19. Before we decide if we should investigate a complaint in more detail, we look at a few different factors. We consider whether there are signs the organisation concerned has got something wrong. We do this by comparing what should have happened with what did happen. If what happened fell far short of what should have happened, we call this a failing. We also look at whether what happened had a negative impact on the person in question. If we think it did, we will go on to consider what, if anything, the organisation has done to try to put things right.
20. If we think there was a failing, and that this had an impact that has not been put right, we will usually investigate in more detail.
Psoriatic arthritis
21. Miss A told us that doctors at the Practice failed to recognise her symptoms of psoriatic arthritis or refer her for specialist care between October 2021 and September 2024. Miss A says the Practice should have recognised that high uric acid is a symptom of psoriatic arthritis, and she is concerned this was missed. She told us she had to repeatedly remind doctors she had psoriasis and that ultimately, it was only on her suggestion that psoriatic arthritis was suspected.
22. In the complaint response, the Practice explained that Miss A’s presentation was not typical of psoriatic arthritis. This was because Miss A’s symptoms presented in just one finger. It says the overall picture of raised uric acid, with normal inflammatory markers, and pain in one area led to the initial diagnosis of gout.
23. The Practice explained that Miss A’s symptoms evolved over time, and there was a change in the X-ray findings from March 2022 to November 2024, as the initial X-ray did not show any bony abnormalities, whilst the X-ray in November 2024 suggested some inflammatory arthritis, which could be psoriatic arthritis.
24. We have considered the Practice’s care and assessment of Miss A’s symptoms from 2021 to 2024 in line with the GMC guidance ‘Good medical practice’. This sets out the standards of care for doctors and says doctors must adequately assess a patient’s condition and promptly provide or arrange investigation or treatment where necessary.
Care in 2021
25. Miss A attended the Practice in September 2021 with a three-week history of a red, hot swollen right middle finger, purplish discolouration at the joints, and pain upon bending.
26. The NICE guidance on gout sets out that gout should be considered in people presenting with rapid onset of severe pain, redness or swelling in joints, which is what Miss A had. In light of Miss A’s symptoms, our adviser explained it was appropriate to consider a diagnosis of gout at this time.
27. Miss A next attended a follow-up appointment at the Practice in October 2021 with her middle finger still very swollen but no longer red or hot. At this point, the GP was still considering gout as the likely cause, so it was appropriate for them to act in line with the NICE guidance on gout. This says to offer treatment (such as colchicine) and provide advice and information about the condition. It says to consider following up after the gout flare has settled to measure the serum urate level, which is what the GP did.
28. We considered if psoriatic arthritis should have been suspected at this time. The NICE guidance ‘Spondyloarthritis and psoriatic arthropathy’ says psoriatic arthritis should not be ruled in or out by the presence or absence of any individual sign or symptom. It explains psoriatic arthritis may present with diverse symptoms, and as a result, may be difficult to identify.
29. The guidance also recommends blood tests to rule out potential differential diagnoses, possibly including vitamin D level, uric acid level, serum calcium level, rheumatoid factor, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and thyroid function tests.
30. The GP arranged these, and they returned normal except for slightly elevated uric acid levels.
31. Our adviser explained that elevated uric acid levels can show a person has gout and that it was, therefore, reasonable for the GP to continue to suspect gout and prescribe colchicine. They also explained that it can be difficult to diagnose psoriatic arthritis in the absence of raised inflammatory markers.
Care in 2022
32. Miss A attended the Practice in February 2022. The GP did an assessment and noted Miss A’s symptoms, which had spread to her right index finger, had previously been slightly helped by colchicine. The GP noted that Miss A’s symptoms did not particularly look like gout, but that Miss A’s uric acid level was elevated and she had some risk factors which would increase the likelihood of gout. The GP prescribed more colchicine and requested further blood tests and an X-ray for any evidence of gout arthropathy (joint disease).
33. This is the first time some uncertainty around the diagnosis arose. The NICE guidance on gout says if gout remains uncertain then consider imaging the affected joints with an X-ray, which is what the GP did, alongside some further blood tests.
34. In March 2022, Miss A’s X-ray was reported as normal and all blood test results, including her uric acid level returned normal. Miss A attended the Practice the following month to discuss the test results and symptoms. The GP noted that the cause of Miss A’s symptoms was unclear and it was unlikely to be osteoarthritis or gout. The plan was to review Miss A’s symptoms if they had not got better in two to three months, or sooner if Miss A had new or worsening symptoms. Miss A did not return to the Practice for an appointment relating to her joint symptoms until August 2024.
35. Our adviser explained that the GP was right to doubt the previous diagnosis of gout at this point, following blood test results which showed Miss A’s uric acid levels had returned to normal. They explained that some GPs might have considered psoriatic arthritis at this point, but by no means all would. Again, because of the rarity of the condition, and the lack of obvious findings pointing to it in the tests that were done, it was not clear what was causing Miss A’s problems.
36. We cannot say what the GP would have actually done had Miss A returned with ongoing or worsening symptoms, but we know they planned to review them. That review might have led to an onward referral, but as it was, Miss A did not go back for over two years, so that opportunity was lost.
37. To conclude, we think the GPs acted in line with the applicable guidance up until this point. It was, clearly, incredibly unfortunate that the possibly of psoriatic arthritis was not more evident at this stage and the fact it was not a clear possibility means that we are not critical of what the GPs did.
Care in 2024
38. On 6 August 2024, Miss A returned to the Practice with swollen and sore joints which had spread from her hands to her knees and toes. The GP requested more blood tests which showed that Miss A’s uric acid levels had returned to normal, erythrocyte sedimentation rate (ESR) and serum c-reactive protein (CRP) (both blood tests which detect inflammation in the body) were slightly raised, and folic acid levels were low.
39. The following month, Miss A attended the Practice discuss her blood test results. The GP prescribed colchicine and requested another X-ray and further blood tests. The repeat blood tests showed that Miss A’s ESR had returned to normal, but that her CRP level was still slightly raised. Our adviser said that for the same reasons as before, it was reasonable for the GP to continue to suspect gout at this point and to arrange for further tests.
40. Miss A had a GP appointment a few days later. The GP referred Miss A to rheumatology with the suspicion that she had psoriatic arthritis.
41. Our adviser explained that Miss A was referred within a reasonable timeframe following the blood test results which showed inflammation (raised levels of ESR and CRP).
42. We can understand why Miss A has questioned the continued diagnosis of gout and the timeliness of her rheumatology referral given she first attended the Practice in 2021. We do not underestimate the impact of psoriatic arthritis upon Miss A’s mobility, health and general wellbeing, and the further impacts these have had upon her quality of life and employment.
HRT
43. Miss A complains that GPs should have prescribed her HRT to manage her menopausal symptoms from early 2024. She believes the GP should have proactively arranged to monitor her menopausal symptoms and arrange a follow-up appointment.
44. We think this complaint point arose from a misunderstanding of the clinical record. This says ‘agreed to monitor symptoms, review if any concerns... will arrange for apt for HRT review and consider starting estrogen gel’. Miss A believes the GP should have monitored her symptoms and arranged the follow-up appointment but that is not the case. Likely, there has been a misunderstanding here. We thought about whether we could reliably investigate how this might have come about but decided we could not.
45. In the complaint response, the Practice said the GP appointment in January 2024 it was noted Miss A did not want to start HRT as advised by a gynaecologist recently. The Practice said that Miss A did not request HRT from the Practice and that they would be happy to discuss the suitability of HRT with her.
46. One of the other factors we consider when deciding whether to investigate in more detail is whether we can reach a fair, robust conclusion on what happened.
47. Miss A had three appointments in which HRT was mentioned. Firstly, it is noted on 23 January 2024 that Miss A did not want to start HRT. On 16 August 2024, Miss A received more information on HRT through a leaflet. Finally, on 25 November 2024, during an appointment focused on Miss A’s severe joint symptoms, Miss A requested HRT. The GP agreed to review Miss A’s request for HRT in a follow-up appointment. This was the responsibility of Miss A to arrange – it is not for the GP to make appointments on behalf of their patients.
48. There is no evidence that Miss A requested HRT until November 2024. As that appointment was focused on another medical issue, the GP invited Miss A to return to discuss HRT. However, Miss A did not arrange another appointment to focus on HRT. Ultimately, we cannot be critical of the GP for not offering or prescribing HRT, when there was no follow-up appointment made to request it.
49. We recognise that there may have been a lack of clarity on the part of the GP around who would make the follow-up appointment. They may have presumed that Miss A simply knew it was for her to do, when she may not have realised. The only evidence about what was said is in the clinical record and Miss A’s account. We have already considered that evidence and been unable to ascertain what happened and so have decided that there is no reasonable prospect of us making a fair, robust conclusion, even if we did investigate further. It was also open to Miss A to make a follow-up appointment once she realised one had not been made for her.
50. We are pleased to hear from Miss A that since receiving her complaint, the Practice has had a meeting with Miss A and they have now prescribed her HRT, which we hope has positively impacted Miss A’s health and wellbeing.
B12
51. Miss A complains that GPs should have prescribed her a higher dose of B12 from August 2024 to 31 May 2025.
52. The Practice said that Miss A’s low B12 became apparent after receiving blood tests following her consultation on 30 August 2024, which showed a very minimal reduction. They said because Miss A’s intrinsic factor returned negative (positive results can show that a patient has pernicious anaemia which can reflect poor B12 absorption) and there was no evidence of anaemia (B12 deficiency causing body to produce abnormally large red blood cells that cannot function properly), they prescribed Miss A oral B12 therapy. The Practice said they prescribed 50mcg of CyanocoMinn (a brand name of cyanocobalamin – B12) to treat the reduction in B12 Miss A was experiencing in line with relevant guidelines, as Miss A was already taking over the counter B12.
53. NICE guidelines on B12 say that when the patient’s cause of B12 deficiency is unknown, clinicians should consider oral B12 instead of B12 injections and then review the patient’s response to the treatment. NICE guidelines also outline that clinicians should prescribe 50-150 micrograms of cyanocobalamin once daily, which may be increased depending on the patient’s specific health needs.
54. Our adviser confirmed that Miss A’s B12 level was borderline low. This means that the Practice prescribed Miss A the dosage of 50 micrograms of Cyanocobalamin once daily in line with NICE guidelines.
Complaint Handling
55. Miss A complains that the Practice failed to adequately deal with her complaint by initially including inaccurate information with their response and delaying their response, which she found frustrating.
56. On 12 February 2025, Miss A complained to the Practice. On 28 March, the Practice posted a response. On 3 April, Miss A responded to the Practice’s letter requesting a specific senior clinician to review her medical notes and respond. On 6 May, the Practice sent its final response from the requested senior clinician, alongside two additional individual responses from clinicians involved in Miss A’s care.
Inaccurate Information
57. Miss A complains that the Practice’s initial response included inaccurate information outlining that her first contact with the Practice was on 6 August 2024. We can appreciate that after dealing with different health issues for many years, Miss A wanted a thorough and accurate response to her complaint. We think that the Practice could have done more to avoid this inaccuracy; to show Miss A they took her complaint seriously. However, we do not consider this mistake to amount to a failing.
58. The NHS Complaints Standards outline that staff should demonstrate a clear understanding of what the main issues are for the complainant. Ultimately, Miss A did receive a thorough response from three different clinicians who all clearly understood what Miss A’s complaint was. They all reflected on Miss A’s care, outlined why they made the decisions they did and demonstrated where they would take learnings from Miss A’s case. In the round, the Practice handled this complaint in line with our Complaint Standards, despite the minor error.
Delay
59. Miss A complains that the Practice delayed its response. NHS Complaints Standards outline that complaints should be responded to promptly. We consider twelve weeks an appropriate period to carry out an investigation into Miss A’s care, given the complaint was about Miss A’s care and treatment from 2021 to 2025 and contained three different complaint components: psoriatic arthritis, B12 and HRT. We think that the Practice could have, perhaps, done more to update Miss A on when she was likely to receive a response, which we appreciate may have been frustrating for Miss A. However, we do not consider this to be such a serious shortcoming that it would amount to a failing.
60. Ultimately, the Practice did respond in a reasonable time frame with a thorough response.