Appointments and prescription
13. Before we decide if we should conduct a detailed investigation of 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. We have done this and have not seen any indications that something has gone wrong in how her symptoms were considered or the actions taken on these. We do think there was an unnecessary delay in prescribing medications, but we think the action the Practice has taken to put this right is sufficient.
14. Miss A says she first contacted the Practice with symptoms of frequent urination after she had been struggling with this. She says she was told she would be added to a list for a routine appointment, but one was not provided until she rang back several weeks later with worsening symptoms. She says when she was prescribed antibiotics, the Practice delayed signing this off and she almost missed being able to collect these.
15. The Practice maintain their approach was correct. They say her initial call was triaged and it was decided a routine appointment was the best course of action. We therefore thought about what the appropriate course of action would have been here, in mind of the symptoms Miss A was experiencing around this time.
16. When Miss A first contacted the Practice in February, it was recorded in her medical records that she had been experiencing frequent urination for several years, but this had previously been investigated but nothing had been identified. It was also recorded that she would like advice on whether there was anything further which could be done. Our clinical adviser suggested the most appropriate guidance for an issue such as this would be NICE guidance (Incontinence - urinary, in women: Scenario: Managing urinary incontinence). This states that patients should be referred to a specialist if certain symptoms are present. Having reviewed these, we see Miss A did not report anything which would have meant a referral would be necessary at the time.
17. Where a referral is not necessary (as was the case here), it suggests that a patient should be offered lifestyle advice, be provided with self-help resources, and help with identifying issues which may contribute to or complicate their symptoms. There is nothing in this guidance which states this should be done urgently, and so we think arranging a routine appointment to discuss this further would have been appropriate. This was done in this case.
18. We also asked our adviser about the management of this situation to see whether it was reasonable. They agreed this contact was managed appropriately and in line with guidance. We have reviewed the text message Miss A was sent about this, and it does advise her to contact the Practice if her symptoms worsened before she could be offered an appointment. We are satisfied this was appropriate.
19. Before an appointment was arranged, Miss A contacted the Practice again in late March as she had found out she was pregnant, and her symptoms had worsened. Our adviser explained that at this point it was appropriate to arrange for a urine sample. This is because she was now pregnant, and her symptoms worsening meant it was now reasonable to suspect a urinary tract infection (UTI). This is in line with appropriate guidance (Urinary tract infection (lower) - women: How should I assess a woman with suspected UTI?). This says a urine dipstick test and possibly a further culture (where the urine is sent to a lab for further analysis) should be carried out.
20. We know Miss A did take in a urine sample the following day. This was tested with a dipstick and sent for further laboratory testing, and so this is in line with what we would expect to see. Our adviser also shared that it was appropriate to begin antibiotics at this point, in line with relevant guidance (Urinary tract infection (lower) - women: Scenario: UTI in pregnancy (no visible haematuria)). This guidance states that where a UTI is suspected in pregnancy, an antibiotic should be prescribed immediately. We agree the prescribing of antibiotics was appropriate in this case.
21. However, Miss A says when she was prescribed antibiotics, the Practice delayed signing this off and she almost missed being able to collect these. She explained that she was contacted and told she would need to start these, but the prescription was awaiting sign off from a doctor. She says she was told that it should be available before the surgery closes. She explained that waiting this long would mean the pharmacy would be closed and she would not be able to collect her medication. She said she contacted the Practice multiple times, but it was only prescribed at 5.15pm after she asked for this to be done urgently. In its response, the Practice apologised for the delay with her antibiotics but did not explain why this had happened.
22. Our adviser explained that in line with the above guidance (Urinary tract infection (lower) - women: Scenario: UTI in pregnancy (no visible haematuria)), the medication should have been prescribed immediately, and it is not clear from the records why there was a delay. They explained that the GP could have signed this off at the time of their discussion with Miss A, and there is no clear reason why the prescription would need to wait to be signed off later.
23. We thought carefully about this, and see an indication of a failing in this. While we recognise the delay is only a few hours, we are mindful both the guidance and our adviser suggest this should have been immediate. Further to this, there is no clear explanation as to why the doctor did not sign this off at the time of their consultation with Miss A. We therefore went on to consider what impact this might have had.
24. We know Miss A was able to access her prescription later the same day, although we recognise the concern and stress she would have felt chasing these up throughout the day. We also know her blood tests later came back and confirmed there was no infection (we will discuss this further later). This means that there would not have been a risk of any infection worsening over this time, as there was not one present. Our adviser explained it is their view that even if there had been an infection present, the few hours delay would not have made a difference in this case. Therefore, we do not see there was any clinical impact here.
25. Having said this, we do recognise there would have been a short period of stress and inconvenience while Miss A was trying to access her prescription. We are sorry this was her experience. In situations such as this, we usually ask the organisation to apologise. We see the Practice has apologised for this delay, and so would not ask it to do anything further. Therefore, we will not investigate this issue further, as it has been appropriately resolved.
Misdiagnosis
26. Miss A says she was initially told she had a urinary tract infection and needed antibiotics. She said she later found out the sample she provided had been negative. She also says that when she later attended an appointment at A&E, she was told she had overactive bladder syndrome and would need a referral.
27. The Practice says in its response that when it dipped the urine, there was evidence of white blood cells and a trace of blood. It said it therefore prescribed antibiotics as a precaution. Following this, it says the sample sent to the lab did not grow cultures and so there was no infection present. It said it does not usually inform patients of negative results. It also said Miss A’s blood results (which it had also taken) showed an increased white blood cell count, and so antibiotics may still have been beneficial if there was an infection elsewhere.
28. We reviewed guidance related to the diagnosis of a UTI (Urinary tract infection (lower) - women: How should I assess a woman with suspected UTI?), which says if leukocytes (white blood cells) and red blood cells are present on a urine dipstick test, then a UTI is a likely diagnosis. On reviewing these results, we do see these were both present in the sample, and so a UTI was a reasonable diagnosis to make at this stage.
29. Following this, the sample was tested at the laboratory and no infection identified. We asked our adviser about this, who explained that while GMC guidance (Good Medical Practice) does outline how doctors should communicate in general, there are no specific guidelines related to this situation. They explained that broadly, it is not possible to communicate negative results as there would be too many across all patients for this to be reasonable.
30. We recognise Miss A’s concern here is that she was not told to stop her antibiotics. Our adviser explained that in many circumstances, courses of antibiotics should be completed even if later results are negative. We see this supported in information about the medication which Miss A was prescribed (Cefalexin: Uses, Side Effects, and Warnings).
31. Following this, Miss A contacted the Practice again in mid-April to report she was still experiencing symptoms. She was asked to bring in a urine sample for testing, however she attended hospital the following day. Therefore, we cannot say now what would have come of this. We would expect to see some kind of follow up, but since the opportunity for this was overtaken by the attendance at A&E, we cannot make comment as to whether the Practice would have done so or not.
32. As such, we cannot see there is an indication of a failing here. This is because it was in line with guidance to continue the course of antibiotics, and so there was no direct need for the Practice to contact Miss A. We do understand the worry Miss A felt, as she worried about any side effects this medication could have had. We know it would have added to her concern to later discover there had not been a UTI present. We hope it reassures her to know that the Practice did act in accordance with guidance by prescribing these, and by not asking her to stop taking them once it was known there was no UTI.
Referral
33. By mid-April, Miss A’s symptoms had still not improved, and the NHS 111 service booked her to see an out of hours GP at the A&E department. Miss A says she was told during this appointment that she likely has overactive bladder syndrome and would need a referral in relation to this. She says the doctor told her they would write to her GP to outline this and to ask for the referral to be made.
34. The Practice says it did not receive any correspondence from the hospital requesting a referral to be made. We have reviewed Miss A’s notes and could not see this was communicated to the Practice by the doctor at A&E. We do see they advise for the Practice to arrange to see Miss A and to ask for a urine sample. There is not a complaint about the hospital and so we will not comment on whether this advice was appropriate, as we have not looked into this.
35. Having reviewed the medical records, we see the letter from the A&E GP was dated on a Friday, and so we would not expect this to be followed up until the following week. We see this is followed up the following Tuesday, where it appears there has been some confusion over whether the contact details for Miss A are up to date. We see the Practice do try to contact her via text message at this time to ask her to bring in a urine sample. This is in line with the request we see from the GP at the A&E department.
36. Following this, we see the Practice did try to contact Miss A by phone on two occasions two days later. On the first attempt, the record states the call was ended by Miss A, and the second call went to voicemail. We do see there were further attempts to contact Miss A after this, however these are outside of the timeframe we are investigating. Later, in early May, the Practice sent a text asking Miss A to get in touch if she would still like to be contacted about this, but we cannot see this was responded to.
37. Having reviewed this, we are satisfied the Practice did attempt to follow up on the information shared by the doctor at A&E. We see it made timely attempts to contact her but were unable to. While there are not any specific clinical guidance we can point to regarding this, our adviser shared their view that the steps the Practice took here were appropriate.
38. While there are no clinical guidelines, we have reviewed our own guidance in relation to administration (Principles of Good Administration). While it does not specifically address a situation such as this, it does say services should be easily accessible. It also says organisations should behave helpfully and communicate effectively. We think the actions of the Practice were in line with this. It is clear it made attempts to contact Miss A, and to communicate what the next steps would be. We think this represents a service which is trying to support its patient in accessing the necessary care. Given the Practice could not contact Miss A, there was not an opportunity to follow up, and so we do not the Practice failed here.
Complaint handling
39. Miss A has raised several concerns around the responses the Practice offered to her complaint. She says the Practice contradicts itself and gives opposing answers to the same issues. These centre around issues such as the prescribing of her antibiotics, whether the urine test indicated infection, and whether the Practice accepts responsibility.
40. We have reviewed the complaint responses, and do not see there are contradictions in its answers. Having said this, we do see how the issues within the complaint and the circumstances surrounding these led to answers that may be confusing and gave the impression they are contradicting. For example, the urine sample when dipped showed an infection may be present, but later lab testing showed there was not. We do see that explaining circumstances such as this can be difficult and could lead to confusion. We will now go on to discuss our views on this in more detail.
41. To consider this part of the complaint, we reviewed our own complaint standards (NHS Complaint Standards), which outline how we expect NHS bodies to manage complaints. These broadly say the organisation should give a clear and balanced account of what happened, and that answers should be open and honest. As there were several points raised, we will not specifically outline our thoughts on each individual point. This is because our view is consistent on each of these, and we do not think repetition of this would be beneficial. However, we will use two examples to illustrate our view.
42. Miss A has explained in one point that there were inconsistencies in whether the Practice felt she had a UTI or not. She outlined that in the first response, the Practice said results showed her symptoms were not related to a UTI. However, she says in a later response the Practice said she may well still have had an infection. We see why this has come across as confusing and seems contradictory.
43. Having reviewed the letters, we see the Practice first explained that when the urine sample was dipped, the results suggested an infection may be present. Therefore, it sent the sample for further testing and began antibiotics. However, it explained the further testing was negative and so confirmed no infection was present. In the later letter, the sentence Miss A is quoting is within a section which was intended to explain why her antibiotics were not stopped. This means it was not directly answering a question about the sample itself at this point.
44. In this part of the response, it states that it would not usually notify patients of negative results, but there may have been a benefit to her taking the antibiotics as she may have had an infection at the time the sample was dropped off. We think this statement could be understood in different ways, and it was not unreasonable Miss A took it to mean she may still have had a UTI. However, having reviewed the letter in full, and considering the considering the context of the answer, we think it is more likely this meant she may have had an infection elsewhere which was not a UTI. While we do think this could have been explained better, we do not think the overall impression suggests Miss A did indeed have a UTI after receiving the results from the lab.
45. Having looked at the rest of this letter, it is explained that the further testing had come back normal. This is pointed out clearly and it is explained that no further action was needed due to the sample being normal. However, we acknowledge the sentence Miss A is referring to was confusing. Having said this, we do think the responses overall do give an honest and accurate account of what happened, which is what we would expect to see. It is therefore our view that while we do not think the responses are contradictory overall and so cannot point to this as a failing, we do understand how Miss A came to feel this way.
46. Another issue Miss A raised is that the first response accepts responsibility for issues such as the delay in prescribing her antibiotics, and a later response seems to shift blame onto her for issues such as difficulty contacting her. She says there is a difference in tone between these letters.
47. Again, we see why it may appear contradictory to accept responsibility for some issues at one time, but then later not take responsibility for other seemingly related issues. We understand this. Having reviewed the letters, we do not think the answers are contradictory. It is correct that the Trust does take responsibility for the delay and apologised for it, which we are pleased to see. It is also correct that it later explained there were difficulties in contacting Miss A. However, these were in relation to different issues. Where it outlines these difficulties, this is in relation to Miss A attending phone appointments and requesting for her to bring in urine samples.
48. We think this reflects the Practice explaining what had happened over the course of the period of time in question, and why it was not able to do certain things. This seems to be a factual account of the circumstances, rather than the Practice trying to avoid responsibility. Again, this is in line with what we would expect to see. We appreciate Miss A felt the tone was different in the later response. She says it was defensive and seemed to imply fault lay with her. We do not dispute she felt this way, and this would be upsetting. We cannot say whether the tone was indeed different, as this would be subjective and open to interpretation. Having said this, we do not see any instances where there is clear blame placed on Miss A, although we do understand that the Practice pointing out the difficulties in contacting her could have felt critical to her.
49. Overall, we are satisfied that the responses Miss A received broadly do not contradict one another. We think they represent a factual and honest account of what happened, which is what we would expect to see. Therefore, we do not think the Practice has failed in the process of responding to Miss A’s complaint. We do understand Miss A feels strongly about this, and so we know she may be upset with our decision. We do not think it was wrong to feel the way she has, as we do see where confusion would have arisen. We hope our explanations will be helpful moving forward.