The Practice did not investigate a low blood pressure recorded in late February 2025
14. 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 found any indications that something has gone wrong.
15. Miss D said the Practice did not properly investigate her low blood pressure reading, of 90/47, in late February.
16. Blood pressure measurements measure systolic and diastolic blood pressure. The first, or top number, is the systolic blood pressure. This is the highest level your blood pressure reaches when your heart beats, forcing blood around your body. The second, or bottom number, is the diastolic blood pressure. This is the lowest level your blood pressure reaches as your heart relaxes between beats. Ideal blood pressure is between 90/60 and 120/80.
17. Miss D believes if the Practice had investigated her low blood pressure reading in February, it could have indicated she had an ectopic pregnancy and prevented her ectopic rupture.
18. An ectopic pregnancy is when a fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes. An ectopic rupture happens when an ectopic pregnancy bursts. This can cause damage and internal bleeding.
19. The Practice said that Miss D’s blood pressure reading in February and her subsequent normal blood pressure reading in mid-March, could not have identified Miss D’s ectopic pregnancy.
20. Miss D measured her blood pressure in the waiting room at the Practice in February. This is common practise at the Practice. It asks patients to measure their own blood pressure in the machine available in the waiting room. Patients then hand in their readings to the clinician or reception to record them, on the patient’s records.
21. Miss D’s blood pressure measurement in February was 90/47. The Practice receptionist recorded this in Miss D’s medical records, after her appointment.
22. Miss D measured her blood pressure at the Practice’s waiting room machine again, in mid-March. Her blood pressure reading was 101/80. This reading was within the normal range.
23. Our clinical adviser reviewed Miss D’s medical records. They told us there are no guidelines to identify a low diastolic blood pressure in a female in her thirties. They said there is large variability in blood pressure between individuals. Our adviser told us, in the context of Miss D’s historic blood pressure readings, her reading of 90/47 in February was much lower than previous ones.
24. They also told us the Practice should have repeated Miss D’s blood pressure reading of 90/47, in February. Our adviser also explained to us that blood pressure machines can sometimes provide wrong readings.
25. Our clinical adviser told us low blood pressure is not a symptom of ectopic pregnancy. The main symptoms of an ectopic pregnancy are missed periods, vaginal bleeding, and stomach pain.
26. Our clinical adviser explained that with an ectopic rupture, a person’s blood pressure drops, due to the loss of blood. This could explain why Miss D’s blood pressure, when paramedics took her to Hospital while suffering from an ectopic rupture, was low and a similar number to her reading of late February.
27. NHS guidance states symptoms of an ectopic pregnancy are: • a missed period • a positive pregnancy test • vaginal bleeding • stomach pain • shoulder tip pain. Shoulder tip pain is an unusual pain felt where your shoulder ends and your arm begins • discomfort when going to the toilet.
28. These symptoms do not include low blood pressure.
29. Based on what we have seen, we would have expected the Practice to repeat Miss D’s blood pressure reading made in late February, with a diastolic value of 47, as this was lower than her previous readings. The Practice did not offer Miss D a second reading to check her blood pressure.
30. Our service guidance allows us to consider how serious an event is and whether what happened fell so far below the standard we would expect to consider it a failing. Although the Practice acknowledged it should have recognised Miss D’s low blood pressure reading at the time of her appointment, and taken a second reading, we do not consider this fell so far short of what we would expect for us to consider it a failing.
31. Our Principles say public bodies should behave professionally and with regard to individual circumstances. We recognise offering Miss D a second blood test would have been helpful and may have reduced her concerns.
32. In its final response the Practice said if they had appreciated Miss D’s blood pressure reading with a diastolic value of 47 at her appointment, it would have taken it seriously and rechecked the reading. The Practice also said it has reflected on the consultation and how Miss D felt after it.
33. We are satisfied with the steps the Practice has taken on this matter. We hope we have clearly explained our decision.
The Practice delayed referring her for an aortic aneurysm screening referral
34. Due to her family history, Miss D raised concerns with the Practice regarding the possibility of an aortic aneurysm in late February 2025.
35. An aneurysm is a bulge in the wall of an artery. Aneurysms can burst, leading to bleeding or can cause blood cloths that block the flow of blood in the artery. An aortic aneurysm is an aneurysm that develops in the aorta artery. The aorta is the artery that carries blood from the heart to the abdomen.
36. The Practice requested electronic advice from a cardiologist in early March about screening Miss D for an aortic aneurysm. A week later, the cardiologist advised the Practice Miss D would need an ultrasound scan.
37. An ultrasound scan is used to see images inside the body. The Practice referred Miss D for an ultrasound scan at the radiology department at the Hospital in mid-March. The Hospital later cancelled the referral but did not tell the Practice.
38. Miss D contacted the Hospital about her referral. The Hospital said there was no referral for her. She then contacted the Practice about her referral. The Practice chased her referral in mid-June and found the Hospital had cancelled the referral but not told it.
39. The Practice spoke to a consultant vascular surgeon at the Hospital who agreed to request a scan for Miss D. The Practice told Miss D about the new scan request approximately one week later.
40. Our clinical adviser told us that due to Miss D’s medical history, age and on clinical grounds, this would have been a routine referral. They told us the Practice’s decision to ask for advice from a cardiologist before making the referral was correct. Requesting advice ensured the referral was appropriate for Miss D.
41. Our clinical adviser said when the Practice become aware the Hospital had cancelled the referral, it took appropriate action to resolve the issue.
42. Our clinical adviser also told us there is no general guidance on when or how quickly referrals must be progressed, as referrals for different purposes have their own guidance.
43. The GMC’s Good medical practice, domain 1, paragraph 7 says that in providing medical care you should properly assess a patient's condition and take account of their history. It says, where necessary, you should carry out a physical examination and arrange suitable advice, investigation or treatment. It says you should consult colleagues and refer the patient to another qualified practitioner where it suits their needs.
44. The Practice assessed Miss D’s medical history and condition before referring her. It promptly requested cardiology advice to ensure the referral was correct and appropriate. It also consulted colleagues as appropriate to ensure Miss D referral went ahead after the Hospital cancelled the referral.
45. In our view, the Practice took all the required and appropriate steps to refer Miss D for an aortic aneurysm screening and there is no indication of service failings. We are satisfied the Practice acted in line with GMC Good medical practice guidance. We will not consider this further.
The Practice miscommunicated her blood test results on the 22 and 25 April 2025 and 16 May 2025.
46. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events 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 these events.
47. Miss D said the Practice sent her conflicting messages about her blood test results within one week, in April 2025. She told us this meant she had to delay purchasing travel insurance for an upcoming trip, until the Practice clarified her tests results.
48. The Practice said that as soon as it was aware it had sent Miss D contradictory messages about her blood pressure result, a GP clarified the matter. It explained to Miss D her haemoglobin results were good given the stage she was at in her recovery from her ectopic rupture, even though they were lower than the expected normal value.
49. Haemoglobin is a protein found in the red blood cells that carries oxygen around the body and gives blood its red colour.
50. The Practice confirmed Miss D’s haemoglobin levels were improving. Once it had provided clarification, Miss D could go ahead with her travel insurance and travel plans.
51. In mid-April, the Practice told Miss D her haemoglobin levels were both normal and low, contradicting itself.
52. In late April, Miss D emailed the Practice about this, requesting an explanation about her blood test results.
53. Miss D’s medical records show, on the same day, the Practice texted her blood test results.
54. The Practice said Miss D’s blood test results showed she was recovering well from the blood loss caused by her ectopic rupture, and there was no reason for concern. It said it wanted to run the blood test again, to continue monitoring Miss D’s recovery. It offered to repeat the blood tests the next day.
55. The Practice telephoned Miss D two days later. It said her that her blood test results from the previous day were normal. Miss D could now arrange her travel and travel insurance.
56. Miss D said in mid-May, the Practice incorrectly told her she had Hepatitis B. Hepatitis B is a liver infection spread through blood and body fluids. It told her she might have caught this while in hospital. It said she could pass it to her children through breastfeeding.
57. Miss D said she tried to stop breastfeeding her children but was unable to. She said as a result she worried more than necessary about her health, and the health of her children. She also said she felt embarrassed and avoided social gatherings for a while.
58. Miss D’s medical records, note the Practice telephoned Miss D to tell her she had tested positive for Hepatitis B antibodies, meaning she might have been, or be, infected with Hepatitis B.
59. Antibodies are protective proteins produced by the immune system.
60. Miss D’s records also note the Practice texted and telephoned Miss D. It apologised to Miss D for sharing someone else’s test results with her. It said it had not tested Miss D for Hepatitis, and her antibodies had not been positive.
61. Miss D’s medical records further note she was in shock and very stressed about what the Practice had told her. The entry also recorded the GP apologised to Miss D for the mistake in person and she accepted the apology. The entry on this day also records a discussion around Miss D’s stress and anxiety with regards to her health and healthcare experiences in previous months.
62. In the Practice’s final response, it apologised for the miscommunication of test results and confirmed it had reported the matter to the Learn from Patient Safety Events (LFPSE) service.
63. The LFPSE service is a national NHS system for the recording and analysis of patient safety events that occur in healthcare with the goal to improve learning from patient safety events.
64. The Practice should have ensured it was communicating the blood test results to the correct person, before sharing them with Miss D. Its failure to do so is a service failing.
65. PHSO’s severity of injustice scale says a case will generally be level one if we consider the person affected has experienced a low impact injustice such as annoyance, frustration, worry or inconvenience. This would typically arise from a single (one-off) incidence of maladministration or service failure, where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact. We will usually consider an apology to be an appropriate remedy for these cases.
66. Miss D experienced several healthcare events around the time the Practice miscommunicated her blood test results. She has told us this time was very distressing for her and her family. When the Practice miscommunicated test results to her, she was worried. It is understandable this brought to mind her concerns about other healthcare events, that while not connected, were still similar in nature.
67. When looking at the impact of a failing we must consider if the impact flows directly from the service failing identified. We acknowledge Miss D was under considerable stress and anxiety during this time. We believe some of the stress and anxiety Miss D experienced was also linked to her other health issues. We cannot link Miss D’s stress and anxiety solely to the failings we identified.
68. The impact of the service failing was of shorter duration, under two weeks, and was of a one-off nature. Based on the PHSO’s severity of injustice scale we consider the impact to be at level one.
69. Our guidance says an apology is the appropriate remedy for a level 1 impact. The Practice has already apologised for the failing.
70. For this reason, we consider it has taken the appropriate steps to remedy the injustice. We will not look into this further.
71. We understand how difficult it is to make a complaint. We would like to thank Miss D for bringing her concerns to us.