19. 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 indication that something has gone wrong for some aspects of the complaint.
The Trust
20. Miss A complains the Trust refused to give her an MRI scan in June and July 2024. We understand and appreciate this was a very challenging time for Miss A.
21. The Knee MRI guidance says an MRI is not recommended for a suspected degenerative meniscal tear (gradual wear and tear of the meniscus cartilage in a knee) unless there are mechanical symptoms. These include locking or lack of improvement with conservative treatment such as exercise, therapy, weight loss, bracing, topical or oral analgesia.
22. The guidance also says degenerate meniscal tears and osteoarthritis (arthritis characterised by degeneration of joint cartilage) are extremely common in the general population.
23. The GMC’s Good Medical Practice says if doctors are assessing or diagnosing patients, they must promptly arrange suitable investigations.
24. Our physician adviser has explained an MRI scan would usually be an outpatient investigation for a person who has suffered an injury to their knee. They also said it is not usual practice for the ED to organise an MRI scan for the knee joint the same day, particularly where there has been no trauma to the knee. They said an X-ray of the knee would be a sufficient starting point.
25. We can see from the records in June 2024, Miss A presented at the Trust ED with increased pain whilst walking, right knee and ankle pain. The Trust recorded there had been no trauma. When she presented to the Trust in July 2024, she also presented with similar symptoms, with no knee trauma.
26. The Knee MRI guidance sets out symptoms when an MRI would be recommended (set out in paragraph 21). There was no indication from Miss A’s presentation that these symptoms were present. In line with the guidance, an MRI was therefore not recommended.
27. Given Miss A’s presenting symptoms at the Trust, and that she had suffered no trauma to her knee, the Osteoarthritis guidance says there is a higher likelihood of osteoarthritis being the cause of the pain in people over the age of 45. The guidance says osteoarthritis should be suspected where a person presents with symptoms like Miss A, including swelling and tenderness in the area together with restricted and painful range of movement.
28. We understand Miss A was suffering with pain to her right knee and acknowledge this period of time would have been extremely difficult for her. After reviewing her medical records and guidance, we have seen no indication the Trust did anything wrong when she presented to it in June and July 2024.
29. The Trust appears to have acted in line with the Knee MRI guidance when it did not arrange an MRI, as Miss A’s symptoms did not suggest this was necessary. The Trust’s decision to complete an X-ray on her knee appears to be in line with the GMC’s Good Medical Practice, as it was a suitable investigation.
30. Due to the reasons outlined above, we will not be considering this complaint further. We hope our consideration provides Miss A with reassurance the Trust acted in line with guidance on both her attendances to its ED. We hope we have explained our decision clearly.
The Practice
MRI referral
31. Miss A complains the Practice lied about having made a referral for an MRI on her right knee in July 2024.
32. The Knee pain guidance outlines what investigations are recommended for knee pain. It says further investigations are not normally required in primary care (a GP practice). If referral is indicated this should not be delayed while waiting for test results. It also says investigations should be guided by the suspected cause.
33. An MRI scan is often used but usually in secondary care (a hospital), particularly for cruciate or meniscal injuries, malignancy, osteomyelitis (bone infection) or vascular (blood vessel) injury.
34. From the records, we can see Miss A’s GP did refer her for an MRI scan towards the middle of July 2024.
35. The Knee pain guidance does not go into detail about how urgent a referral should be. Our GP adviser said using clinical judgement, for the time Miss A was suffering with knee pain and had osteoarthritis, the Practice making a routine referral would be fine.
36. Usual practice for a GP to make a referral is 2-3 working days. We can see from the records the Practice completed Miss A’s referral on the same day.
37. After reviewing her medical records, we have seen no indication of failings as the Practice did not mislead Miss A. The Practice did make a referral for an MRI scan and it completed this on the same day.
38. We have not seen an indication anything has gone wrong here. We will therefore not consider this complaint further. We hope this provides Miss A with some reassurance.
Verbal Abuse
39. Miss A complains a doctor at the Practice verbally abused her during a meeting in November 2024.
40. GMC guidance says doctors must treat patients with kindness, courtesy and respect.
41. Miss A supplied to us a recording of the meeting which we subsequently made the Practice aware of.
42. In the recording we can hear Miss A begins the meeting by communicating her frustration of having to wait to see the doctor. During the meeting, Miss A asked the doctor regarding the purpose of the meeting, if a referral was made for an MRI scan and why she had not received a response to the questions she raised via email.
43. We can hear the doctor at the Practice was listening to Miss A’s concerns. He tried to explain he deals more with medical side of the things but most the issues Miss A has relate to the administrative side of the Practice. He goes on to explain all her concerns may not be addressed in the time they have available, but a plan can be put in place to address the issues.
44. At some points in the meeting, the doctor is interrupted while answering Miss A’s questions and he asks if he can complete his sentences before she answers. Towards the end of the meeting, Miss A says to the doctor she ‘does not believe a word’ the doctor was saying. It is at this point the doctor terminates the meeting and says he does not wish to be spoken to this way and Miss A will be removed from the Practice.
45. We understand how difficult and stressful it would have been for Miss A to feel she was verbally abused by the doctor.
46. However, after considering the recording of the meeting, we do not consider the doctor verbally abused her. He adhered to the GMC guidance and treated Miss A with courtesy and respect. He also remained professional throughout given the intense nature of the meeting and terminated this when he felt Miss A did not believe anything he was saying.
47. We have therefore seen no indication of a failings here. We acknowledge this time would still have been difficult for her and understand our decision may be disappointing.
Removal from Practice list
48. Miss A complains the Practice wrongfully removed her from its patient list. We are sorry to learn Miss A was removed from the Practice patient list. We acknowledge this would have been a stressful and upsetting time.
49. The BMA guidance states Practices have the right to ask for a patient to be removed from their list. In cases other than violence and abuse, the decision to remove a patient should only be made after careful consideration. The removal of a patient from a GP practice list should be a rare event. Reasons for removal include when there has been a disagreement between the practice and patient, and an irretrievable breakdown of the relationship.
50. The BMA guidance also say patients who are misusing services can change their behaviour if it is brought to their attention. Among a wide range of options available to a Practice, it can issue a warning to a patient, preferably in writing. This would give the patient reasons for the possibility of removal.
51. The Practice said Miss A was removed from the patient list due to a breakdown in the doctor-patient relationship. It said Miss A repeatedly interrupted the GP and accused him of dishonesty. The Practice said the lack of mutual trust made it clear that an effective therapeutic relationship could no longer be maintained.
52. From the records we can see the GP recorded Miss A would interrupt him, said ‘why is everyone so rude?’, accused him of being evasive and said she did not believe anything he said. The GP then said he would not tolerate these accusations and removed her from the Practice list.
53. With respect to BMA guidance, Miss A was not abusive or violent towards the Practice to warrant a straight removal. The Practice did not give Miss A an opportunity to change her behaviour by bringing this to her attention by way of written warning. We consider if a patient was talking over the GP and saying they are being dishonest, then this would warrant a warning letter rather than a straight removal.
54. According to BMA guidance, it appears Miss A should not have been removed from the Practice patient list in the manner she was. Although we consider it is likely the Practice should not have removed Miss A from its patient list, the impact of her being without a GP, and the stress associated with this, was for a relatively short period of time, around 14 days.
55. We do not wish to trivialise her suffering, but as an Ombudsman service we can only consider cases which have the most significant impact and have a wider range of betterment to service users. At this stage, we consider it is not proportionate to further consider this issue as the stress Miss A suffered was for a relatively short period of time.
56. We recognise this decision may be disappointing and we acknowledge how Miss A was affected by the removal. We are however happy to learn she was able to register with another GP Practice promptly.
Summary
57. To conclude, we have seen no indication of failings in the Trust’s actions when Miss A presented to its ED. This is because it is not usual practice for a knee MRI to be carried on the same day especially due to atraumatic knee pain.
58. We do not think the Practice misled Miss A regarding an MRI scan referral and this was completed according to her medical records. We have also seen, after reviewing the meeting recording, the GP at the Practice did not verbally abuse her.
59. We have seen an indication of a failing in the Practice removing Miss A from its patient list, and we think it is likely it should have given her a warning instead. Because of the relatively short length of time she was without a GP, it is not proportionate for us to continue our consideration.
60. We hope our consideration of Miss A’s concerns relating to the Trust and Practice have been explained clearly. We will not be considering these issues further. We thank Miss A for bringing her complaint to us.