The Practice’s investigation of symptoms
20. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs anything went wrong. If we see any signs of things that went wrong, we consider if this had a negative effect which the organisation has not put right. Having done so, we have not found any indication that anything went wrong which had a negative impact on Mrs F.
21. Mrs F said the Practice did not investigate her ongoing symptoms at consultations between 24 June and 21 August 2024, and this meant she had to endure these symptoms for longer than necessary and caused her a long period of suffering.
22. In the complaint responses, The Practice said it investigated Mrs F’s symptoms and spent sufficient time on the concerns raised at every appointment she had at the Practice.
23. Mrs F was eventually diagnosed with PoTS in December 2024. PoTS is when the heart rate increases very quickly after getting up from sitting or lying down, often making the patient feel dizzy or lightheaded.
24. Our GP adviser explained there is no specific guidance for GPs for the diagnosis and treatment of PoTS. PoTS UK is a charity which provides information on the condition. The PoTS UK GP guide says the mean time to diagnosis is seven years. It also says 50% of patients receive a psychiatric misdiagnosis.
25. In addition, an NHS.uk article on PoTS (2023) also mentions it can take time for people to be diagnosed with PoTS, as the symptoms are similar to other conditions.
26. Mrs F had an appointment with a pharmacist advanced clinical practitioner on 24 June 2024. The pharmacist documented the consultation was to explain the results of her recent hospital admission. This was due to Mrs F having ongoing symptoms of blackouts, heart palpitations (fast and strong heartbeat), chest pains and shortness of breath for several months. Our GP adviser commented she had had extensive tests at the hospital including: • electrocardiogram (ECG) – a test that records the electrical activity of the heart to check its rate and rhythm • echocardiogram (echo) that creates moving pictures of the heart using sound waves - it checks the structure of the heart, assesses how it pumps blood, monitors heart valve function, and diagnoses conditions like heart failure • head CT scan which uses X-rays and computer technology to create detailed images of the body • ventilation-perfusion scan (V/Q scan) which checks air and blood flow to the lungs to diagnose conditions like blood clots.
27. Our GP adviser said all these tests had come back as “unremarkable” and therefore did not give a clear indication what was causing Mrs F’s symptoms.
28. GPC Guidance says pharmacists must keep risks to patients as low as possible and must make sure their prescribing is evidence-based, safe and appropriate. It also says they should fully assess a patient and carry out an examination when it is necessary.
29. The pharmacist prescribed a beta blocker (propranolol) for heart palpitations. Beta blockers are a medication that make the heart beat more slowly.
30. Beta-blockers (like propranolol) carry risks of adverse effects, including dizziness (due to low blood pressure) and bradycardia (slow heart rate) as listed in the BNF. In line with the GPC guidance about safe prescribing, our GP adviser told us the pharmacist should have measured Mrs F’s physical observations (vital signs such as blood pressure, pulse, temperature and breathing rate) before prescribing propranolol.
31. The medical records do not document Mrs F’s physical observations in this appointment, which indicates the pharmacist did not measure them.
32. The Practice acknowledged this failing in its complaint responses of 5 August 2024 and 15 November 2024. The Practice said the pharmacist should have completed blood pressure and heart rate checks given the decision to prescribe propranolol.
33. Reassuringly, we have seen no evidence Mrs F suffered any negative impact from the failure to conduct physical observations at the appointment 24 June 2024. The pharmacist prescribed propranolol for heart palpitations which our GP adviser confirmed was appropriate for the symptoms Mrs F presented with. The PoTS UK GP guide says beta blockers can be used to treat PoTS.
34. It is also in the medical records for appointments on 3 and 22 July 2024 that Mrs F said propranolol had helped with her palpitations. Therefore, despite the Practice not measuring Mrs F’s physical observations, we have seen no evidence the prescribing of propranolol had a negative impact.
35. Mrs F had another appointment at the Practice on 28 June 2024, where she reported ongoing palpitations and fainting episodes. She requested further investigations as she had a private report which suggested problems with her thyroid. The thyroid gland is a small gland in the front of the neck which makes hormones that control the way the body uses energy.
36. The GP said Mrs F needed investigation for possible PoTS and completed a referral for a tilt table test that same day. A tilt table test is a cardiology (heart) test that shows how changes in body position affect the heartrate and blood pressure.
37. The GP also requested a full thyroid function test (TFT). This is a blood test that measures the levels of thyroid hormones to check how well the thyroid gland is working.
38. NICE hyperthyroidism guidance says a diagnosis should be suspected if there are symptoms such as palpitations, anxiety, tremor, and fatigue. The PoTS UK GP Guide says diagnosis of POTS requires a ‘stand test’ such as a tilt table test.
39. We have seen no indications of failings for this appointment. Our GP adviser confirmed the Practice appropriately investigated Mrs F’s symptoms, and organised relevant tests according to guidance.
40. Mrs F had another appointment with a GP at the Practice on 3 July 2024 to discuss her TFT results. The results showed: • a normal Thyroid-Stimulating Hormone (TSH) – TSH tells the thyroid how much thyroid hormones to produce and release into the bloodstream • a very slightly raised T4 and a normal T3. T3 and T4 are thyroid hormones that regulate the metabolism, affecting how the body uses energy, and are crucial for heart and muscle function.
41. The GP explained the slightly raised T4 to Mrs F and arranged for the blood test to be repeated in four weeks. Our GP adviser explained this is accepted practice as small increases in T3/T4 hormone levels are common. NICE hyperthyroidism guidance says TFTs can produce misleading results in certain clinical situations and clinical judgement should be used when interpreting situations.
42. The Practice’s approach of repeating the TFTs was later confirmed by a Consultant Endocrinologist, who stated that a “mildly raised free T4 is not uncommon” and suggested repeating the blood tests in six to eight weeks.
43. We have seen no indications of failings for this appointment as the GP discussed the results of the thyroid tests with Mrs F, and booked further tests for investigation, in line with relevant guidance.
44. Mrs F had another appointment at the Practice on 22 July 2024. The decision for this appointment is outlined below under ‘prescribing sertraline’, starting in paragraph 65.
45. Mrs F had another appointment at the Practice on 14 August 2024 via telephone. The GP called her regarding a response from an endocrinology specialist. Mrs F said she felt “ok” on Ivabradine (medication to slow the heart rate). Ivabradine had been started following her hospital discharge on 29 July 2024.
46. The GP explained the endocrinologist's advice that the marginal TFT results were unlikely to be clinically significant and required repeating in six to eight weeks to confirm the trend. The GP organised further blood tests. We have seen no indications of failings for this appointment. The GP appropriately communicated the specialist advice and arranged further tests in line with this.
47. Mrs F had an appointment with a nurse at the Practice on 23 August 2024. She presented with lumps around the neck, sore throat, and an increase in heartburn symptoms associated with a history of hiatus hernia. Heartburn is a burning pain in the chest caused by stomach acid leaking back up into the food pipe. A hiatus hernia is a common condition where the upper part of the stomach pushes up through an opening in the diaphragm called the hiatus.
48. The medical records show the nurse took Mrs F’s observations and did a physical examination of her throat and chest. They noted some swelling in the upper abdomen. The nurse described Mrs F as alert and clinically well.
49. The nurse measured Mrs F’s vital signs and examined her throat and chest. This was in line with the NMC Code which says nurses must accurately identify, observe, and assess signs of normal or worsening physical and mental health in the person receiving care. This was also in line with NICE hyperthyroidism guidance which says symptoms such as neck lumps should prompt suspicion of thyroid disease, requiring examination.
50. The nurse recorded that Mrs F likely had a viral infection of the nose and throat and was experiencing acid reflux and had some swelling in the upper stomach area. Our clinical adviser said neck lumps and sore throat are also commonly associated with viral upper respiratory tract infections.
51. The nurse recommended that Mrs F rest and use over the counter pain relievers such as paracetamol or ibuprofen. For acid reflux, the nurse prescribed lansoprazole capsules. This is a type of medication known as a proton pump inhibitor (PPI) that reduces stomach acid.
52. The NMC Code says nurses must only prescribe, advise on, or provide medications or treatment if they have enough knowledge of the person’s health and are satisfied that the medicines or treatment serve the person’s needs.
53. Our GP adviser confirmed the prescription of lansoprazole was in line with the examination and NICE acid reflux guidance which says clinicians should offer a PPI for four weeks for acid reflux symptoms to aid healing.
54. The nurse advised Mrs F to call back if the neck lumps remained in four weeks or worsened. This is line with NICE lymphadenopathy (swollen lymph nodes) guidance which says if this has not resolved after two to four weeks, the clinician should arrange urgent referral to an ear, nose, and throat surgeon for further investigation, depending on clinical judgement.
55. We have seen no indications of failings for this appointment as the nurse considered all Mrs F’s symptoms and provided advice and prescribed medication according to the relevant guidance.
56. Overall, the Practice appropriately considered and acted on Mrs F’s symptoms that she presented with at the above appointments. There is only one indication of a failing for the appointment on 24 June 2024, when the clinician should have conducted physical observations before prescribing propranolol. The Practice has acknowledged this omission, and we have seen no evidence this had a negative impact on Mrs F. Therefore, we do not need to take further action.
Referral to cardiology
57. Mrs F said the Practice did not refer her to cardiology early enough which meant she suffered with the symptoms of PoTS for longer than necessary.
58. A hospital discharge letter dated 21 June included a follow-up plan to refer Mrs F to a syncope clinic for a tilt table test if her symptoms were ongoing. Our GP adviser said if the referral had been urgent, the hospital would usually have made the referral themselves.
59. The medical records show at the appointment on 24 June 2024 the pharmacist (in conjunction with the GP) decided to delay a referral to the cardiology syncope (fainting) clinic for four weeks pending a trial of propranolol.
60. Mrs F told the Practice on 28 June she had ongoing dizziness and fainting. She saw a pharmacist the same day who referred her to the syncope clinic for a tilt table test to investigate suspected PoTS.
61. NICE fainting guidance says a clinician should make specialist referral to a falls and syncope service or cardiologist if there is diagnostic uncertainty or unexplained fainting. NICE TLoC guidance says a clinician should refer a patient for a specialist cardiovascular assessment by the most appropriate local service.
62. GPC guidance says pharmacists should take action when there is a need for urgent referral to another healthcare professional. It also says they should refer people to an appropriate healthcare professional when they need further examination or assessment.
63. Our GP adviser confirmed that as the referral was not urgent, and Mrs F had recently had comprehensive tests done in hospital, it was appropriate for the pharmacist to put the referral on hold on 24 June while Mrs F trialled propranolol. Our GP adviser explained that propranolol is used to control symptoms like palpitations. The PoTS UK website explains that beta blockers can be used to treat PoTS. It was appropriate to try propranolol and see if that stopped Mrs F fainting.
64. We have seen no indications of failings in the Practice’s decision not to refer Mrs F to the syncope clinic on 24 June. The Practice made the referral four days later, on 28 June, as Mrs F continued to experience symptoms after starting propranolol.
Prescribing sertraline
65. Mrs F said the Practice should not have prescribed her sertraline at her appointment on 22 July 2024 as she was taking propranolol. She said taking the two medications made her very unwell, leading to a hospital admission. We recognise it was worrying for Mrs F to feel unwell after she started taking sertraline.
66. The medical records show the pharmacist talked to Mrs F about her history, which included two episodes where she blacked out, palpitations, chest pains, and shortness of breath. The pharmacist also noted extensive prior investigations had all returned unremarkable or normal. Mrs F reported that propranolol, prescribed previously for palpitations, did make her symptoms better.
67. The pharmacist explored Mrs F’s psychological and environmental history in detail. Following this assessment, the pharmacist noted generalised anxiety disorder was a possible cause.
68. Our GP adviser said as Mrs F presented with persistent physical symptoms (including fainting/blackouts and palpitations) that remained unexplained despite extensive and repeated investigations, it was reasonable for the pharmacist to consider a non-physical, psychological cause.
69. Our GP adviser said it was reasonable for the pharmacist to consider anxiety as a cause for Mrs F’s symptoms as she had a history of unresolved physical symptoms, high frequency of attendance at the Practice, and psychological trauma revealed during the extended consultation.
70. Mrs F consented for treatment with a selective serotonin reuptake inhibitor drug (SSRI), sertraline. An SSRI is a common type of medication that can help improve mood and wellbeing by increasing the amount of a natural chemical messenger called serotonin in the brain. SSRI’s are often referred to as anti-depressants.
71. The pharmacist explained the side effects of sertraline to Mrs F and the time it takes to come into effect. They also encouraged her to access links for counselling.
72. NICE anxiety guidance says if a patient is presenting with Generalised Anxiety Disorder (GAD) and ‘marked functional impairment’ (meaning the symptoms are having a significant impact on their ability to complete daily activities), psychological intervention or drug treatment should be offered.
73. Our GP adviser said it is within the guidance to prescribe medication at the same time as referring a patient for counselling or therapy to maximise effectiveness.
74. Mrs F said that sertraline should not have been prescribed with propranolol, and she believed the combination of these medications made her very unwell.
75. The Practice’s complaint response of 5 August 2024 said there is no documented interaction between sertraline and propranolol in the British National Formulary (BNF), and these drugs are commonly used in combination.
76. We can confirm the BNF does not list any known interactions between the two medications.
77. It must have been worrying for Mrs F to feel unwell after taking sertraline. We can see she went to ED on 24 July (two days after sertraline was prescribed) with abdominal pain and further episodes of fainting. The BNF lists gastrointestinal discomfort (an umbrella term to include symptoms like abdominal pain, bloating, and changes in bowel habits) as a common side effect of sertraline. It is unfortunate that Mrs F experienced this side effect.
78. We have seen no indications of failings regarding the Practice prescribing sertraline to Mrs F. The pharmacist’s decision to prescribe sertraline to treat her ongoing symptoms which had not been explained by physical tests was within the relevant standards and guidance. We have also seen no indications the Practice did anything wrong in prescribing sertraline alongside propranolol as this is acceptable practice in line with the BNF.
The Practice’s complaint handling
79. Mrs F said she felt the Practice had not explained in its complaint response why it did not investigate her symptoms and give her the care and treatment she needed to get a PoTS diagnosis. She also said she felt the Practice did not explain why it had prescribed her sertraline, which led to a decline in her health.
80. The response outlines details of appointments and visits to the Practice and visits to other organisations from November 2023 to July 2024. The details of each visit are very detailed and include the symptoms Mrs F presented with on each occasion, what was discussed, the treatment that was agreed or done, and appointment lengths.
81. We understand Mrs F suffered with a number of symptoms for a long period of time, and this was distressing as it took a long time to reach the correct diagnosis. However, the Practice in its response explained that many of the tests and observations that were done came back as normal and it was not clear what was causing Mrs F’s symptoms.
82. We can see no indications of failings in the Practice’s complaint handling as it provided a clear and detailed account of all the appointments Mrs F had at the Practice, and with other organisations.
The Trust’s investigation of symptoms
83. Mrs F complains about aspects of care and treatment she received from the Trust. Specifically, she said the Trust failed to take her symptoms seriously when she attended the ED on 24 July 2024.
84. Mrs F told us when she attended the ED she was fainting every ten minutes, and her heart rate was fluctuating a lot. She said she was there for 35 minutes and seen was by a receptionist and a triage nurse. She said Trust staff did not do any checks on her and told her she should not be attending ED for symptoms that are being dealt with by the Practice.
85. She said staff sent her home and told her there was nothing wrong with her. She said she then collapsed in reception as she was leaving, and The Trust admitted her to a ward.
86. To investigate this part of the complaint, we reviewed the medical records and obtained clinical advice to find out what should have happened, and what did happen on 24 July 2024, and if there were any gaps.
87. The medical records say the main reason Mrs F attended the ED was ongoing abdominal pain for the previous 24 hours. The triage nurse and clinician noted an ongoing history of fainting. The records show the clinician conducted observations and a clinical assessment. This is in line with GMC Good Medical Practice which states a clinician must carry out a physical examination where necessary.
88. Staff noted at triage Mrs F’s observations were normal. The notes also show the clinician did a physical examination and documented Mrs F was alert, aware of her surroundings and had a normal, healthy skin colour.
89. The records also indicate ED staff did a cardiovascular examination, noting normal heart sounds and good blood flow to the extremities (hands and feet). They also conducted blood tests and an electrocardiogram (ECG). This came back as normal.
90. According to NICE TLoC guidance, the clinician assessed Mrs F correctly regarding her fainting episodes by conducting an ECG. This came back with no abnormalities or ‘red flags’.
91. Our ED adviser said it was appropriate for the clinician to provide no further treatment for Mrs F’s fainting symptoms. This is because her symptoms and investigations fit the criteria of an uncomplicated faint, and NICE TLoC guidance says no further immediate management is required for this.
92. The clinician also conducted a physical examination of Mrs F’s abdomen (tummy area). They recorded her abdomen felt soft and not firm when they applied pressure. A "soft" abdomen is normal.
93. The clinician recorded there was no guarding or rigidity when they pressed Mrs F’s tummy. Guarding is when the abdominal muscles tense during an examination. Rigidity is when the muscles tense involuntarily and continuously. Guarding and rigidity can indicate a problem that requires further investigation.
94. The clinician recorded there were bowel sounds present, meaning the intestines were likely not blocked. They also recorded full epigastric tenderness which means Mrs F experienced pain or discomfort when the area just below the sternum (breastbone) and above the belly button (the epigastric region) was pressed.
95. The clinician documented they thought Mrs F may have gastritis (irritation of the stomach lining). They advised her to start taking lansoprazole again.
96. It is documented that while Mrs F was waiting to be picked up, she knew she was going to pass out, so she returned to ED. The Trust then admitted her to hospital. This must have been very frightening for Mrs F to have felt this way while waiting to go home in the early hours of the morning.
97. The clinician’s assessment for Mrs F’s abdominal pain was appropriate according to GMC Good Medical Practice and BMJ’s guidance on assessment of an acute abdomen. Our ED adviser explained there was no suggestion of an acute abdomen (life threatening issue) based on the examination findings and blood tests.
98. We have two conflicting accounts of what happened. We have Mrs F’s account which says the Trust did not do any checks on her in ED and this led to her collapsing in reception when she was sent home. We also have the medical records from the Trust, which evidence that tests and observations were done. We also have clinical advice which said based on the symptoms she presented with, the clinicians in ED acted within the guidance.
99. On this basis, we carefully weighed up these accounts, and other evidence from the sequence of events Mrs F complains about, to reach a view on the balance of probabilities on what happened.
100. We recognise Mrs F does not recall having investigations done in ED before staff sent her home. The clinical records and clinical advice present a strong source of evidence as they are detailed and were written at the time of what happened on 24 July 2024, and therefore, hold more weight in our decision making about what happened.
101. We can see no indications of failings regarding Mrs F’s visit to the ED department on 24 July 2024. The clinicians recorded her symptoms and investigated them according to the relevant guidance. There is no indication they ignored any symptoms or failed to carry out the necessary investigations for the presented symptoms. There was no indication Mrs F required any further treatment when she first presented at ED. Reassuringly when Mrs F became faint again, the Trust admitted her for observations and further tests.
102. We were sorry to hear of Mrs F’s experience and recognise she went through a long period of ill-health leading up to her diagnosis of PoTS. We understand this was very distressing. We and thank her for bringing her concerns to our attention.