Not referred for an ultrasound
15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right.
16. In her complaint to us, Ms S tell us on 11 July 2024 she had an appointment at the Practice for routine removal of her contraceptive coil and insertion of a new one.
17. During the consultation, the doctor expressed concern that the new coil they had inserted might not be fitted correctly because they observed Ms S has a small cervix. They said this can make insertion challenging. The doctor told her they would refer her to the Trust for a routine ultrasound scan to confirm the coil’s position.
18. On the 27 August 2024 Ms S asked about the ultrasound and the doctor told her a referral was not sent on 11 July. The Practice apologised and explained it was a human error, and it sent a referral straight away.
19. Ms S had an ultrasound scan on 18 October 2024.
20. GMC guidance says doctors should ‘promptly provide (or arrange) suitable advice, investigation or treatment where necessary’.
21. On 11 July the Practice identified Ms S needed an ultrasound, but it did make the referral to University Hospitals Birmingham NHS foundation Trust (the Trust) until Ms S raised the issue on 27 August, around seven weeks later. We do not think the Practice acted promptly; this was not in line with GMC guidance.
22. We looked at what difference it would have made if Ms S’ referral had been made seven weeks earlier.
23. Ms S was seen around 14 weeks after her initial consultation. She says the delay led to an infection and she needed antibiotics. She also says the damages to her body are unknown.
24. We have reviewed records provided by Ms S and the Practice. The evidence does show the coil was not in the optimal position, however there is no evidence it was causing any complications such as infection at the point of referral, or that the Practice was concerned about Ms S’ overall health.
25. NHS guidance on waiting times says patients should be offered an appointment within 18 weeks of receipt of referral. Ms S was seen by the Trust 14 weeks after the initial referral should have been made. that was in line with the timeframes specified in guidance.
26. We recognise how difficult it was for Ms S to know the coil’s position had not been checked promptly. Records show the Practice quickly rectified the referral once staff became aware of the omission and took prompt action. It is our view it sincerely apologised for the oversight.
27. PHSO guidance says ‘Wherever possible, staff explain why things went wrong and identify suitable ways to put things right for people. Staff give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.’
28. The Practice accepted full responsibility for the human error in Ms S’ referral. It also recognised this failure caused her significant frustration and stress. It is our view the Practice’s complaint response gives a genuine apology.
29. Following Ms S’s complaint, the Practice says it recognised the process of coil fittings are at times ‘not as expected’ and the referral for an ultrasound can be distressing. It also explains how it has improved the service.
30. Specifically the changes are: • Issuing new patients an information sheet with a QR code linking to a video that explains the full intrauterine device (IUD) appointment process.
• Clearly outlining the potential need for an ultrasound scan referral in cases of complex coil fitting to ensure future patients are fully informed of the process.
31. We do not have detailed information about the other referrals the Trust were receiving in July, so we cannot see exactly how much longer Ms S had to wait because of the delay. We have decided given Ms S was seen in the recommended timeframe, and that the Trust has apologised for this delay and taken action to prevent it recurring, it is not proportionate for us to look at the length of the delay any further.
32. Overall we have seen the Practice implemented proportionate measures and delivered an appropriate apology and service improvement explanation to Ms S, in line with PHSO guidance and what we would expect to see.
33. We do not diminish the frustration and distress the delay caused Ms S, however we would not request any more than what the Practice has already done to remedy this. We hope this offers Ms S reassurance about the actions the Practice has taken.
Length of time for her coil removal and refitting
34. On 18 October the ultrasound scan showed Ms S’ coil was slightly embedded and incorrectly positioned. The Trust advised the Practice to arrange another fitting.
35. That day, Ms S visited the Practice in person and stated she did not wish to have the coil removed by the same doctor. The Practice considered local services and on 22 October it advised her it could not provide an alternative, and due to the complexity of the procedure it would need to refer her back to the Trust.
36. The Trust told her there was a wait of up to 12 months for the procedure. Consequently, Ms S told us she felt she had no option but to proceed with the procedure privately.
37. GMC guidance says doctors must ‘recognise a patient’s right to choose whether to accept your advice and respect their right to seek a second opinion’.
38. Ms S made it clear to the Practice she did not want to be seen by the same doctor. That was the only doctor at the Practice who could remove and replace a complex coil. The Practice explored other options but found none. It told her it would refer her to the Trust for follow up and did so promptly.
39. We recognise that this experience was distressing for Ms S and that it led to her feeling unable to return to her initial doctor. In exploring alternatives and offering and referring to an appropriate alternative service, we are satisfied the Practice accepted Ms S’ right to choose and helped to support this in line with GMC guidance. Unfortunately waiting times for the Trust were long, however this was outside the Practice’s control.
40. As we have not seen any indications anything went seriously wrong with this part of her complaint, we cannot say the Practice are responsible for the costs Ms S occurred through seeking private treatment.
41. We thank Ms S for bringing her complaint to our attention, we hope our consideration helps bring this matter to a close for her.