A GP practice in the Darlington area

5. Mr A complains about the Practice’s treatment when he had a numb foot and a ‘fuzzy head’. He says:

• on 24 July 2019 the Practice diagnosed him with ‘dropped foot’ but failed to refer him for an urgent MRI scan • when he returned to the Practice on 5 and 13 August and asked about the MRI scan, it told him scans can take a while to be booked, but nobody checked if the referral had been sent.

6. Mr A says a later MRI scan showed he had likely had a stroke before 24 July 2019. He feels that if the Practice had referred him for a scan on 24 July, he could have been given medication or treatment to prevent the stroke he experienced on 22 August 2019.

7. Mr A says because of the stroke he temporarily lost sight in one eye, and the whole experience caused extreme distress for both him and his family. He says because the Practice did not refer him, he had to pay for a private MRI scan on 27 August 2019.

8. Mr A would like the Practice to accept its mistakes, make changes to its procedures, and apologise. He would also like financial compensation for the private MRI scan and for the distress caused by the Practice’s errors.

9. The following is a brief background to put the complaint into context. We have not provided all detail as both parties are aware of the circumstances of the complaint.

10. On 24 July 2019 Mr A visited the Practice with a numb foot and what he describes as a ‘fuzzy head’. The GP diagnosed a ‘dropped foot’ (a muscular weakness or paralysis that makes it difficult to lift the front part of your foot and toes). His GP booked an urgent referral for an MRI scan.

11. On 8 and 13 August Mr A visited the Practice and asked about his MRI scan. He says it told him it can sometimes take a while to arrange. There is no evidence the Practice chased up the reason for the delay.

12. On 22 August Mr A had a severe headache affecting the vision in his right eye.

13. On 27 August after an optical appointment, he was seen by an ophthalmologist who felt it was a stroke and referred him to the stroke team. As he had not heard about his MRI scan referral, the family booked a private MRI scan, which Mr A had on the same day.

14. On 29 August Mr A’s GP told him the results of the MRI scan showed there were signs of a stroke in July 2019. Mr A went to a stroke facility at a local hospital on the same day.

24 July 2019 consultation

17. At this time, Mr A had been experiencing his symptoms for six to nine months.

18. The Practice says its diagnosis of a dropped foot was reasonable based on Mr A’s presentation, and it arranged for further investigations including an MRI and blood test. The Practice has accepted it did not send the MRI scan referral because of an administrative error.

19. NICE guidance says to arrange immediate emergency admission to an acute stroke facility for anyone with ongoing neurological symptoms suspected of having acute stroke or emergent transient ischaemic attack (TIA). A TIA is brief episode of neurological dysfunction resulting from an interruption in the blood supply to the brain or the eye, sometimes as a sign of a stroke.

20. At the time of the consultation Mr A was in his early seventies and had existing medical problems of type 2 diabetes (a common condition that causes the level of sugar (glucose) in the blood to become too high) and hypertension (high blood pressure).

21. NHS online advice on causes for strokes says that certain conditions increase the risk of having a stroke, including:

• high blood pressure (hypertension) • high cholesterol • irregular heartbeats (atrial fibrillation) • diabetes.

22. The medical records show Mr A was feeling dizzy, lightheaded and was having difficulty walking as his right leg was trailing behind him. He said that he nearly fell as a result. The GP’s examination also showed weakness of his right foot. Our GP adviser said this is a sign of a focal neurological deficit (a problem with nerve, spinal cord, or brain function. It affects a specific location, such as the left side of the face, right arm, or even a small area such as the tongue).

23. Our GP adviser said that because of what Mr A’s symptoms suggested and his pre-existing risk factors for a stroke, the Practice should immediately have sent him to hospital. This action would be in line with NICE guidance. Our GP adviser added that if the GP was unsure about a suspected stroke, they could have taken telephone advice from a local physician, neurologist, or stroke advice service (depending on local arrangements).

24. Mr A’s medical history and the symptoms he was experiencing at the time of his consultation met the criteria for signs of a suspected stroke. Therefore, taking into consideration NICE guidance and the advice of our GP adviser, we find the Practice should have arranged an emergency admission to a stroke facility or A&E to investigate. This did not happen and this was a failing.

25. We considered the impact of the Practice’s failure to refer Mr A to hospital on 24 July.

26. Mr A says that if the Practice had referred him for a scan on 24 July, he could have been given medication or treatment to prevent more problems. He thinks the second stroke he had on 22 August could have been avoided. He says after the second stroke he lost the sight in one eye for eight weeks (and was advised his sight may not return). He tells us the whole experience caused extreme distress for both him and his family.

27. Our physician adviser said that had the Practice referred Mr A to A&E or a TIA clinic on 24 July, he would have been assessed for suspected stroke/TIA. He would have had a full clinical comprehensive assessment including of the risk factors of diabetes and hypertension. He would have had urgent brain imaging.

28. The MRI brain scan that was done on 27 August privately showed evidence of a stroke. Had a scan been done at the time, Mr A would have had urgent treatment to reduce the risk of another stroke. This could have included antiplatelet medications (used to prevent blood clots) like aspirin or clopidogrel and modification of other treatments. In addition to treatment, he would have had further investigations including electrocardiogram (ECG) to look for atrial fibrillation ((AF), a common abnormal heart rhythm or arrhythmia) as a cause of stroke, and carotid imaging to look for any narrowing (carotid duplex is an ultrasound test that shows how well blood is flowing through the carotid arteries. The carotid arteries are in the neck. They supply blood directly to the brain).

29. Our physician adviser said the risk of another stroke is up to ten percent in the week after TIA or minor stroke. The ‘EXPRESS’ study says that early initiation of existing treatments after TIA or minor stroke was associated with an 80 percent reduction in the risk of more strokes. The ‘Rothwell’ 2016 study says that medical treatment greatly reduces the risk of more strokes after TIA and minor stroke.

30. Based on the evidence, we consider it is likely that had Mr A been referred to A&E or a stroke clinic on 24 July and been treated, this would have significantly reduced the risk of further TIA/stroke events. Our decision is it is more than likely that had Mr A been referred and treated, the second stroke on 22 August would not have happened. The second stroke likely caused Mr A to lose sight in his eye for several weeks.

31. Mr A was told his eyesight may never return. Mr A explained how his experience affected his everyday life. We can see how it would have caused him significant unnecessary distress. This would have been particularly difficult for him as there was a possibility that his sight loss may be permanent. Because we have found failings linked to an injustice, we are making recommendations to the Practice at the end of this report.

MRI referral

32. Mr A said the Practice marked his MRI scan referral as urgent. The Practice said it was not marked urgent. There are two different versions of events and no other independent evidence for us to consider. Therefore, we are unable to decide whether the referral was marked as urgent or not. We have already explained the Practice should have referred Mr A for further investigation straight away. As a referral for an MRI scan was not the right action to take, we do not need to look at whether the referral should have been marked as urgent or not.

33. We can see Mr A followed up the MRI scan referral with the Practice on 5 and 13 August. He said no one checked if the referral had been sent. The Practice accepts Mr A did follow this up two times and there is no evidence that the administrative staff checked or chased the referral. By the time this was realised, Mr A had already paid for an MRI scan privately.

34. Our principles say that 'public bodies should do what they say they are going to do. If they make a commitment to do something, they should keep to it, or explain why they cannot’.

35. We would expect that if a patient has followed up on a requested scan, the Practice would have checked or followed this up for the patient. We can see the Practice has accepted that processes were not followed. This would suggest that something did go wrong. It appears the staff did not act in line with our principles. This was a failing. We next considered the impact of this.

36. Mr A had to pay for a private MRI scan on 27 August 2019 as the Practice’s referral did not happen. We understand why Mr A wanted to know what was happening with his MRI scan referral as he believes he was told it was urgent. We consider that having to chase this up with the Practice twice and not getting any information on whether it had been done, would have been frustrating and worrying for him. Mr A was already clearly very worried about his health, and keen to know what was causing his symptoms. This resulted in Mr A feeling he had no alternative but to pay for a private MRI scan to get a diagnosis.

37. Mr A would not have needed a private MRI scan if the Practice had done what it said it was going to do. We consider Mr A’s actions in paying £250 for a private referral reasonable, as he was concerned about a delay affecting his health.

38. The Practice has apologised to Mr A for the distress caused by not sending the referral. It has also put in place service improvements to prevent this from happening in the future. It has reviewed the process for chasing up referrals to make sure all clinical and non-clinical staff know what to do if a patient reports they are waiting for a scan. The Practice said it reminded all staff what to do to stop this from happening again.

39. However, the actions taken by the Practice do not address the money Mr A spent on a private MRI scan, which he could have had without a cost if he had been referred to a stroke facility on 24 July in line with NICE guidance.

40. We consider there is a link between the Practice’s failure in not following up the referral and the distress Mr A felt which led to him paying for a private MRI scan. We make a recommendation to put this right at the end of the report.

1. Our decision is the GP practice in the Darlington area (the Practice) should have sent Mr A to a stroke facility when he attended on 24 July 2019. The Practice also failed to send a referral for an MRI scan which the GP had requested and to follow up on this. An MRI scan is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body.

2. The failings identified did affect Mr A and we find that the second stroke was avoidable. This likely caused Mr A to lose sight in his eye for several weeks. At the time of events, Mr A was told his eyesight may never return. Mr A says this has turned him from ‘an outgoing social person to a sheltered man living in fear that he is not being looked after competently’. We can see how the events would have caused him significant unnecessary distress.

3. Our recommendations are that the Practice should reflect on the failings identified in this report and send us an action plan within 12 weeks of the date of this l report. The action plan should explain what actions it will take to reduce the chance of these failings happening again. The Practice should pay Mr A £950 for the impact of its failure to refer him to A&E or a stroke facility after the consultation on 24 July. The Practice should also pay Mr A £250 for the cost of his private MRI scan.

4. We understand these events are very important to Mr A. We recognise the experience has been very distressing for both him and his family.