SPSO Individual Decisions

Mr C complained about the care and treatment provided by the practice. Mr C had attended the practice over the course of approximately three months with symptoms including weight loss, diarrhoea and vomiting. He was ultimately diagnosed at A&E with an intussusception of his small bowel (a condition in which a part of the intestine folds into another section of the intestine). Mr C raised concerns about the time taken to diagnose his condition, including whether appropriate investigations (including a CT scan, which uses x-rays and a computer to create detailed images of the inside of the body) were arranged. He also raised concerns that a GP had identified he had signs of an intussusception but did not appropriately treat this as an emergency. The practice said Mr C's symptoms were fully and appropriately investigated. They observed that Mr C was referred for specialist investigation at an early stage which provided an alternative explanation for his symptoms. They also said intussusception is a very rare condition in adults. The practice said the medical records did not indicate the GP had diagnosed an intussusception. After receiving independent advice from a GP, we did not uphold Mr C's complaint. The adviser agreed that there were complicating factors in the diagnosis. The adviser considered that the investigations arranged were appropriate in the circumstances, and found no evidence that a GP had diagnosed an intussusception prior to Mr C's admission to A&E. While we found Mr C's care and treatment was reasonable in the circumstances, we recommended that the practice use this case to consider and share any learning on the presentation and causes of intussusception in adults.

Mr C suffered from cystic acne. He attended the practice on several occasions over a number of years and received treatment. His GP referred him for treatment from a skin specialist. The specialist prescribed him medication which cleared his acne. However, he was left with significant scarring on his face which he was reportedly told may have been prevented if he had been referred sooner. Mr C complained that, had he been prescribed the medication sooner, he would not have been so badly scarred by his acne. He considered that the practice should have referred him to the specialist earlier, or that they should have prescribed him the medication directly. We took independent advice from a consultant dermatologist (a specialist in diseases of the skin, hair and nails). The adviser said that GPs would never prescribe this medication directly and that the correct course of action is for the GP to refer the patient to a specialist for consideration of a prescription. We found that the practice had reviewed Mr C's acne on a number of occasions and had provided treatment according to his presenting condition. His treatment was appropriately altered as required and his acne was noted to have improved at various times. We concluded that he was appropriately referred to a specialist when his acne had recurred and showed signs of scarring, so we did not uphold the complaint. Related reading View Decision Report 201502794 as a PDF (11.26 KB) Updated: March 13, 2018

Mrs C, who is an advocacy worker, complained on behalf of her client (Mrs A). She said that Mrs A had complex medical conditions and that she began to suffer from seizures after the practice had prescribed indapamide (medication for high blood pressure). The practice said that Mrs A's blood pressure had risen due to her other medication and that they prescribed indapamide in order to control her blood pressure. They said they monitored her condition and also sought medical advice from a hospital specialist. We took independent advice from one of our GP advisers. Our adviser was satisfied that the practice had prescribed the medication appropriately, and that they had sought specialist advice and monitored the situation. We did not uphold the complaint. Related reading View Decision Report 201502577 as a PDF (10.93 KB) Updated: March 13, 2018

Mr C complained that the GPs at the practice had failed to provide adequate care to his wife (Mrs C) resulting in the late diagnosis of her pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs). Mr C said that this late diagnosis had led to subsequent serious health problems for Mrs C. He said she had repeatedly attended the practice with symptoms consistent with a pulmonary embolism, but that GPs had failed to refer her for the appropriate investigations. He added that on one occasion his wife had been asked to contact a hospital by herself, despite a dangerously elevated heart rate. We obtained independent advice from an adviser on general practice medicine. They found that Mrs C was appropriately investigated initially. The advice also said that Mrs C's symptoms were non-specific and appeared to resolve for extended periods following treatment, so it was reasonable of the practice to have adopted a policy of watchful waiting. The advice noted that Mrs C's incidents of elevated heart rate were in fact in keeping with the monitored limits as defined by her pacemaker clinic and that it was, therefore, appropriate for her not to be referred as an emergency on that occasion. We found that although Mr C had repeatedly referred to alternative medical opinion having been provided which supported his complaint, no attributed submissions were contained within his complaint. We found the actions of the practice were reasonable and appropriate, although we acknowledged the experience had been distressing for Mr C and his family. Related reading View Decision Report 201406833 as a PDF (11.4 KB) Updated: March 13, 2018

Ms C, an advice worker, complained on behalf of her client (Mrs A) that the care and treatment provided by her medical practice between June and August 2011 was unreasonable. Mrs A had a history of abdominal and gynaecological (relating to the female reproductive system) problems and some stress-related illness. She saw three different GPs in June, July and August 2011 for recurrent symptoms of bloating and stomach pain. Some investigations were undertaken but no conclusive results were obtained. Mrs A was seen again by one of the GPs in November 2011 and was referred on a routine basis for a colonoscopy (examination of the intestines by a camera). Further investigations were undertaken in February 2012 and Mrs A was diagnosed with ovarian (part of the female reproductive system) cancer later that month. She has since undergone treatment that was ongoing at the time she complained to us. Our investigation included taking independent medical advice from one of our GP advisers. They considered that in view of the symptoms reported by Mrs A, the 'watchful waiting' approach taken by the GPs between June and August 2011 was reasonable and in line with national guidance in place at the time. However, our adviser considered that, in view of the duration of Mrs A's symptoms by the time she was seen in November 2011, the referral made at that time should have been made on an urgent basis. This would have indicated a suspicion of cancer, which would have meant that she would have been seen within two weeks of the referral. The adviser did not, however, consider that the resultant six-week delay had an effect on the overall outcome or treatment for Mrs A. The complaint was not upheld but the findings were drawn to the attention of the GPs involved. Related reading View Decision Report 201401735 as a PDF (11.48 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment her late husband (Mr C) received from the practice in the final months of his life. Mr C died after a period of illness and Mrs C felt he did not get the level of care he required as his health deteriorated. In particular, she raised concerns that her requests for GPs to attend were ignored despite Mr C having been very ill and in a lot of pain. Mrs C was also unhappy that the practice recorded the cause of Mr C's death as dementia, as she considered that he had shown signs of many other illnesses. We took independent advice from one of our GP advisers. Our adviser considered that the practice provided a reasonable standard of care and treatment to Mr C. She said there was a good level of multi-disciplinary involvement, particularly in the last 24 days of his life when he had multiple visits from a range of clinicians. She also considered that the recorded cause of death was appropriate, advising that Mr C's deterioration was consistent with the decline exhibited by patients with dementia. She acknowledged that Mr C had other illnesses that could potentially have been listed in part 2 of the death certificate. However, she explained that this part should not be used to list all conditions present at death but rather only those felt to have directly contributed to the death. She noted that this was a matter of clinical judgement and considered that the practice acted reasonably, and in line with national guidance, in this instance. We accepted the advice we received and did not uphold these complaints. Related reading View Decision Report 201402980 as a PDF (11.39 KB) Updated: March 13, 2018

Miss A was unhappy with the advice she had received on the management of her hypothyroidism (where the thyroid gland produces too little thyroid hormone) with regards to conception and pregnancy. Mrs C, who complained on behalf of Miss A, added that Miss A had complained that she was never offered a face-to-face appointment with a GP at the medical practice and that she had been added to the thyroid follow up register without her knowledge. We took independent medical advice from our GP adviser. We found that the practice were reasonable in adding Miss A's name to the thyroid follow up register as this is a way to ensure that the patient has annual blood tests to manage the condition. In addition, the practice had responded by apologising and said that this was simply an administrative tool and they had not anticipated it causing any concern. Our adviser told us that there are no guidelines dictating any treatment prior to pregnancy with regards to hypothyroidism, only about actions that should be taken after the woman becomes pregnant. In addition, we found that, given the nature of the consultations, it was reasonable to offer phone appointments. We found that the practice had given a reasonable standard of care. Related reading View Decision Report 201403639 as a PDF (11.22 KB) Updated: March 13, 2018

Mr C had been diagnosed with alopecia (hair loss) when he was a child. His condition deteriorated and progressed over the years to the extent that he has now been diagnosed with alopecia universalis (a condition were a patient has no body hair). He complained that his GP failed to show him any sympathy or understanding and that the effectiveness of the prescriptions he was given was not reviewed. He said that he was not referred to a dermatologist until his condition had reached a stage where little could be done. We took independent advice from a dermatology adviser and found that Mr C had been treated reasonably and appropriately in accordance with the symptoms he presented with; there was no evidence to suggest that his GP had been either unsympathetic or showed a lack of understanding. His medication was monitored and Mr C had declined some treatment which would have led to an earlier hospital referral. In the circumstances, we did not uphold Mr C's complaint. Related reading View Decision Report 201403460 as a PDF (11.1 KB) Updated: March 13, 2018

Since 2010, Mrs C had been attending her medical practice complaining of stomach and breast pain. She said that she was incorrectly treated for thyroid problems and an ulcer and complained that the extent of her pain was never recognised and that she was not referred for tests. More recently Mrs C was diagnosed with a carcinoid tumour in her liver (a rare cancer). She felt that as a fit and healthy patient attending the doctor a lot, with symptoms that were not resolving, the practice should have sent her for tests and sought specialist help. We took independent advice from one of our medical advisers and, after considering this, we did not uphold the complaint. Our investigation showed that over the period of time concerned, Mrs C was treated correctly in accordance with her symptoms. Amongst other things, she had symptoms suggestive of an underactive thyroid and an ulcer, for which she was treated appropriately. She also had a breast scan that showed a breast lump, but this was benign. It was only in late 2013 after an emergency admission to hospital and extensive investigations, including an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) and a scan of her abdomen, that Mrs C was diagnosed with the tumour, which was noted to be extremely rare. Our adviser said that until then doctors had always provided reasonable diagnoses to explain Mrs C's symptoms. Related reading View Decision Report 201306175 as a PDF (11.33 KB) Updated: March 13, 2018

Mrs C's stepfather (Mr A) was diagnosed with advanced bowel cancer and received chemotherapy (a treatment where medicine is used to kill cancer cells). Mrs C said that he attended the medical practice regularly over the two years leading up to his diagnosis, during which time his health deteriorated. Mrs C believed that his symptoms were indicative of cancer and that he should have been investigated for this sooner. She also complained that the GP made a routine - instead of an emergency - referral for a colonoscopy and gastroscopy (a fibre-optic telescope looking into both the upper and lower parts of the bowel). After Mr A was diagnosed with bowel cancer, he attended the practice with a sore leg. His wife contacted the oncology department (who specialise in treating patients who have cancer) at the local hospital (the first hospital), who arranged a scan that showed that he had a blood clot in his leg and lung, and the following year his health began to deteriorate significantly. Mrs C said that there was a failure by healthcare professionals in the community to provide a discussed and implemented care plan about support throughout Mr A's illness and end of life care. Mr A wanted to receive end of life care at home but at no time was he consulted about his wishes or preferred place to die. He had a number of admissions to hospital due to blood clots and his deteriorating condition. In the last month of his life, it was noted in the GP records that chemotherapy treatment had stopped due to progression of the disease. During his last admission to the first hospital, Mrs C said a doctor told them surgical intervention was not possible and the aim was to get Mr A's pain under control and discharge him home. However, Mr A's wife received a phone call several days later saying that her husband would be transferred to a second hospital where he would be under the care of his GP practice. Mr A remained unresponsive for several days, and his GP said Mr A was dyi

Mr C complained that his medical practice had failed to appropriately assess and diagnose the cause of pain and swelling in his leg. Mr C saw three GPs at the practice and was diagnosed with a Baker's cyst (a fluid-filled swelling that develops at the back of the knee and is caused by a problem with the knee joint or the tissue behind it). However, he subsequently had a pulmonary embolism (a blockage, usually a blood clot, in the pulmonary artery, which is the blood vessel that carries blood from the heart to the lungs). Mr C considered that the pain in his leg had in fact been a blood clot that had travelled up his veins and caused the pulmonary embolism. We took independent advice on Mr C's complaint from one of our medical advisers. We found that the GPs who saw Mr C had carried out the correct investigations and had provided him with a reasonable standard of care in relation to the pain and swelling in his leg. Based on the investigations, it had been reasonable to assume that the swelling was a Baker's cyst. The GPs had also considered alternative diagnoses. We found that the pulmonary embolism could not have been foreseen and we did not uphold this aspect of Mr C's complaint. Mr C also complained that the results of a specialised blood test he had to try to detect pieces of blood clot in his bloodstream were inaccurate. The blood test had been negative. However, there was no clear evidence that Mr C had a blood clot at that time. We found that there was no evidence that the test results were inaccurate and we did not uphold this aspect of his complaint. Related reading View Decision Report 201305691 as a PDF (11.33 KB) Updated: March 13, 2018

Mr C's late wife (Mrs C) had cancer and was terminally ill. After one of their daughters phoned the medical practice, a GP prescribed a strong morphine-based liquid painkiller. The family also phoned community services, and a community nurse visited Mrs C at home the following week. A few days later, another phone consultation was held with another GP who ordered an electrocardiogram (a test that measures the electrical activity of the heart). Further visits were made by a community nurse and the family agreed that a 'just in case' box (containing medicines that may be needed to help relieve a patient's unpleasant or distressing symptoms while being looked after at home) should be provided. Early the following month, one of Mrs C's daughters was concerned about her condition and spoke to the duty GP at the medical practice, who advised the family to use painkillers and said that Mrs C would be reviewed the following week. When a GP then visited Mrs C at home, they noted that she was at the terminal stage of her illness, and Mrs C died later that day. Mr C complained about the way that GPs at the medical practice dealt with Mrs C's medical problems, saying that they did not visit and relied on the community nurses instead. He said that his wife was in severe pain and great distress. For four weeks she was not examined by a doctor and additional medication was not prescribed, as the community nurse was not able to prescribe medication. The family accepted that a 'just in case' box was in the house, but Mr C said that they did not know at what point to give Mrs C the medication and that a GP should have provided an explanation. We took independent advice from one of our medical advisers, after which we upheld the complaint. We found that the medication and explanation provided were reasonable but that, by not visiting Mrs C, the practice failed to provide her with a reasonable standard of care. This led to a great deal of distress for her family, and made a

Mr C said that he had suffered from repeated bouts of sinusitis (inflammation of the lining of the sinuses, causing facial pain) since he was a teenager. He said that he had tried a variety of different treatments, but the only one that had consistently worked for him was a short course of antibiotics. Mr C complained that when he contacted his medical practice suffering from sinusitis, he was not initially given an appointment but told to contact his pharmacist. He then called NHS 24 and was referred back to the practice, where he was given an appointment that day. Mr C was unhappy that when he went there he was seen by the practice nurse, rather than a doctor. The nurse did not accept that Mr C needed antibiotics, and refused to prescribe them. Mr C said that he was forced to return to his previous medical practice to get them. He said that the practice nurse refused to allow him to see a doctor and inaccurately recorded his symptoms to support her diagnosis. We took independent advice on this complaint from one of our medical advisers, a specialist in general practice medicine. He said that Mr C had symptoms that corresponded with acute sinusitis, but that current guidance was not to prescribe antibiotics for this condition, as research suggested they were ineffective. He also said that it was standard practice in busy surgeries for patients to be seen initially by a practice nurse. He found no evidence of the notes being altered, or of Mr C having asked to see a doctor. Having taken this advice into account, we did not uphold Mr C's complaint. Related reading View Decision Report 201301507 as a PDF (11.37 KB) Updated: March 13, 2018

Mr C complained about the care and treatment provided to his father (Mr A) by the medical practice after he raised concerns about Mr A's deteriorating health. Specifically, he was concerned that doctors failed to assess his father's deteriorating mental health. Mr A refused to go into respite care, was suffering from kidney failure and liver disease and was an alcoholic. Mr C felt that his father no longer had capacity to make decisions for himself. The practice agreed that Mr A's medical condition was very poor. However, they considered that, despite not being willing to go into respite care, stop drinking or allow some visits by doctors, Mr A did have capacity to make his own decisions about his health and welfare. We reviewed the complaints correspondence and medical records and sought independent advice from our medical adviser, who is a GP. We found that a formal mental health assessment was carried out a couple of weeks before these events and that Mr A had scored highly. In addition, our adviser noted that doctors reviewed Mr A's mental health whenever they visited him and that the records of this did not show any concerns. In addition to the reviews by doctors from the practice, Mr A attended the local renal unit for kidney dialysis, where he had to give informed consent for this procedure to be carried out three times a week. Doctors in the renal unit were also content that he had capacity to make such decisions. As we found no evidence to support the view that doctors had failed to properly assess Mr A's mental health, and as the care provided was reasonable in this regard, we did not uphold the complaint. Related reading View Decision Report 201302723 as a PDF (11.41 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment that her late father (Mr A) who was 93 years old, received from his medical practice. In January 2012, Mr A went to his GP with backache. He said that he was told he was wearing too many clothes and to return to see the nurse for blood and urine tests. Mrs C contacted the practice and arranged for a nurse to call at the house, but she only took blood tests. Mr A continued to deteriorate and his GP said he would refer him to hospital as he had swallowing difficulties. Mr A went to the hospital on a number of occasions and was seen in various departments. A scan in June 2012 confirmed lesions in Mr A's pancreas, and that this was likely to be pancreatic cancer. A multi-disciplinary team met in the hospital, and decided that Mr A would not be offered surgery in view of his age, other medical conditions (including diabetes) and because it was unlikely to be successful. Palliative care was to be offered instead. The hospital wrote to the practice with the results of the scan 17 days later. Mr A's condition continued to deteriorate and Mrs C requested a home visit from the GP, who was delayed in getting there. When he arrived and assessed Mr A, the GP requested an ambulance to admit Mr A to hospital. Mr A died six days later. Mrs C complained that the practice did not treat her father's backache, and did not treat or refer him to hospital for problems with his diabetes. In his last few weeks, Mr A stopped eating, lost a tremendous amount of weight and was bedridden. She said that the practice also failed to offer additional homecare. Mrs C said that the GP should have visited and admitted Mr A to hospital earlier. She believed that the practice displayed a lack of care and attention towards Mr A and failed in their duty of care to him. As part of our investigation we took independent advice from one of our medical advisers. The advice, which we have accepted, was that the practice provided a reasonable standar

Mr C's son (Mr A) attended his then medical practice in June 2011 complaining of left hand rib pain and pain in his elbows, right hip and shoulder, left wrist and lower back. He was examined by the GP, blood tests were taken and he was prescribed pain medication. Mr A's pain worsened and he had a further phone consultation with his GP. Advice was given, and Mr A was encouraged to join a different practice closer to home, as he no longer lived in his current GP's area. Mr A transferred to a new medical practice. Before his first consultation there, Mr A's pain worsened again and he attended a hospital accident and emergency department (A&E) where x-rays were taken, showing evidence of possible cancer. He was referred to the hospital chest clinic, but the chest physician reviewed the information and decided that he did not need to see Mr A. When Mr A attended his first consultation at the new medical practice, his health records had not yet arrived from the previous practice. Because of the time it took to add Mr A's information to the computer system, important results from A&E were not available at his next appointment. Before Mr A had his second consultation at the practice, the chest physician from the hospital contacted them and advised that Mr A had nothing to be concerned about. Mr A was treated with pain killers on the understanding that he had a cracked rib. Mr C complained that the new practice did not ensure they had all of Mr A's records and test results to hand when examining him, and that the GPs who examined him did not conduct thorough examinations, preferring to prescribe stronger pain medication to alleviate his symptoms. Having taken independent advice from one of our medical advisers, our investigation found that the initial lack of records during the first consultation was outwith the practice's control. The call from the chest physician then reassured them that there was nothing sinister in Mr A's chest x-ray. We considered that, once

Ms C complained to us that, at a medical appointment, a GP unreasonably requested her granddaughter (Miss A) to make a further appointment to discuss her low mood. This was the third issue that Miss A raised during the consultation, and Ms C felt that her granddaughter had little choice but to comply with the GP's request. Ms C felt that this had left her granddaughter in a vulnerable position. As part of our investigation, we took independent advice from one of our medical advisers. The adviser noted that low mood was a potential symptom of depression. However, the adviser also noted that a doctor would, ordinarily, assess the patient while the patient was making such a statement (for example, by observing eye contact). The adviser also noted that there was a delay of around a month before the subsequent appointment was made, at which point Miss A declined the offer of assistance from a mental health worker. Even taking account of the doctor/patient dynamic and acknowledging that it took courage for Ms C's granddaughter to raise the issue with her GP, the adviser noted that the GP had followed accepted practice. In addition, the delay in Miss A making the subsequent appointment (in addition to the offer of a mental health worker being refused) indicated that the GP's request was reasonable. Related reading View Decision Report 201204045 as a PDF (11.32 KB) Updated: March 13, 2018

Mr C complained about the care that his late mother (Mrs A) received from doctors and nurses at her medical practice. Mrs A's overall health had been deteriorating for some time. She was admitted to hospital with advanced lung disease and died shortly after admission. Mr C was concerned about the condition of his mother's legs and felt in particular that the doctors and nurses had failed to treat ulcers. Our investigation found that the care provided to Mrs A was good, and that there was clear evidence that an ulcer was identified and treated appropriately until it healed. We noted that Mrs A's legs had changed colour towards the end of her life due to poor circulation, but we received independent medical advice that this did not reflect unreasonable care. Although we did not uphold the complaint, we did make a recommendation in relation to the practice's complaints handling.

Mrs C complained about the treatment prescribed by her medical practice for fungal nail infection. In addition, Mrs C was unhappy with the practice's response to her complaint and with their view that she and her husband behaved inappropriately towards staff. Mrs C has lupus (an autoimmune disease that causes inflammation in various parts of the body). She did not take the prescribed medication after reading on the information leaflet that it was potentially harmful to lupus sufferers, and complained that it had been inappropriately prescribed. Although Mrs C's prescription was subsequently changed, she said that the new course of treatment also had an adverse effect on her health. As part of our investigation, we took independent advice from a medical adviser. He said that available treatments for fungal nail infection can have a number of side effects, interact with many other drugs and can cause reactions including impairment of liver function. The initial drug Mrs C was prescribed can cause a lupus type effect and the British National Formulary (BNF - national guidance for healthcare professionals regarding the prescribing of medicines) advises caution when prescribing it to patients who suffer from an autoimmune disease. Our adviser said that although the BNF does not advise against prescribing the drug, there was no record to suggest that the medical practice had considered Mrs C's medical history when prescribing it, nor did they note a follow-up plan or request blood tests. We also found that there was no evidence to show that the medical practice considered any follow-up plan when prescribing the replacement treatment. The BNF recommends that if the treatment is prescribed for more than a month, liver function should be monitored. We noted that the blood tests taken from Mrs C after she complained of being unwell were only carried out as a result of her symptoms, rather than being planned at the time of prescribing. We concluded that although it was

Mrs C had a complex medical history including pelvic, back and shoulder pain, arthritis, kidney problems, ovarian cysts, endometriosis, hypertension, depression and gastric problems. Over the course of 2009 to 2012 she attended her medical practice for pain management and treatment of these and other illnesses. GPs referred her to a number of specialists for treatment and exploratory tests, including consultants in neurology, neurosurgery, pain management and gynaecology. GPs also prescribed Mrs C with various drugs to treat her pain symptoms, including a number of different types of opioid analgesics (pain relief that acts on the central nervous system), but with limited success. In July 2011, Mrs C became very unwell with dizziness and weakness and was confined to bed. A GP diagnosed severe postural hypotension (a drop in blood pressure than can cause dizziness), which they considered was likely to be drug-induced with inactivity contributing to it. They advised Mrs C to reduce her intake of opioid medications. During a hospital admission, specialists noted that Mrs C had a decreased level of a particular hormone and carried out extensive tests. These established that she was suffering from drug induced suppression of another hormone. Mrs C complained to us that between 2010 and 2012 the practice did not provide her with appropriate care and treatment. As part of our investigation, we obtained independent advice from our medical adviser, who said that this is a recognised, but rare side-effect of long-term opioid analgesic use. However, he advised that the treatment that the practice prescribed for Mrs C was appropriate, and was taken with the appropriate secondary care advice, and that the referrals made were reasonable. We, therefore, did not uphold this complaint. Related reading View Decision Report 201200254 as a PDF (11.63 KB) Updated: March 13, 2018

Mrs C had a method of contraception, an intrauterine device (IUD), fitted by a doctor in March 2010. She subsequently developed symptoms including abdominal pain, bleeding and difficulty with bowel movements. Mrs C attended the practice three days later and was prescribed antibiotics for a possible infection following the fitting. In June 2010, Mrs C found out that she was pregnant. After her baby was born, she had surgery to have the IUD removed. It was found to have caused internal damage and to have moved. Mrs C complained that the doctor had not taken reasonable care when fitting the IUD and did not properly investigate her symptoms. Although we were unable to assess the procedure, we found that Mrs C’s medical notes were comprehensive and detailed, and that the doctor had undergone suitable update training and fitted an appropriate number of IUDs per year. We also noted that Mrs C had undergone IUD counselling before having the device fitted, where she had been told about the risks, including the risk of internal damage. Although this was a rare complication, the fact it had occurred did not mean the doctor had not carried out the procedure with reasonable care, so we did not uphold this complaint. We also found that the practice carried out reasonable investigations of Mrs C’s symptoms. They examined her at three appointments and located the threads of the device. Guidance states if these threads can be seen and felt then it can be assumed the IUD is in the correct place. When Mrs C attended a second appointment after the fitting, she said that the symptoms had resolved so we found it was reasonable that the practice did not undertake further investigations. We also found that the practice would not have been expected to arrange an ultrasound scan to confirm the positioning of the IUD, as this is not recommended by guidelines. Related reading View Decision Report 201103773 as a PDF (11.65 KB) Updated: March 13, 2018

Mr C told us he had a history of chest tightness, chest pain and severe heartburn. He said he twice raised concerns about these symptoms with his GP. Shortly afterwards, while working overseas, Mr C suffered a heart attack and had a coronary artery bypass graft (a surgical procedure to improve blood supply). When he came back to the UK, he asked his GP to refer him to a cardiologist (heart specialist) for review. His GP felt that this was unnecessary as Mr C had already received the best treatment for his condition and appeared to be recovering well. As Mr C needed a fitness to work certificate, he was ultimately referred to a cardiologist, but this was done privately. Mr C complained that the practice failed to appropriately assess the symptoms that he had reported before he had the heart attack. He also complained that it was unreasonable of them not to refer him to a cardiologist after he returned to the UK. We found no evidence in Mr C's clinical records that he had told the practice about his chest tightness and heartburn. Whilst recognising that he may have provided this information without it being recorded, we were unable to say conclusively that the records were deficient or that the practice failed to act on information that Mr C provided about these symptoms. We did not uphold this complaint. We did, however, uphold his complaint about referral. Mr C was ultimately referred to a cardiologist and we did not find it unreasonable that this was done privately, given his desire to return to work. However, we found that it would have been good practice for a referral to have been made when he returned to the UK, as a cardiologist was able to perform specific tests that would highlight the extent of residual damage to the heart. The cardiologist ultimately found that Mr C had a blood clot which necessitated a change in treatment plan. We felt that this highlighted the benefit of referral to cardiology but also considered that there was a strong argument for refe

Mrs A had been receiving treatment for high blood pressure for a number of years. She had three strokes within six months. Mrs A's husband, Mr C, complained that their GP practice failed to provide appropriate advice to him when he contacted them about the first and second strokes. Mr C also complained that the practice failed to respond within a reasonable timescale when Mrs A's stroke nurse reported high blood pressure results shortly before the third stroke. In looking at the records, we could not determine exactly what was said when Mr C spoke to the practice on the day Mrs A had her first stroke, as there was no direct objective evidence. However, the records did show that the practice's advice to bring Mrs A to the evening surgery on the day of her first stroke was reasonable. While we acknowledged this, there was no record of advice given to Mr C about what to do if Mrs A's symptoms worsened. In addition, one of our medical advisers was of the view that Mrs A should have been taken to hospital that evening by emergency ambulance. In relation to the day of Mrs A's second stroke, the practice advised Mr C to bring her in for a consultation the following morning. In our view, she should have been seen and assessed on the same day, given her history and unresolved symptoms. Taking all of this into account, and noting the views of our adviser, on balance we upheld this complaint. In relation to Mr C's second complaint, the records showed that the practice discussed Mrs A's high blood pressure results with the stroke nurse, and arranged for further review and a home visit. Our adviser's view was that the practice acted appropriately in the circumstances. Taking this into account, we concluded that the practice did respond within a reasonable timescale and, therefore, we did not uphold this complaint. Recommendation We recommended that the practice: • review their protocol for the management of hypertension, in terms of the threshold for referring patients to a hosp

Mr C complained that his GP failed to refer him to a specialist for carpal tunnel syndrome. He also complained that his GP failed to diagnose him with cubital tunnel syndrome. He said that his GP did not examine him and dismissed his concerns about pins and needles in his little finger because this was an unusual symptom of carpal tunnel syndrome. In response to Mr C's complaint, the practice said that the GP had carried out an examination and referred him to a specialist. The practice also said that there was no mention of tingling or numbness in his little fingers in either his medical records or the correspondence from the hospital orthopaedic consultant. We took advice from our medical adviser. The adviser said that although the entry in Mr C's medical records was inadequate in terms of the examination carried out by the GP, a referral had been made to the appropriate specialist. We also confirmed that there was no evidence in Mr C's medical records or letters from the specialist to reflect that Mr C had specifically complained about pins and needles in his little finger. The GP records referred to pins and needles across Mr C's fingers and a hospital letter in particular referred to numbness in Mr C's left middle finger. We concluded that it was made clear that Mr C was experiencing symptoms of cubital tunnel syndrome only after surgery for carpal tunnel syndrome had left symptoms of numbness in his little finger. We did not uphold the complaint. Related reading View Decision Report 201101686 as a PDF (17.15 KB) Updated: March 13, 2018