A practice in the North Hertfordshire area

3.Mrs R complains about the care and treatment she received from the Surgery in March 2023. She specifically complains:

• the doctor did not appropriately assess her and dismissed the symptoms of a stroke on 20 March 2023 • the Surgery did not check her blood pressure during the appointment on 20 March 2023 • the Surgery only agreed to prescribe blister packs temporarily without any charges • the wrong prescription was given initially which meant some medications were missing and others were prescribed at the incorrect dosage • the justification for a diagnosis of carpal tunnel syndrome was given as loss of power in the hands for months but this had only been an issue for a week at the time of diagnosis.

4.Mrs R says she now has limited movement in right arm and hand, is unable to care for herself and needs carers for self-care needs, including getting washed, dressed and preparing meals. She feels this could have been prevented or the symptoms may not have been as severe if the doctor assessed her symptoms and diagnosed her stroke earlier.

5.She also says she cannot afford to pay for blister packs to help administer her medications because she is on a state pension. Mrs R says she requires these because she is very frail, feels vulnerable living alone and cannot administer medication one handed. Mrs R says she suffers from anxiety and is extremely reluctant to see the doctor as she has lost all confidence in their ability to care for her.

6.Mrs R would like the Surgery to acknowledge its failings, apologise, put service improvements in place and pay her financial remedy.

7.What follows is a brief background to the complaint. We have not included all details as both parties are aware of the details.

8.Mrs R contacted the Surgery on 20 March 2023 because she was experiencing loss of movement and use of right hand and fingers. She was given an urgent face-to-face appointment for the afternoon and in attendance was then diagnosed with carpal tunnel syndrome. Mrs R’s symptoms worsened over a twenty-four-hour period so she contacted the Surgery again because her right arm had gone limp, and she could not move it.

9.A GP at the Surgery had a telephone consultation with Mrs R on 23 March 2023. The GP ordered an ambulance for Mrs R due to symptoms reported. Mrs R was taken to hospital and diagnosed with having had a stroke and subsequently spent two weeks at hospital where she received treatment.

10.Mrs R was discharged from the hospital to a rehabilitation centre to receive further treatment on 7 April 2023. Mrs R was discharged home on 17 May. Mrs A subsequently raised a complaint on behalf of her mother on 20 May. The Trust provided responses to this complaint on 28 June and 28 July. The complaint was raised with our office on 10 July 2023.

Lack of assessment of the symptoms of a stroke during the appointment on 20 March 2023

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. The above guidance from NICE & GMC informs us what should happen during a consultation.

15.Mrs R complains that the GP at the Surgery failed to appropriately assess her and dismissed the symptoms of a stroke. The Surgery in the complaint response replied that based off the symptoms reported during the appointment on 20 March 2023, the investigation into possible Carpal Tunnel Syndrome (CTS) by the GP was clinically appropriate and did not consider there was maladministration in the clinical approach.

16.From the clinical advice we sought we can see the GP performed the appointment on 20 March 2023 in line with GMC good medical practice. The GP assessed the patient and took a detailed history which indicated the issue was in the area where CTS occurs. The symptom of on and off numbness in the right second and third fingers along with wasting of thenar eminence (a group of three muscles at the base of the thumb) would indicate CTS as stipulated in NICE guidelines on CTS. The GP subsequently performed Phalen’s test (a hand test performed by bending the wrist down) and Tinel’s test (light tapping over a nerve to elicit a tingling sensation) which were positive. This is advised to examine a patient for CTS in NICE guidance.

17.Mrs R states that the GP failed to assess the symptoms for a stroke during the appointment on 20 March 2023. However, the medical records do not support that there was an indication that the patient was having a stroke at that time. From advice sought we understand that the medical records for the consultation on 20 March 2023 state the numbness had been on and off for a few months. This is in line with CTS. NHS guidance on strokes state that the onset of a stroke is usually sudden. Therefore, our clinical adviser said that there was not a clinical suggestion of a stroke during the appointment on 20 March 2023.

18.The GP subsequently referred Mrs R to the Musculoskeletal (MSK) department with the examination findings included in the referral. We understand this was clinically appropriate as was the safety netting advice detailed in the medical records to review the situation once the referral had been completed.

19.We recognise Mrs R was worried the consultation did not fully explore her health and reassure that the GP assessed Mrs R during the appointment on 20 March 2023 correctly. The records do not suggest the GP dismissed a potential stroke. The symptoms presented by Mrs R were in line with CTS, not a stroke. The GP conducted the appointment in line with GMC good medical practice guidance as a detailed history and assessment was undertaken with appropriate tests carried out. The GP subsequently referred the patient on appropriately and provided safety netting advice as detailed in the medical records.

20.From consideration of the clinical advice we received, at the time of the appointment on 20 March 2023, the symptoms reported indicated a diagnosis of CTS. This is because the medical records state at the next appointment on 23 March 2023 that the patient listed worsening symptoms since 20 March 2023 and a different presentation with a sudden loss of power of the whole hand.

21.Given the symptoms reported on 20 March 2023 were in line with CTS, there are no indications of a service failure in how the GP assessed Mrs R in this appointment. By the next appointment on 23 March 2023, the reported symptoms had changed which led to the GP in this appointment arranging an ambulance to rule out a stroke.

Failure to check blood pressure during the appointment on 20 March 2023

22.Mrs R complained that the GP failed to take her blood pressure during the appointment on 20 March 2023. Our clinical adviser answered that the taking of Mrs R’s blood pressure was not required given the symptoms reported in this appointment were in line with CTS and not those that may be suspected to be a stroke as per the outlined NHS information provided.

23.We can see that in considering the complaint, the GP from the Practice explained that prior to the appointment, Mrs R who was being treated for hypertension had provided a blood pressure reading a month prior and noted this was within range and hypertension was being managed and, ‘well controlled’.

24.The GP performed an examination based on the history taken as per their approach under GMC guidance. As the symptoms suggested CTS as a likely diagnosis, the blood pressure would not need to be taken. The GP therefore did not do this. From seeking clinical advice to assist in our decision making, we consider that as the symptoms reported did not suggest a stroke, the blood pressure would not be required to be taken.

25.As previously detailed, the appointment on 20 March 2023 was carried out in line with GMC good medical practice. The symptoms presented during this appointment indicated a diagnosis of CTS according to our clinical adviser. The GP carried out appropriate tests and made appropriate referrals to MSK to follow up on this.

26.A blood pressure reading would not be required to ascertain CTS. For this reason, the GP did not take Mrs R’s blood pressure. There are therefore no indications of a service failure from the GP failing to take Mrs R’s blood pressure during this appointment and would only be undertaken if clinically necessary. The medical records indicate that it was not clinically necessary during the appointment on 20 March 2023.

Blisters Packs

27.Mrs R complained that the Surgery only agreed to prescribe blister pack medicine temporarily without any charges. She adds that the blister packs give her independence as her carers cannot give her medication. Further, she would struggle to pay for these but needs them due to being disabled and vulnerable.

28.A blister pack (also known as a dosette box) is a type of monitored dosage systems (MDS) that can help a patient to take the correct medication at the correct time as tablets are placed in individual boxes in a tray. Each one indicates when they should be taken. They are not always free on the NHS and not suitable for all types of medication according to NHS medication tips for carers.

29.We understand The Surgery in the complaint response state that the criteria to determine who is eligible for blister packs is set by the NHS Integrated Care Board and NICE guidelines, not the Surgery. It was agreed that Mrs R would be offered blister packs free of charge for six months before reviewing the situation. This is because Mrs R was having physiotherapy to improve her grip and therefore may not need to use blister packs in the future.

30.Mrs A confirmed via email that her mother is getting them free of charge, but this will be reviewed in the future. Whilst we understand that Mrs R is worried about the blister packs potentially being stopped in the future, similarly, though we recognise the worry caused, we can only investigate issues that have happened and not things that may or may not be an issue in the future. The Ombudsman can ask an organisation to look again at a decision it has made. However, the Surgery have not made a decision and therefore we cannot look at it.

31.Mrs A stated in an email to our office that her mother’s use of her arm/hand is not improving which is why she needs the blister packs. The Surgery would consider this when the use of the blister packs is reviewed. There are no indications of maladministration at this time given the complaint point raised is hypothetical and future dated.

32.The Ombudsman’s normal approach is to identify (using relevant standards) what should have happened, what did happen and then whether any gap between the two amounted to maladministration or service failure.

33.With regards to the blister packs for Mrs R, she has been receiving these free of charge and continues to do so. Mrs R is worried this may be stopped in the future when the decision is reviewed. Though we do recognise her worry at the time we have not identified a failing that we can link this to, therefore there are no indications of maladministration regarding blister packs being issued to Mrs R.

Incorrect Prescription

34.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 Surgery has already done enough to put right the impact of these events.

35.Mrs R complained that an incorrect prescription was issued on 17 May 2023 which meant some medications were missing and others were incorrectly prescribed. This was subsequently picked up by a pharmacist at the Pharmacy that the prescription had been sent to who notified Mrs A. Mrs R complained that this could have a disastrous effect on her health had it not been picked up.

36.The Surgery in the complaint response acknowledge that mistakes were made regarding medications on this prescription which they state led to a delay of three working days in Mrs R receiving her medication. Thus, this was a Practice issue and not a dispensary one.

37.Mrs A clarified in an email to our office that Mrs R was discharged from hospital with a short supply of medication but did not have blister packs and some of the medication was in liquid form which Mrs R could not take on her own. Therefore, Mrs A had to travel to her mum’s address each day to pour out the correct medication for the day. She was therefore worried that she may take too much of her medication in error due to her being confused.

38.Whilst we understand that Mrs A was worried that her mum may take an incorrect dose of medication, it has not been reported that this happened. An incorrect prescription was issued by the Surgery, but this was picked up by a pharmacist. Mrs R was discharged from hospital with a short supply of medication and therefore was not left without any medication during this time.

39.From engaging to understand the impact, we understand the worry this caused. We use our severity of injustice scale to assist in quantifying which of six levels upon the scale this may sit at ranging from mild or moderate frustration at level one to extreme maladministration such as profound disability or loss of life at level six.

40.It is our consideration this would likely fit into level one on our severity of injustice scale as this is listed as ‘inconvenience or hardship lasting no more than a few days’ or ‘distress, worry, annoyance and similar emotional impacts, injustice of the sort which a healthy adult would be expect to deal with on a regular basis, and which does not impact on the affected person’s day to day functioning, or their ability to live a normal life; for a period of up to two weeks. One-off clinical or administrative failures causing minor worry or annoyance.’

41.The Surgery advised that a member of staff had made a mistake in how Mrs R’s discharge summary was scanned onto the system. An apology was given from the member of staff for this as it should have been saved on to Mrs R’s medical records and then forwarded to a GP or clinical pharmacist to action the medication changes. An updated workflow was created to provide clearer guidance to the scanning team when receiving discharge summaries.

42.Therefore, an apology and service changes have been given by the Surgery. Our severity of injustice scale details that we would generally consider an apology to be an appropriate remedy for a level one injustice. There is therefore no evidence of an unremedied injustice, and we would not consider financial redress for financial loss needed at this level of injustice. Similarly, in conducting precedent checks (regarding previous complaints to our office about an organisation) we are not minded of wider organisation wide issues. Thus, we consider an apology for the short duration of failing suitable remedy on its own.

43.We understand it caused worry and distress for Mrs R and Mrs A, but this was for a period of less than two weeks which would mean it fits into level one on our severity of injustice scale. The remedy we would likely recommend for this would be an apology which has already been achieved.

Justification given for a diagnosis of carpal tunnel syndrome

44.Mrs R stated that the justification given for the diagnosis of CTS was incorrect in the complaint response from the Surgery. The Surgery detailed that ‘numbness, pain and wasting or weakness of the muscles, which she had experienced for a few months.’ Mrs R states that the symptom of loss of power in the hand had only been an issue for a week at the time of the appointment with the GP on 20 March 2023.

45.The medical records for the appointment on 20 March 2023 detail ‘on and off numbness in rt 2nd and 3rd fingers for few months loses grip at time difficult with ADLs’ (activities of daily living). As detailed previously, from advice sought, we understand that the symptoms reported on 20 March 2023 would indicate a diagnosis of CTS and that the medical records do state the numbness in the right second and third fingers had been going on for a few months.

46.Further, in consideration of clinical advice, that even if the symptom of numbness in the right second and third fingers had only been reported for a week or two, then CTS would still be a fair diagnosis to make and the most likely one. The wasting of the thenar eminence and the Phalen’s test and Tinel’s test being positive indicate CTS. The onset of a TIA (Transient ischaemic attack) is under 24 hours whilst a stroke is over 24 hours according to NHS Guidance on TIA’s. Our clinical adviser added that it would not be consistent with a stroke for symptoms to have an onset over a few weeks or months.

47.Our clinical adviser also highlighted the contrast with the symptoms reported during the appointment on 20 March and 23 March 2023. The reported symptoms on 23 March 2023 were now a different presentation and had changed to ‘sudden loss of power of the whole hand’ in the right hand and forearm which is a symptom of a stroke according to NHS guidance on a stroke.

48.There are therefore no indications of maladministration in the justification given for a potential diagnosis of CTS during the appointment on 20 March 2023. The appointment was conducted in line with GMC good medical practice and the symptoms reported are consistent with CTS.

49.Mrs R complained that the symptom of loss of power in the hand had only been an issue for a week at the time of the appointment with the GP on 20 March 2023. The medical records for the appointment say the numbness in the right second and third fingers had been going on for a few months.

50.We take medical records as both a legal and clinical account of what happened and in conducting our work have not seen any reasons to doubt their accuracy nor their completeness. Though we do recognise Mrs R says this was only an issue for a week, records conflict by explaining ongoing for a few months.

51.We have gone onto consider what approach we should take to this to reach a view independent of both parties and concluded, using the Ombudsman’s discretion there would be no value or merit to progressing further to a detailed investigation to reach a view independent of both conflicting accounts. This is because whether the symptom had been going on for a week or a few months, from the specialist clinical advice sought that forms additional material evidence in our decision making, we recognise CTS would still be the most likely diagnosis and a fair one to make.

52.Medical records are a legal document which form a clinical account of what happened during an appointment or consultation with regards to a patients care. If Mrs R believes that the information in her medical records is inaccurate then she can raise this with the Surgery who can consider adding a note to her medical records detailing that Mrs R disagrees with the information listed. Mrs R has the legal right to ask for her records to be amended but this would be considered by the Surgery and cannot be achieved as an outcome by our office. Any outstanding issues regarding this should be taken to the Information Commissioner’s Office (ICO).

53.The reported symptoms changed at the next appointment on 23 March 2023 at which time a stroke was suspected, and an ambulance called. However, this does not mean that a stroke was the most likely diagnosis during the appointment on 20 March 2023. Strokes usually begin suddenly according to NHS guidance on strokes with one of the main symptoms being weakness or numbness in one or both arms. Mrs R reported this symptom during the appointment on 23 March 2023 but not during 20 March 2023 according to the medical records.

54.It is our role to be impartial and transparent in explaining our decision. We hope Mrs A and Mrs R understand the reason for our decision. We appreciate that this complaint is important to them both and the impact having a stroke has had on Mrs R’s health and life.

1. We have carefully considered Mrs A’s complaint about the a practice in the North Hertfordshire area (the Surgery) on behalf of her mother, Mrs R. We have seen no indication that anything went seriously wrong. With regards to an incorrect prescription issued to Mrs R, we have decided the Surgery has already done enough to put right the impact of these events on Mrs R.

2.In conducting our work, we recognise the importance of this complaint to Mrs A and Mrs R. We understand that Mrs R continue to live with the effects of her stroke and feels this could have been prevented or the symptoms may not have been as severe if the doctor assessed her symptoms and diagnosed her stroke earlier.