking an appointment at the Practice, even when necessary.

8. Ms X would like an acknowledgement of failings from the Practice and a formal apology for its mishandling of her care. She would also like the Practice to implement service improvements to ensure it provides service in line with relevant policies and guidelines.

9. Ms X attended the Practice on several occasions from December 2023 to July 2024 complaining of unintentional weight loss, abdominal cramps, change in bowel habit (ranging from diarrhoea to constipation), vomiting and nausea. Throughout this time, Ms X says she was given no plan or support, the only pain relief offered to her was paracetamol, and GPs inaccurately recorded consultations with her. This included recording she was using codeine, which she says is untrue. A brief history of Ms X’s consultations from December 2023 to July 2024 is set out below.

10. On 6 December 2023, Ms X had a telephone consultation with the Practice regarding abnormal weight loss and intermittent mild abdominal cramps. Ms X reported no change in bowel habit, bleeding or vomiting. Following this consultation, the Practice took blood tests to check for a variety of issues.

11. Ms X attended the Practice on 11 March 2024, reporting ongoing weight loss, episodes of loose stools, and some indigestion. A GP performed an examination and documented that these symptoms required some investigation. They requested two Faecal Immunochemical Tests (FIT tests) and an ultrasound scan to rule out gall stones. They also trialled Ms X with lansoprazole, a medication used to reduce the amount of acid made by the stomach. The GP recorded that Ms X’s case would be reviewed in four weeks if her symptoms had not improved.

12. On 3 June 2024, following a trip abroad, Ms X returned to the Practice complaining of loose stools, abdominal discomfort, and generally feeling unwell and drained. Ms X had no urinary symptoms, vomiting, or blood in her stools at this time. The clinician performed an abdominal exam and ordered a stool culture to test for infection. They recorded that they would review the results of this test and manage appropriately, with consideration to repeat the FIT tests and order a stool test for calprotectin (a protein released by the body in response to inflammation) if the results returned as normal. The clinician also documented that this plan would be reviewed if Ms X’s symptoms worsened in the meantime.

13. In June 2024, Ms X visited the Emergency Department (ED) at a hospital because she was experiencing pain, weight loss, diarrhoea and constipation, sweating, tremors, and abdominal distention. Following this, on 10 June 2024, Ms X saw a Physician Associate (PA) at the Practice. The PA recorded that a private CT scan had identified extensive faecal loading, which Ms X had tried to manage using laxatives and suppositories. Ms X reported that she had not eaten for two days and was struggling to work because of her symptoms. The PA ordered more blood tests and weight monitoring. They asked Ms X to come back once they received the test results and to contact the Practice if her symptoms did not improve or worsened.

14. On the same date, the PA contacted Ms X to give her stool sample results and provide information relating to her symptoms. Ms X’s case was reviewed by a doctor that afternoon and another ultrasound scan was requested.

15. The Practice phoned Ms X on 13 June 2024 regarding a raised white blood cell count, with suspected Cryptosporidiosis, an illness caused by a type of parasite. Ms X reported that she had been feeling ‘out of sorts’ and had been purchasing over the counter Canesten every two weeks for some time. The Practice requested two vaginal swabs and further blood tests. It advised Ms X it would treat whatever infection was found from these tests.

16. On 17 June 2024, Ms X had a telephone consultation with a GP from the Practice. Ms X complained of ongoing issues with bowels and weight loss. Ms X reported diarrhoea, gas and vomiting and said she had also been passing mucus. The GP recorded one of the previous stool cultures showed presence of the parasite cryptosporidium. The GP queried Ms X’s family history and requested a calprotectin test. They advised Ms X to book a face-to-face appointment to discuss the results and instructed her to go to the ED if she stopped passing gas, started vomiting excessively, or had severe abdominal pain.

17. Ms X saw the same GP on 26 June 2024. They recorded that Ms X was taking various medications to try and help her symptoms, including co-codamol and laxatives. They recorded these medications could cause issues with her bowels. They also advised her to discontinue these medications and only take buscopan (an antispasmodic medication) and paracetamol if needed. As Ms X complained of nausea, the doctor prescribed metoclopramide, an anti-sickness medication. The GP also conducted an examination at this appointment, reporting fullness and bloating. The results had not been returned from the calprotectin test that was previously taken, but the doctor recorded that they would arrange a colonoscopy once they had returned.

21. When we consider 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. If we see signs of a mistake, we look at the likely impact caused and what the organisation has done to put things right. We have done this and seen indications that the Practice made an error but that it has taken appropriate action to put things right. We explain why below.

Inadequate care and treatment

22. Ms X says the Practice provided inadequate care and there was a lack of essential treatment following consultations with her, leading to a failure to diagnose her with IBS, and either Cryptosporidiosis or Giardiasis at the earliest opportunity. Cryptosporidiosis and Giardiasis are both illnesses caused by parasites, usually transmitted by swimming in or drinking contaminated water.

23. We considered this issue with the help of our Adviser. After reviewing Ms X’s clinical records, we can see the Practice took a consistent approach to her care. This is in line with the GMC’s ‘Good Medical Practice’, specifically, the guidance set out in ‘Domain 1: Knowledge, Skills and Development’, in the section on ‘Providing Good Clinical Care’. This says clinicians should carefully check a patient’s condition by looking at their symptoms, medical history, and anything that may affect their health (including mental wellbeing, beliefs, social situation, money, culture, and personal values).

24. If needed, they must carry out a physical exam. Clinicians must ensure they give or arrange the right advice, tests, or treatment quickly and should only suggest or prescribe medicine or treatment if they know enough about the patient’s health and believe it will help them. It also says clinicians must always choose treatments based on the best available evidence.

25. At each of Ms X’s appointments, the Practice GPs recorded a history of her symptoms, which shows staff provided an ongoing assessment of her condition. The Practice also arranged investigations on 6 December 2023, 11 March 2024, 10 June 2024, and 17 June 2024. The only appointment where further investigations were not arranged was on 26 June 2024, and this was because GPs were still waiting on test results. The Practice also planned for follow-up at each appointment, showing a continuous approach to Ms X’s care. Having carefully considered the above, we have not seen anything to indicate the Practice failed to take Ms X’s concerns seriously when she attended consultations with its staff.

26. With regards to medication, the Practice prescribed Ms X lansoprazole for indigestion on 11 March 2024, and gave her advice on possible medications for IBS. It also prescribed her with metoclopramide, which is an anti-sickness medication, on 26 June 2024. We understand from our Adviser that these were appropriate medications for staff to provide, based on the evidence available to them at the time. As such, we consider the actions taken were appropriate, based on the evidence available, and in line with the GMC’s ‘Good Medical Practice’.

27. To explore Ms X’s concerns that the Practice delayed a diagnosis of IBS, we have referred to the NICE ‘Clinical Knowledge Summaries: Irritable Bowel Syndrome’ (CKS) and the British Society of Gastroenterology (BSG) ‘Guidelines on the Management of Irritable Bowel Syndrome’. Both sources state that a diagnosis of IBS in primary care should only be made when a patient has experienced abdominal pain and associated bowel symptoms for at least six months.

28. At Ms X’s first appointment on 6 December 2023, the GP documented that there had been no change in bowel habit. At her second appointment on 11 March 2024, Ms X described four episodes of diarrhoea that had resolved. Therefore, in line with NICE and BSG guidance, we have not seen anything to indicate that the Practice should have reached an earlier diagnosis of IBS, as Ms X had not experienced a six-month period of symptoms at that time.

29. Both NICE and BSG guidelines also emphasise that IBS should only be diagnosed after other conditions have been ruled out through appropriate investigations. NICE recommends blood tests to help exclude other diagnoses, and BSG guidance advises clinicians to arrange blood tests for all patients with symptoms suggestive of IBS.

30. From reviewing Ms X’s medical records, we can confirm that blood tests were arranged following her appointments, except where the Practice was awaiting results from tests already taken.

31. When patients report potentially concerning symptoms, such as weight loss, both NICE and BSG guidelines advise that further investigations should be carried out. They specifically recommend that local and national guidelines for colorectal and ovarian cancer screening be followed.

32. When considering this, following Ms X’s appointment on 3 June 2024, where she reported weight loss, the Practice requested a stool test to investigate possible bowel cancer. After her appointment on 10 June 2024, she was referred for an ultrasound scan to rule out gallstones and explore other potential causes of her symptoms, which included upper abdominal tenderness.

33. The BSG and NICE guidelines also recommend stool testing for calprotectin (a protein released in response to inflammation) in patients under the age of forty-five, to help identify inflammatory bowel conditions such as Crohn’s Disease and Ulcerative Colitis. These conditions typically present with severe diarrhoea, often accompanied by blood and mucus.

34. Our Adviser confirmed that at Ms X’s appointment on 6 December 2023, there was no record of diarrhoea, so there was no need for a calprotectin test at that time. At her March 2024 appointment, although she had experienced diarrhoea, the clinical records show it had resolved, so again there was no reason to request the test. However, by 17 June 2024, Ms X’s symptoms had worsened, and a stool test for calprotectin was appropriately requested.

35. At Ms X’s appointment on 26 June 2024, a diagnosis of IBS could not yet be confirmed as the calprotectin result was still pending. Nevertheless, the GP encouraged Ms X to take buscopan (an antispasmodic medication recommended in the NICE guidelines for managing IBS symptoms) whilst awaiting test results.

36. We also asked our Adviser whether the Practice acted in line with applicable guidance and standards in providing pain relief to Ms X during this period. Ms X experienced ongoing pain and discomfort during this time, and she tells us that paracetamol, as recommended by the GPs, did not provide adequate pain relief.

37. Our Adviser confirmed that paracetamol, although not listed in the guidelines, was a reasonable option based on her symptoms. They told us other painkillers would have been inappropriate because of their possible side effects that affect the bowels, for example constipation. Ms X was also advised to take buscopan for pain relief at an appointment on 26 June 2024, which our Adviser confirmed is appropriate when IBS is suspected, and consistent with NICE guidelines.

38. We also considered Ms X’s symptoms following her return from abroad, reported during her 3 June 2024 appointment. Our Adviser explained that gastroenteritis, an inflammation of the stomach and intestines often caused by infection, can lead to symptoms such as vomiting and diarrhoea. The Practice clinician appropriately requested a stool sample to check for infection. According to our Adviser, there was no reason to conduct this test at earlier appointments when Ms X had not reported diarrhoea.

39. The stool test showed a positive result for the parasites cryptosporidium and giardia, although it did not specify which was present. In line with guidance, the Practice should have requested a repeat stool test. Had giardia been confirmed, Ms X may have received a prescription for metronidazole (an antibiotic used to treat parasitic infections) approximately two weeks earlier, possibly by 17 June 2024.

40. Nevertheless, when Ms X saw a private colorectal consultant on 1 July 2024 and was prescribed metronidazole, they noted that her symptoms were already improving. Our Adviser explained that this pattern of improvement is more consistent with a cryptosporidium infection, which typically resolves without treatment. Therefore, whilst the delay was understandably distressing for Ms X, the clinical impact appears to have been minimal as if the infection was caused by cryptosporidium, it would have resolved itself without medication, and if caused by giardia, the delay and clinical impact were very limited. What we can see is that it will be frustrating for Ms X to learn that these steps were not taken at the earliest opportunity.

41. We can see that the Practice did not request an additional stool sample or repeat the test to determine which bacteria was present, which is not in line with the guidance. We have therefore thought carefully about what the Practice has done to put right the avoidable frustration we have identified.

42. Following discussions with the Practice, it has since reviewed its procedures and confirmed it will apologise to Ms X for this mistake. Having considered our Principles for Remedy, which say public bodies should ‘return complainants to the position they were in before the maladministration or poor service took place’ or ‘if that is not possible, compensate them appropriately’, we can see the Practice has taken appropriate action to put things right.

43. For the reasons outlined above, we will take no further action. We do recognise that Ms X had to attend the Practice repeatedly and that the ongoing uncertainty of the reasons for her illness caused her frustration and distress. We hope this explanation clarifies why the process of exploring her symptoms took so much time.

Failure to accurately complete medical records

44. Ms X also complains the Practice failed to accurately complete her medical records following consultations, contributing to the delay in diagnosing her IBS and parasitic illness.

45. When considering this part of the complaint, we referred to the GMC’s ‘Good Medical Practice’. Specifically, we considered the guidance in ‘Domain 3: Colleagues, Culture and Safety’ which says clinicians need to make sure that any official records they keep, particularly patient records, are clear, accurate, up to date, and easy to read. Whilst the amount of detail can vary depending on the situation, patient records should usually include important clinical findings, any medications, tests, or treatments that were suggested or given, as well as the information they shared with the patient.

46. They should also note any concerns or preferences the patient mentioned that could affect their care, and whether those were addressed. If the patient needs any special adjustments or help with communication, that should also be recorded. It also says clinicians should include what decisions were made, what actions were agreed (even if the decision was to do nothing), when those decisions should be reviewed, who made the record and when.

47. After reviewing Ms X’s medical records with our Adviser, we can see that GPs at the Practice:

• Documented each consultation with Ms X, making a note of her symptoms.

• Recorded findings from examinations when she attended face-to-face appointments.

• Made a record of investigations carried out.

• Clearly documented plans for follow-up actions.

• Noted advice they had given with regards to medications.

48. With this in mind, we do not see any indications of failings, and we consider the Practice acted in line with applicable GMC guidelines and standards in recording the consultations. As such, we have decided not to take any further action.

49. Following conversations with Ms Y, we understand that Ms X had specific concerns regarding the Practice’s documentation of her use of codeine, as she was worried the records wrongly suggested she was taking it inappropriately. Whilst we explained to Ms Y that we are unable to amend Ms X’s medical records, we discussed the matter with the Practice to explore why codeine was listed.

50. The Practice confirmed that Ms X had been taking co-codamol, a medication that contains codeine. They explained ‘codeine’ and ‘co-codamol’ had been used interchangeably and noted that the inclusion of ‘codeine’ in the record was intentional, as it was clinically relevant due to its direct impact on Ms X’s bowel function. We hope this clarifies for Ms X why codeine was listed and reassures her there is no suggestion that she was taking codeine inappropriately.

51. We understand this experience has been upsetting and stressful for Ms X and Ms Y, and we appreciate them taking the time to raise their concerns and speak with us. We hope our review and explanations have been helpful and provide some clarity and, for the reasons explained above, we will now bring our work to a close.

1. We have carefully considered the complaint raised by Ms X, represented by her sister Ms Y, about the Practice. We are sorry to learn of Ms X’s experience with the Practice. We acknowledge the upset and distress Ms X has faced from the circumstances surrounding this complaint.

2. We have considered the evidence available to us carefully, including obtaining independent clinical advice, and for the majority of the care given to Ms X we have not seen any indication of failings by the Practice.

3. We also considered symptoms Ms X reported in June 2024 after returning from abroad. The Practice appropriately requested a stool test, which identified a parasitic infection. Whilst guidance recommends a repeat test, this was not done. As such, this is an indication of a failing, and we have considered what the Practice has done to put right the impact caused.

4. The Practice has acknowledged the error, reviewed its procedures, and has agreed to apologise to Ms X. As there is no evidence of a clinical impact to Ms X, and as these steps put right any distress caused, we have decided to take no further action.

5. We are aware this has been a challenging time for Ms X and her family, and we explain the reasons for our decision below. We hope this statement provides Ms X and Ms Y with some reassurance that we have not seen anything to indicate Ms X’s experience and pain were avoidable.