25 July 2023 to 7 February 2024
10. Mr A complains the Practice did not refer him for further tests when he described lip smacking in appointments between 25 July 2023 and 7 February 2024. Mr A suffered a seizure on 7 February 2024. He says an MRI (magnetic resonance imaging) on 17 June 2024 showed he had been having seizures for over a year prior.
11. In its response, the Practice did not comment on any appointment prior to 7 February 2024. The Practice set out Mr A attended A&E on 7 February 2024 following a seizure. Following this the Practice did not find any failings in its treatment of Mr A.
12. For context, there is no specific guidance on how a GP appointment should be conducted or when a referral should be made. These decisions are based on specific symptoms and conditions. To help us review the events, we have taken independent clinical advice. We have also reviewed specific condition guidance to help us decide if the Practice acted appropriately.
13. We reviewed the appointments between 25 July 2023 and 7 February 2024. We have not seen any record of lip smacking. The first note in the records of lip smacking is dated 8 February 2024. The complaint’s partner told the Practice he had been lip smacking on and off for a few months but was not sure if he had mentioned it in other appointments.
14. We asked our advisor to review the appointments Mr A attended between 25 July 2023 and 7 February 2024. Our adviser said these appointments appear to be carried out appropriately and there were no indications further investigations were required into the symptoms assessed.
15. We acknowledge following Mr A’ seizure on 7 February 2024 he was concerned there may have been an opportunity to treat him earlier, especially after he was told on 17 June 2024 he may have been having seizures for over a year prior. We understand this would have caused Mr A anxiety and distress. Mr A acknowledged he was not sure he had mentioned the symptom of lip smacking to the Practice. We have not seen it noted in the records. The appointments between 25 July 2023 and 7 February 2024 showed no indication further investigation was required for a potential seizure. There is no indication of a failing in the Practice’s actions.
7 February to 30 May 2024
16. Mr A complains the Practice did not refer him for further tests between 7 February and 30 May 2024 after he had a seizure. He explains his condition has worsened due to the lack of investigations and referrals from the Practice during this time.
17. The records show on 7 February Mr A had a seizure. He attended the local trust following this.
18. On 8 February Mr A’s partner contacted the Practice twice. The first contact was at 9.30am using an online form. Mr A’s partner explained Mr A had a seizure the day before. Mr A’s partner requested a referral for scans to see what was happening. The second contact was at 10.20am. Mr A’s partner explained Mr A was due at the Trust for a brain scan this morning, but he was asleep. She was unsure what to do. The Practice advised to wake him up as it was important he attend his scan. During this contact it was noted Mr A had a symptom of lip smacking. As noted above it says Mr A and his partner were unsure if this had been mentioned previously.
19. NICE guideline epilepsies in children, young people and adults says:
‘1.1 Referral after a first seizure or remission and assessing risk of a second seizure Referral after a first seizure 1.1.1 Refer children, young people and adults urgently (for an appointment within 2 weeks) for an assessment after a first suspected seizure: • For adults, refer to a clinician with expertise in assessing first seizures and diagnosing epilepsy’
20. In line with guidance the Practice noted Mr A was booked for a brain scan. The Practice informed Mr A’ partner to wake him so he could attend. The trust had referred Mr A for the scan following his attendance. The Practice appropriately made it clear Mr A should attend the appointment as was the appropriate course of action. There was no further action for the Practice to take, as a scan had already been arranged.
21. Our advisor agrees the advice to wake his was appropriate as he required a scan after his seizure for further investigation into its cause. The Practice was aware there was a timely investigation in place following a first seizure episode. We see no indication of a failing.
22. We have continued to review the appointments.
23. On 9 February Mr A contacted the Practice. Mr A explained he felt the medication he was taking had caused the seizure. Mr A explained he had been lip smacking for around a year. He was requesting a referral for a scan to see what was happening.
24. Mr A confirmed he had been referred by the local trust for a CT (computed tomography) scan. This was due to take place on 8 February. Mr A says he did not attend due to wait times. Later the same day (9 February) a GP at the Practice contacted Mr A. The GP explained it had contacted the Trust and Mr A could attend the local hospital for a CT head scan today.
25. GMC Good medical Practice says:
15. You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: c. refer a patient to another practitioner when this serves the patient’s needs
26. We consider the Practice appropriately referred Mr A when he informed them his scan had not gone ahead. This is in line with GMC guidance noted above. Our advisor said the Practice used its clinical judgment and took advice from the colleagues for appropriate referral to provide the best and appropriate clinical care. We cannot see the Practice got anything wrong here.
27. We continue to review the records.
28. Mr A contacted the Practice on 12 February. The Practice tried to contact him back the same day but was unable to speak with him. The Practice booked in an appointment for 14 February.
29. On 14 February Mr A attended a face to face appointment at the Practice. Mr A explained he was worried about seizures. It is noted he attended the Trust on 10 February. He was discharged by the Trust and referred for a first fit clinic.
30. Mr A explained he has stopped taking all his medications. He described high stress managing the household alone, poor sleep, low appetite, palpitations, and a racing mind. The Practice advised Mr A to self refer to a local mental health service. The Practice would review him in four weeks.
31. Our adviser directed us to NICE Generalised anxiety disorder clinical knowledge summary (CKS), says:
‘When should I suspect generalised anxiety disorder?
Suspect generalised anxiety disorder (GAD) in a person who reports chronic, excessive worry which is not related to particular circumstances, and symptoms of physiological arousal such as restlessness, insomnia, and muscle tension.
How should I manage a person with generalised anxiety disorder?
• Provide information about the nature of GAD and treatment options.
• Arrange active monitoring of the person's symptoms and functioning at intervals based on clinical judgement.’
32. In line with the NICE GAD clinical knowledge summary the Practice discussed potential treatment and advised Mr A to self refer to a local mental health service. The Practice also agreed to review him in four weeks. Our advisor said the Practice listened and documented recent events. We have seen the Practice noted Mr A is awaiting a first fit review and provided another treatment option directing to a local mental health service. We consider the Practice’s actions are appropriate and in line with guidance.
33. On 8 March Mr A contacted the Practice via an online form. He explained he has symptoms of lip smacking and a headache. On the form, under the section ‘how you would like the Practice to help’ Mr A did not enter any information. The Practice said in its complaint response Mr A was directed to the emergency department as there was the risk of imminent seizure. We have not seen this advice in the medical records.
34. We have seen in the records Mr A did attend the emergency department on 9 March at 7.03am. It is not clear from the records if Mr A was or was not advised by the Practice to attend the emergency department. We have not seen this was disputed by Mr A when he received the Practice’s complaint response.
35. As Mr A did attend the emergency department following the contact with the Practice, it is likely this advice was given. We consider the Practice acted in line with GMC Good medical practice. The Practice was concerned of an imminent seizure and so he was referred to a practitioner that serves the patient’s needs. We see no indication of a failing.
36. On 15 March Mr A attended a face to face appointment at the Practice following contact from his partner earlier in the day. The notes indicate this was following Mr A’s contact on 8 March. Mr A explained he had a seizure on 8 March. He is awaiting a neurology review and has not had a seizure since. He was also concerned about a sore throat. The Practice said this was most likely tonsillitis. Mr A was advised to contact the Practice if his sore throat got worse.
37. We have seen Mr A had confirmed he was awaiting neurology input and therefore no further referral was required. GMC guidance states the Practice should refer a patient to another practitioner when it serves their needs. As this had already been done, there was no further action for the Practice to take. The Practice acted appropriately.
38. We have considered NICE sore throat acute scenario management. It says:
‘Advise all people with acute sore throat that: • They should seek medical help if symptoms worsen rapidly or significantly, or they become very unwell.’
39. We consider the Practice provided suitable advice for Mr A sore throat. Further investigation was not required.
40. On 20 March Mr A contacted the Practice. Mr A complained of a medication he had been given from the local trust. He was feeling stressed and angry. The Practice explained his symptoms were normal for the medication, lamotrigine (a medicine used to treat epilepsy). The Practice said the side effects normally settle down once his body is used to the medication. The Practice said to continue with the medication and see how he feels over the next few days.
41. The British National Formulary (BNF), Lamotrigine information says:
‘Side-effects Common or very common Aggression; agitation; arthralgia; diarrhoea; dizziness; drowsiness; dry mouth; fatigue; headache; irritability; nausea; pain; rash; sleep disorders; tremor; vomiting’
42. We consider the advice the Practice provided is in line with the BNF. The Practice were correct to say the symptoms Mr A experienced were normal. Our advisor says the Practice assessed Mr A with its clinical knowledge and responded him with the evidence based advice. We have seen no indication there was a requirement for further referrals or tests. The Practice acted appropriately.
43. On 30 May Mr A and his partner contacted the Practice. Mr A contacted the Practice at 1.34pm and his partner 2.40pm. Mr A was seen at the Practice later the same day.
44. He explained he was having warning signs of a seizure. He explained he was lip smacking and clapping his fingers together. He said he had not been well for the last few weeks with back and leg pain. Mr A was seeking something for his pain. The Practice advised to take naproxen with omeprazole and paracetamol.
45. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve symptoms of arthritis (eg, osteoarthritis, rheumatoid arthritis, or juvenile arthritis) such as inflammation, swelling, stiffness, and joint pain. Omeprazole is used to treat certain conditions where there is too much acid in the stomach.
46. The Practice advised to call an ambulance, however Mr A did not want to go to hospital. An appointment was booked for the following day for an exam at the local hospital.
47. We consider the advice from the Practice to call an ambulance is in line with GMC Good medical practice. The Practice asked Mr A to request an ambulance as there was a concern a seizure was imminent. We have seen the Practice took additional steps and booked an exam for Mr A at the local trust. The Practice acted appropriately.
48. On 31 May Mr A attended the Practice. Mr A explained he had a seizure the night before and paramedics had attended. He explained he was fine now. Mr A requested a referral to the pain clinic. The Practice noted this and a task was sent to the admin team for a referral.
49. The main purpose of this appointment was to arrange for a referral for Mr A. We consider the Practice did this. The referral is line with GMC guidance to refer a patient to another practitioner when this serves the patient’s needs. Our advisor notes Mr A was appropriately assessed and a plan was made.
50. We acknowledge the period Mr A complains about was stressful for him and those close to him. We do not understate the concern he had for his health during this period. We have reviewed the appointments during this period we have seen when appropriate the Practice made referrals. The Practice also requested tests and investigations in line with NICE and GMC guidance. When further investigations were not required, we consider each appointment was carried out in line with national standards and guidance.
6 June 2024
51. Mr A complains the Practice failed to provide an appointment for him on 6 June 2024. On this date his partner had attended and contacted the Practice regarding a lost prescription.
52. The Practice said Mr A informed it, a controlled drug had been lost. The Practice said this needed to be reported to the police and on receipt of a police reference number, a replacement prescription can be issued. The Practice apologised if Mr A and his partner had felt the Practice had been rude.
53. We have reviewed the records.
54. On 6 June Mr A’ partner contacted the practice three times and attended once.
55. The first contact was made at 8.37am via an online application by Mr A’s partner. Mr A’s partner explained Mr A had misplaced his epilepsy tables and was unable to find them. She explained Mr A urgently needed a prescription to unsure he did not miss a dose.
56. The next contact was when Mr A’s partner attended the Practice. The Practice asked if the lost medication was a controlled drug. Mr A’s partner confirmed it was. The Practice explained it will need to be reported to the police. It is acknowledged the Practice and Mr A’s partner hold different views of how the conversation went. As we were not there, we will not be able to say exactly what was said, or how it was said. We are sorry to hear Mr A’s partner feels the conversation was not a professional one. We can see the Practice did apologise for this.
57. The third contact was at 10.23am via an online application by Mr A’s partner. She explained Mr A prescription had been lost. She requested a new prescription for Mr A. The Practice explained his medication has been requested and it has been marked as urgent.
58. The fourth contact was at 10.40am via an online application by Mr A’s partner. She asked what Mr A was to do in the meantime while he awaited his medication. She did not request any specific action from the Practice. The Practice explained she should contact 111 for an urgent prescription in the meantime. It confirmed again the prescription had been requested.
59. There is no specific guidance on when an appointment should be made. We have not seen in the records a request for an appointment was made. We have asked our clinical advisor for their view. They explain the request for medication is dealt with on an administrative level. There were no clinical signs or symptoms which would have led to an appointment being booked.
60. We acknowledge on 6 June Mr A was anxious as he did not have enough medication. It is understandable this cause Mr A some distress. We are persuaded by the records and advice there is no indication of a failing here. We have not seen an indication an appointment was required. We can see the first contact was 8.37am and by 10.40am a new prescription was requested.