Test result June 2023
20. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so, we have found the Practice has already done enough to put right the impact of the events Ms R complains about.
21. Following Ms R’s annual diabetes review in June 2023, the Practice received her HbA1c test result which was above the high reference limit.
22. The medical records show a GP did identify the abnormal result and recorded this having a high reference limit. However, we can see no evidence they took further action. They should have contacted Ms R or sent an alert to the receptionist to contact her and invite her for a follow up appointment, or an appointment with the diabetes nurse.
23. NICE Type Two Diabetes Guidance says a clinician should discuss and agree an individual blood glucose (HbA1c) target. Ms R’s medical records show the target for her HbA1c blood test was 58 millimoles per mole (mmol/mol). This is a unit doctors use to measure glucose levels. Her result was 89, which is significantly higher than the target.
24. Section 1.6.8 of the guidance says if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher, a clinician should:
• reinforce advice about diet, lifestyle and adherence to drug treatment • support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) • intensify drug treatment.
25. GMC Good Medical Practice says a clinician must listen to patients, take account of their views, and respond honestly to their questions. They must also give patients the information they want or need to know in a way they can understand, and make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.
26. Our clinical adviser said it was the Practice’s responsibility to pass this information to Ms R and take action.
27. Our clinical adviser said as the result was significantly higher than the target, the appropriate action for the clinician would have been to arrange an appointment for Ms R with the diabetes nurse for a review.
28. Her medical records show there was a further missed opportunity in September 2023. A GP called Ms R to discuss a recent protein urine test. The GP noted she was diabetic, and it is “poorly controlled”. This was a missed opportunity for the Practice to identify the high blood sugar results from June 2023 and take action.
29. There was also another missed opportunity in January 2024. Ms R’s medical records show the GP noted ‘bloods up to date: Jun 23 – normal’. They incorrectly noted the blood tests from June 2023 were normal.
30. The Practice said in its response to Ms R’s complaint this is not the standard of care it aims to provide. It also said the GP made a note to book an appointment to discuss the results with her, but unfortunately this was not communicated to her.
31. Therefore, we can see indications of failings as the Practice should have arranged an appointment for Ms R with a diabetes nurse following the high blood test in June 2023. It also failed to take the opportunity to act on this test result in September 2023 and January 2024.
32. Ms R claims the impacts of what happened are:
• she has missed out on treatment options • exacerbated her diabetes as her blood sugar has remained higher than desirable for a prolonged period of time • fears she may need injectable medication in the near future, a more invasive option than her current treatment • experienced significant stress.
33. Below, we have given our consideration on each of these impacts, and whether they link to the indications of the failings we have seen. Where we saw a link, we explain why we consider the Practice has done enough to address the impact.
Impact on Ms R’s available treatment options
34. Our clinical adviser said Ms R’s diabetes would have needed the same treatment whether it was treated earlier or not. If she received it a year earlier in June 2023, the treatment would have been the same, which was changes to her medication to address high blood sugar levels. It is not that the delay in treating the higher sugar levels worsened her condition, but she had ongoing symptoms of the high blood sugar for a longer period.
35. Therefore, we cannot see indications the Practice’s lack of action following the high blood sugar test in June 2023 meant Ms R missed out on treatment options for her diabetes. She still had the same treatment options available later.
Whether the Practice exacerbated Ms R’s diabetes
36. Our clinical adviser said the symptoms Ms R was likely to have due to her high blood sugar were feeling thirsty, drinking more water and passing more urine.
37. Her medical records show in her appointment on 12 September 2024 with the diabetes nurse, Ms R did not report ‘osmotic symptoms’. Osmotic symptoms include feeling thirsty, passing urine frequently, dry mouth and skin, feeling weak or generally unwell.
38. She also did not have any GP appointments following the high blood sugar test in June 2023 to September 2024 reporting these kinds of symptoms.
39. Our clinical adviser confirmed high blood sugar associated with diabetes can cause osmotic symptoms, but not always. Sometimes patients have high blood sugar and do not experience any osmotic symptoms.
40. Therefore, we cannot see indications to suggest Ms R’s condition or symptoms were exacerbated during the period June 2023 to September 2024, when the Practice changed her medication to treat her high blood sugar.
41. We also considered whether the Practice’s delay in acting may have caused damage meaning Ms R’s condition may be exacerbated longer term.
42. Our clinical adviser said high sugar levels can cause damage to the body, for example, to the eyes, blood vessels and kidneys. This usually occurs over many years and decades. Long-term mismanagement of blood sugar levels can cause damage to the body.
43. Our clinical adviser said it is not possible to quantify what kind of damage (if any) occurred to Ms R during the period June 2023 to September 2024. She had already been diagnosed with type two diabetes prior to the June 2023 blood test. They said a diabetes specialist would not be able to say with any certainty if any damage was caused and could have been prevented if the Practice had acted on the blood test in June 2023.
44. We took further advice from our lead clinician to check if we did need to seek specialist advice to ensure we have a robust decision on this matter.
45. Regarding deterioration that could have been caused, our lead clinician said type two diabetes is a chronic condition which develops over many years. The period June 2023 to September 2024 is therefore a short window in the context of this condition. They said this means it would be hard to determine if any damage was caused in this period.
46. The test showing high blood sugar levels should have resulted in changes to medication, which eventually happened in September 2024. Our lead clinician said medication is just one component of managing diabetes, and a significant responsibility is with the patient to self-manage their diabetes through diet and lifestyle changes.
47. They said to be able to make a decision on whether any damage occurred during the time period, we would need to see evidence of:
• Ms R’s medical records and medication history from when she was diagnosed in 2013 • Ms R’s self-management of the condition, e.g., diet, exercise, lifestyle.
48. They said the evidence we would need to decide if there was deterioration would need to be detailed, including dietary records from June 2023 to September 2024. They said as the evidence that is needed and the level of detail is from two to three years ago, it would likely be unreliable. Also, as Ms R was not hospitalised, we cannot see there would be available records on things like her dietary intake. For example, inpatient food charts.
49. Our lead clinician said we would also need to review her diabetes history and determine if there was any pre-existing damage caused prior to the blood test in June 2023. It would be hard to obtain this information and then prove with some degree of certainty if there was pre-existing damage.
50. They also said the medical records indicate no further tests were done between June 2023 to September 2024. Therefore, it would be very difficult without this evidence to decide if damage was done in this period.
51. Having considered this advice, we did not see seeking further evidence or specialist advice would help us reach a view on whether and to what extent the Practice’s mistake exacerbated Ms R’s diabetes. This is something we cannot now, or see we ever could, reach a robust conclusion on.
52. We note our advisers have said, plausibly, the delay acting on Ms R’s test result may have caused preventable damage. This means we cannot rule this out. We recognise this will leave Ms R with uncertainty on whether there has been a negative impact, and whether this has implications on her future health. This stems from the Practice not acting on her test result.
53. We are sorry we cannot resolve this uncertainty for Ms R. We hope we have clearly explained why.
54. We give our consideration on whether the Practice has addressed this impact from paragraph 59.
Fears of injectable medication or invasive treatment
55. Regarding Ms R’s fear she may need injectable medication or invasive treatment in the future, we cannot see this fear links solely to the period the Practice failed to act on her test results.
56. Our lead clinician said this is an ongoing issue for all patients with type two diabetes.
57. They said even if someone with type two diabetes had optimum medication, treatment, lifestyle and self-management of the condition, they would still be at risk of needing injectable medication or invasive treatment at some point. They said it is not possible to determine who may be more susceptible and when these might be needed.
58. Therefore, even if the Practice acted in line with guidelines, we consider this risk and the fear associated with it for Ms R would always exist. On this basis, we do not see this impact links to the indications of failings we saw, or Ms R would have been in a different position had these failings not happened.
Experienced significant stress 59. Ms R said the Practice caused her extreme stress and distress about her future health. She told us this is because she is uncertain whether a negative impact was caused when the Practice failed to act on her blood test in June 2023. Through our work in paragraphs 41 to 53, we also identified this impact.
60. In its complaint response, the Practice apologised for this stress and distress caused by it not acting on her test result. It empathised how frustrating and upsetting it can be when things do not go as expected, especially when it affects your wellbeing.
61. It said it was not the standard of care it aims to provide, and it deeply regretted putting Ms R in this position. It also said it would discuss her complaint at the next meeting with clinical and non-clinical teams to support and improve patient experience at the Practice.
62. This is in line with the kind of remedies our Principles for Remedy recommend. This includes an organisation acknowledging what went wrong and apologising about the impact. Ms R also wants these outcomes.
63. They also say public bodies can revise procedures, train or supervise their staff, or do any combination of these things, to prevent the same thing happening again. We consider the Practice sharing Ms R’s experience in staff meetings as a form of staff training, and it will reduce the chance of similar mistakes happening again.
64. We appreciate Ms R also seeks a financial remedy. Therefore, we reviewed our guidance on financial remedy to consider whether the Practice’s apology is enough for the impact we identified.
65. Our guidance on financial remedy sets out what we consider to be a level one impact in our severity of injustice scale.
66. This includes when someone experiences worry because of a service failing. It is the sort of worry we would expect a healthy adult to deal with without external support, and it does not impact their day-to-day functioning or ability to live a normal life. We would expect them to recover quickly once the direct impact of the poor service ends.
67. In these circumstances, our guidance on financial remedy says an apology is an appropriate remedy.
68. While we appreciate Ms R is uncertain whether the Practice’s inaction may have health consequences for her later, she has not told us, and we cannot see this has impacted on her day-to-day functioning.
69. We saw, within two weeks of the Practice reviewing her HbA1c test result in September 2024, it organised an appointment for her to see a diabetes nurse. The nurse altered her medication and gave Ms R lifestyle advice about managing her diabetes. In paragraphs 22 to 31 we explained this should have happened originally.
70. Having taken this action, we consider the Practice gave her the assurance it could that she and staff were managing her condition as they should from this point.
71. On this basis, we consider the impact we identified sits within level one in our severity of injustice scale. As the Practice has already apologised about this impact, we consider this to be an appropriate remedy. We would not expect it to provide a financial remedy.
72. In summary, we have seen the Practice has done what we would expect and made improvements to prevent similar incidents happening again in future. This means there is nothing more we would expect it to do and no reason to consider the matter further.
73. We hope our explanation provides Ms R some reassurance on what happened during her care and treatment, and that we have reached this decision following careful consideration.