A medical practice in the Lincolnshire area

5. Mr A complains about the care and treatment he received from a medical practice in the Lincolnshire area (the Practice) from 2017. He says the Practice: • failed to appropriately treat his shoulder problem in 2017 • did not treat his spinal issues after a fall he had at work in October 2018 • failed to action a request for a referral to a neurologist in August 2019, then referred him to the wrong specialist and subsequently dismissed his concerns about this • told his daughter during a GP appointment in 2019, he was a hypochondriac • did not provide him with a COVID-19 shielding letter in 2020 • cancelled appointments for a rheumatoid arthritis review at short notice • reception staff misreported what his wife Mrs A said and added this to his notes • asked him repeatedly during the pandemic to go for blood tests

6. Mr A says his experience with the Practice has put him off going to see a doctor and he only goes when he has to. As a result of the delays with referrals and investigations, Mr A says the treatment to resolve the issue has taken longer which has affected his sleep and ability to carry out day-to-day tasks and work.

7. As an outcome, Mr A says he would like an apology and an explanation from the Practice.

8. Mr A’s Rheumatology Consultant (the Consultant) wrote to the Practice in July 2018 and said his recent MRI scan of the lumber spine showed a moderate severe spinal canal stenosis (narrowing) at L4/5 level. The Consultant suggested the GP refer Mr A for a neurosurgical opinion.

9. The Practice referred Mr A to the Spinal team, and he received appointments for Orthopaedics instead of neurosurgery.

10. Mr A had a GP appointment booked for a review of his rheumatoid arthritis on 13 November 2019. The Practice had to cancel at short notice due to staff sickness.

11. Mr A had a further review appointment booked for 13 December 2019. He attended the appointment but then left as it was not with the GP he had requested.

12. Mr A contacted the surgery about not receiving a COVID-19 shielding letter on 30 March 2020. The surgery sent the shielding letter to Mr A on 24 April 2020.

Shoulder issue 2017 and spinal issue in October 2018

15. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so. We have discussed this with Mrs A to understand the reasons why they could not bring his complaint sooner. We have also considered the time the organisation has taken to respond.

16. Mrs A says there were ongoing issues and ‘sometimes you just accept it’. She said she realised how poorly her husband had been treated and felt it was not right. She says the GP calling Mr A a ‘hypochondriac’ to his daughter was the final straw.

17. The Practice responded to Mr A’s complaints relatively quickly. We appreciate Mr and Mrs A complained to the Practice a number of times about different issues from November 2019 onwards.

18. The issues from 2017 and October 2018 were already out of time for us by the time Mr A brought the first complaint to the Practice in November 2019. We consider there was an opportunity for Mr A to have complained to the Practice about his care in 2017 and October 2018, and he could have brought these issues to us at an earlier point. While we do appreciate Mr and Mrs A say there were ongoing issues, we do not consider this is a compelling reason to set the time limit aside and look at these parts of the complaint. We will therefore not investigate these issues.

Neurosurgeon referral

19. Before we decide if we should investigate a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. We have done this and we have found the Practice has already done enough to put right the impact linked to this part of Mr A’s complaint.

20. Mr A says he had MRI scan which showed that he had a pinched spinal cord. This was causing his issues and he needed surgery. The rheumatoid doctor had written to the GP and told them to refer him to a neurological surgeon. He says they just filed the letter away and did not do anything with it. Mr A says when the Practice did make the referral, it was for orthopaedics instead of neurology. The Practice said they would change this but then they sent through another appointment for orthopaedics.

21. The records show Mr A’s rheumatology consultant wrote to the Practice on 24 July 2019 (this was date stamped 26 July). They said Mr A’s most recent MRI scan of the lumber spine showed a moderate severe spinal canal stenosis at L4/5 level. The Consultant suggested the GP refer Mr A for a neurosurgical opinion.

22. Mr A attended an appointment at the Practice on 31 July 2019 to discuss the rheumatology letter. The GP noted ‘he was seen by rheumatologist, and he advised for urgent spinal team referral.’ The GP sent a referral to the ‘spinal clinic’ on the same date.

23. On 2 August 2019, the receptionist noted they spoke with Mr A and he has ‘got an appointment with orthopaedics, need spinal team referral’. On 5 August 2019, the Practice sent a second referral to the spinal clinic via the Orthopaedic Review Referral Service (ORRS).

24. On 8 August 2019, Mr A called the Practice and said he was not happy with the referral process and being referred to an orthopaedic surgeon and not a neurosurgeon. The staff member noted they explained to Mr A that referrals have to go via ORRS, and informed him of the date and time to expect a telephone call from ORRS about his referral.

25. Our Principles of good administration say organisations should behave helpfully, dealing with people promptly, within reasonable timescales and within any published time limits. They should tell people if things take longer than the public body has stated, or than people can reasonably expect them to take.

26. As above, the rheumatology letter was date stamped 26 July 2019. We can see the Practice actioned the referral three working days later, after the appointment with Mr A. We consider this is a reasonable timescale in line with our Principles and there is no indication they just filed it away and did nothing with it.

27. When Mr A called to complain about receiving an orhopaedic appointment on 8 August, the note shows the staff member did listen to Mr A and took account of his concerns in line with our Principles. They explained Mr A would be contacted by ORRS about the referral. I cannot see there is any indication the Practice dismissed him, although we do appreciate Mr A felt he didn’t get the response he wanted.

28. The rheumatologist’s letter says Mr A should be referred to neurosurgery. We can see from the referral letters, the Practice sent the first referral on 31 July to the spinal team via ‘Choose and Book’. The second referral dated 5 August went to the ‘Spinal Team’ at the Orthopaedic Referral Review Service (ORRS). There are no further referrals after this. There is a note in Mr A’s records to say Hospital A had written to the Practice on 28 August to say Mr A had been seen in the neurosurgery clinic.

29. In its complaint response, the Practice say it is unable comment on what the issue with the referral was as this was dealt with the previous manager. It says it is sorry Mr A experienced problems with the referral process.

30. It is clear there were some issues with Mr A’s referral in July and August 2019. The Practice are not able to say what the specific issue was. We cannot say with any certainty whether the issue was solely due to the Practice or if the ‘Choose and book’ service was not processing the referral correctly. We appreciate it would have been very frustrating for Mr A to have to go back to the Practice when he was referred to the wrong service.

31. The Practice have apologised that Mr A experienced problems with the referral process. In line with our Principles of Remedy, the Practice have done enough to remedy the injustice by acknowledging something went wrong and apologising for it.

Review appointments

32. Mr A says the Practice asked him to go for a review for his rheumatoid arthritis and cancelled at the last minute.

33. The Practice say Mr A’s appointment on 18 November 2019 was cancelled at short notice due to staff sickness. It says as this was a routine review, its priority on the day was the acutely unwell patients, therefore the Practice took the decision to cancel the clinic. It says it is ‘extremely sorry for this’.

34. The Practice explain it was changing its appointment booking system during this period. It says all pre-booked appointments in October had been booked at the beginning of the month. It says any appointments that had been reserved for on the day booking had been booked on previous days by the GP themselves with patients that needed to be brought back for a review. It says this was a problem as this left nothing for GP’s on the day and it was one of the reasons it decided to change the appointment system.

35. The Practice say it is sorry Mr A was not successful in booking an appointment, but with the new changes to the appointment system and the use of ‘Ask my GP’ (an online booking system) this should no longer be an issue.

36. The records show Mr A had a telephone conversation with the Practice on 18 October 2019. The note says Mr A was unhappy he had been called in for review again when he had just seen the GP. From the records we can see Mr A was due to attend an appointment on 15 November 2019, but they cancelled the appointment because of staff sickness and called Mr A to tell him this.

37. Mr A had a further review appointment booked for 13 December 2019. He attended the appointment but then left as it was not with the GP he had requested. We can see a receptionist told Mr A on 6 December his appointment would ‘definitely be’ with the specific GP he requested.

38. We appreciate it would have been very frustrating for Mr A to have difficulties booking his annual review appointment, to have it cancelled at such short notice, and then to be told incorrect information about who the next appointment would be with.

39. The Practice have explained what the issues were with the cancelled appointment and apologised to Mr A, although it does appear they referenced 18 November instead of 15 November as the date of the cancelled appointment. The Practice further explain that a Group had since taken over the Practice, and they are investing in training and developing their staff to improve services.

40. Our Principles of Remedy on being customer focused says organisations should: ‘identify and acknowledge maladministration and poor service and apologise for them. An apology means acknowledging the failure, accepting responsibility for it, explaining clearly why the failure happened and expressing sincere regret for any resulting injustice or hardship’.

41. We consider the action the Practice has taken is in line with this and enough to remedy the frustration caused by this indicated failing.

Appointment with Mrs A’s daughter

42. Mr A says a GP at the surgery said he was a hypochondriac during an appointment with his daughter.

43. Mr A’s daughter (M) says at the end of her appointment, the GP asked her how things were going generally. She says they were their family GP and had taken an interest in all the family.

44. M says she mentioned that her dad was having an MRI that day and he was having a lot of pain. She says the GP responded that 'some things are an issue, but your dad adds hypochondria to it as well'. M says she was surprised and taken aback. She says it was not like them (to say something like this) and they were normally very supportive. She says she did not say anything to the GP at the time but told her parents about it afterwards.

44. The Practice say it discussed the inappropriateness of discussing Mr A during his daughter’s consultation in a staff meeting. It says this will be discussed directly with the GP involved and will also be discussed in the next clinical meeting as a learning point for all clinical staff. The Practice apologised to Mr A and his daughter for this.

45. While we cannot say with any certainty exactly what the GP said about Mr A to his daughter, we can see the Practice have acknowledged it was inappropriate for the GP to have discussed him at all during an appointment with a member of his family. This is not in line with paragraph 50 of GMC guidance on confidentiality which says, ‘you must treat information about patients as confidential’.

46. This part of the complaint involves the conduct of a specific doctor. We cannot get involved with disciplinary matters about an individual. The Practice have taken steps to discuss this with its staff and have apologised. While we appreciate this was a distressing experience for Mr A and his daughter, we do not consider we would recommend the Practice take any further action to remedy this.

Incorrect information in records

47. Mr A went to a review appointment for his rheumatoid arthritis on 13 December 2019 and the doctor he was meant to see had been changed. Mrs A says she went to speak to the receptionist and explained he was booked in to see a specific GP and asked if they could tell her why it had been changed.

48. Mrs A says the first receptionist she spoke to denied it had been changed, but another receptionist said the appointment was down for the GP requested, but somebody must have changed it. Mrs A says they made a comment like ‘don’t worry about that, we’ve waited 15 years for this appointment, what’s a few more weeks’. Mrs A says the receptionist added this to her husband’s notes but misreported what she had said. Mrs A raised concerns about this with the Practice and says she wants to make sure it has removed this information from Mr A’s records.

49. In its response letter, the Practice say it has removed the entry made on 13 December 2019, as Mrs A requested. The Practice say it is sorry they feel that the entry was incorrect and derogatory to Mr and Mrs A.

50. We have reviewed Mr A’s records for 13 December 2022 and the entry says that Mr A walked out of an appointment with one of the GP’s. There is nothing on this date to say what Mr or Mrs A said to reception staff after this. There is a notification on 19 February 2020 stating; ‘patient flag marked in error: wrong data entered… 13 Dec 2019’.

51. We appreciate it was distressing for Mr and Mrs A to feel incorrect information was recorded in Mr A’s medical notes. The Practice have taken steps to remove this information and have apologised. We consider this is enough to remedy the injustice of this claimed failing as the Practice has acted in line with our Principles of Remedy on putting this right which says ‘where maladministration or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise’.

Blood Tests

52. Mr A says the Practice contacted him repeatedly during the pandemic to go and have blood tests, which was not appropriate.

53. The Practice said the appointments for the blood test allows the ongoing monitoring of Mr A’s condition to ensure safe prescribing. This means the blood test was appropriate.

54. Mr A has type 1 diabetes. He also takes Methotrexate, which is an immunosuppressant medication, for his rheumatoid arthritis.

55. We have reviewed Mr A’s records from February 2020 onwards. Mr A had blood tests including HBA1c, lipids (fats), LFT (liver function test) on 21 February 2020.

56. According to Diabetes UK, the haemoglobin A1c (HbA1c) test measures the amount of blood sugar (glucose) attached to your haemoglobin. Haemoglobin is the part of your red blood cells that carries oxygen from your lungs to the rest of your body. It is an important blood test that gives a good indication of how well your diabetes is being controlled.

57. The Practice sent a medication monitoring letter to Mr A on 21 April 2020. There is a receptionist note to say Mrs A had been in contact saying she was not happy to bring Mr A down to the Practice. They have blood tests and monitoring done by Hospital B. The receptionist noted they asked another member of staff who said Mrs A would need to discuss with the Practice why she did not want to have monitoring there.

58. There are further blood test results in Mr A’s notes for 22 June 2020, 31 July 2020, 17 September 2020, and 21 December 2020. On 4 August 2020, there is a note to say Mr A has had full blood count (FBC), liver function tests (LFT) and U&Es in last three months ‘so ok to issue Methotrexate’.

59. The British National Formulary (BNF) says for Methotrexate; ‘in view of reports of blood dyscrasias (including fatalities) and liver cirrhosis with low-dose methotrexate. Patients should have full blood count and renal and liver function tests repeated every 1–2 weeks until therapy is stabilised, thereafter patients should be monitored every 2–3 months’.

60. The records show the Practice issued Mr A with his regular prescription for Methotrexate. Although we can see Mrs A did say Mr A was also being monitored at Hospital B, it is not clear if this was for both conditions.

61. As above, Mr A has type 1 diabetes and takes Methotrexate, which means he needs to be monitored regularly as per BNF guidance. We do not consider we can be critical of the Practice offering Mr A blood tests during this time to monitor his long-term health conditions. If Mr A wanted to refuse to attend the Practice for blood tests because he was being monitored elsewhere, this was his decision. We do not consider there are any indications of maladministration in relation to this aspect of the complaint.

Shielding Letter

62. Mr A says the Practice did not appropriately identify he needed a shielding letter in March 2020, at the start of the COVID-19 pandemic. This meant he didn’t get access to additional services he was entitled to.

63. On 22 March 2020, NHS England (NHSE) wrote to GPs advising them on how to manage people at highest risk during the pandemic. NHSE estimated that there were around 1.5 million individuals at risk. It told GPs that that NHSE or secondary clinicians would be sending a letter to extremely clinically vulnerable patients asking them to stay home at all times and avoid face-to-face contact for a minimum of twelve weeks.

64. Guidance on shielding and protecting people defined on medical grounds as extremely vulnerable from COVID-19, published 21 March 2020 says: People falling into this extremely vulnerable group include: • Solid organ transplant recipients.

• People with specific cancers • People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe COPD.

• People with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as SCID, homozygous sickle cell).

• People on immunosuppression therapies sufficient to significantly increase risk of infection.

• Women who are pregnant with significant heart disease, congenital or acquired.

The NHS in England is directly contacting people with these conditions to provide further advice. If you think you fall into one of the categories of extremely vulnerable people listed above and you have not received a letter by Sunday 29 March 2020 or been contacted by your GP, you should discuss your concerns with your GP or hospital clinician’.

65. From the records, we can see Mr A sent a message to the Practice on 30 March 2020. He asked if he fell into the category of being vulnerable, and therefore eligible for a shielding letter, given he takes an immune supressing drug and has type one diabetes.

66. The Practice say there was a delay over the shielding letters and lists of patients to be reviewed by the Government and that it did not receive this information to review for several weeks.

67. On 3 April 2020, NHSE updated GPs and advised that most of the patients had been identified and contacted, and it would be flagged on the GP system.

68. The practice say NHSE initially sent letters out centrally which was initiated by consultants and hospital data. It says it had no control over these letters or who received one. It says it was asked to review these patients to check the data was correct. It says it did not receive this list until 10 April 2020, and it had worked through hundreds of patients by the following week.

69. Mr A was not included on the initial list from NHS England because patients were advised if they felt they were eligible and did not receive a letter to go to the Government website to self-identify, which Mr A did. The Practice say it was then asked to review this list to check suitability and it did this within a week of receiving it. The notes show the Practice sent Mr A a shielding letter on 24 April 2020.

70. NHSE identified the groups that were vulnerable. It cascaded this information to GPs and secondary care services. In Mr A’s case, it appears NHSE did not initially identify Mr A as a clinically vulnerable patient. After Mr A self-identified, and this information was communicated to the Practice, it took action to check his suitability and sent Mr A the shielding letter a short time later. This was in line with the NHS guidance. We therefore cannot see any indication the Practice got something wrong here.

1. We have carefully considered Mr A’s complaint about a medical practice in the Lincolnshire area (the Practice). We are sorry to hear about Mr A’s concerns and appreciate this has been a difficult time for him.

2. We have decided the parts of Mr A’s complaint about the care the Practice provided for his shoulder problem in 2017, and spinal issues in October 2018, fall outside of our time limit. This means we are unable to investigate them.

3. We have seen no indication the Practice got something wrong in how it handled Mr A’s request for a COVID-19 shielding letter or in how it asked Mr A to attend the Practice for blood tests during the COVID-19 pandemic.

4. We can see there are indications the Practice got something wrong when actioning the Mr A’s referral in July 2019. This was when it cancelled his appointments at short notice, discussed him with his daughter during her GP appointment, misreported what his wife (Mrs A) said and added this to his notes. We have looked at what action the Practice has taken and consider it has done enough to put this right.