A practice in the Bromley area

5. Miss K complains about aspects of her care at the Surgery from February to December 2022.

6. She claims the Surgery: • did not send off a nail sample for analysis in February 2022 • did not recognise the severity of Miss K’s thumb infection on 9 December 2022

7. Miss K says the Surgery missed the chance to diagnose the severity of her thumb infection earlier by not testing her nail sample. She also says the Surgery’s failure to treat the nail infection, which meant she needed a partial amputation of her right thumb. She says she had 10 months of excruciating pain and sleepless nights. Miss K says she lost three months of earnings and had to spend money on dressing the injury. She says her thumb is now sensitive to the cold and she has lost fine motor movements.

8. Miss K seeks service improvements and a financial remedy.

9. Over 40 years ago, Miss K injured her right thumb. Since then, the nail has always grown back and lifted from the nail bed. In November 2021, her right thumb began to swell.

10. Over the next year, Miss K went to her GP Surgery and the local urgent care centre (UCC) about her thumb. She says she also submitted three separate nail samples to the Surgery to test for fungal infections.

11. Miss K says the Surgery never sent her first nail sample for testing in February 2022. She feels this was a missed opportunity to diagnose the severity of her thumb infection sooner. The GP records confirm the laboratory only tested two nail samples. Both tests were in December 2022, and both were negative for any fungus.

12. On 9 December 2022, a GP spoke to Miss K over the phone. During the consultation, the GP referred to previous assessments of her thumb. They also assessed a photo of her nail taken on 5 December 2022. The GP noted Miss K had some swelling to her thumb but was well in herself. The GP diagnosed an ongoing infection of the skin around the nail bed which was not responding to antibiotics. The GP changed Miss K antibiotics and recommended saline washes (a mixture of salt and water) for the infected area.

13. The infection did not improve so Miss K went back to her GP on 22 December 2022. Miss K says the GP advised her to try and squeeze out the pus in her thumb, which she was unable to do. The GP then told Miss K to go to the emergency department (ED) so the Trust could surgically assess the area for drainage.

14. Miss K attended the emergency department the following day and doctors diagnosed her with an infection of the bone (osteomyelitis) in her thumb. Unfortunately, surgeons had to partially amputate Miss K’s right thumb due to bone loss from the infection.

February nail sample

18. Miss K says in February 2022, she visited A&E to have her thumb examined. She says the A&E doctor told her to submit a nail sample to her GP Surgery to test for a fungal infection. Miss K says she handed the receptionist her nail clipping, with the relevant form from the hospital. She says the Surgery did not send the nail sample for testing. Miss K explains she developed an infection in her thumb bone ten months later. She feels the Surgery could have prevented this had it tested her nail sample in February 2022.

19. It must have been very traumatic for Miss K when surgeons told her they needed to remove part of her thumb. We recognise this has had an enormous impact on her life and understandably she is concerned the Surgery could have avoided this with earlier tests. We hope to reassure her we have thoroughly considered her complaint.

20. Miss K’s GP records indicate it did not receive a nail sample in February 2022. The Surgery said in its response of 11 September there is no other available evidence to suggest it asked for a nail sample or that one was handed in.

21. It is not possible for us to say what happened to the sample or why the Surgery did not send it for testing. On balance, we consider it is more likely than not Miss K followed the advice from her A&E doctor. Her urgent care records show the doctor ‘asked Miss K to take a clipping to the Surgery.’ This indicates her account she handed the sample in is most likely what happened. We next consider, what difference, if any, it would have made had the laboratory assessed the nail in February 2022.

22. Miss K’s medical records show she attended the UCC which is part of A&E on 3 February 2022. The doctor noted she had bleeding around the base of a nail. The doctor wrote ‘nail appears different with significant onycholysis.’ This is where the nail plate separates from the nail bed, causing white opaque nails.

23. Our adviser says the description of the nail, plus request for a nail sample, shows the UCC doctor felt Miss K had a fungal nail infection. NICE guidelines for ‘Fungal nail infection’ says a clinician may ‘suspect a diagnosis of fungal infection clinically if: the nail looks abnormal and is discoloured or separates from the nail bed.’

24. Miss K is concerned this nail sample may have been a missed opportunity to identify the severity of her infection earlier. We can reassure her we do not believe this is the case. NICE guidelines for ‘Fungal nail infection’ explains if a clinician suspects a patient has a fungal infection, they should send the nail sample for ‘for fungal microscopy and culture to confirm the diagnosis.’ This means the clipping is assessed for fungal infections only. The recommended treatment if a patient has a fungal infection is ‘oral antifungal medication’ called terbinafine.

25. The records show Miss K was diagnosed with an abscess (painful collection of fluid in the pad of her thumb) and a thumb bone infection in December 2022. The cause of the infection and abscess was a bacterial infection, not a fungal one. As outlined above, the nail clipping is not tested for a bacterial infection. It is used to check if fungus is present in the nail. Our adviser explained had the February result come back as positive for fungus, the standard treatment of terbinafine, would not have helped with a bacterial infection 10 months later.

26. On that basis, we do not believe the missing clipping in February 2022 would have changed Miss K’s outcome. The records indicate Miss K had symptoms of a fungal nail infection in February 2022 as set out in NICE guidelines. This is the reason her nail needed to be sent for sampling.

27. Sadly, the records show she later developed a bacterial infection in her thumb, which caused bone loss and needed surgery. We know this bacterial infection, would not have been tested for in the nail clipping in February 2022. We hope this puts Miss K’s mind at rest that her infection could not have been detected if this sample had been tested.

Appointment 9 December

28. Miss K believes the GP did not realise how serious her thumb infection was when they examined her on 9 December 2022. She explains her thumb was ‘overly swollen and misshapen.’ She says the GP put her on a course of antibiotics (Co-amoxiclav) and told her to come back if the swelling did not go down. Miss K feels the GP did not recognise how serious the thumb infection was that day.

29. We are sorry to hear Miss K is disappointed with the service she received from her GP. We recognise she must have felt very unwell during her appointment and was understandably worried about her symptoms. We asked our adviser to tell us whether they felt the GP assessment and advice was appropriate given her symptoms.

30. The Surgery said, in its 6 March 2023 response, the GP recognised the severity of Miss K’s infection. The GP correctly prescribed a hospital only antibiotic which they can only give when clinically justified. The Surgery says this shows the level of care and attentiveness given to Miss K that day. It also says, on 22 December 2022, the GP appropriately referred Miss K to surgeons at the hospital for same day assessment and management.

31. The records show Miss K visited the Surgery on 23 November 2022. She told her GP she had an issue with her nail and she was diagnosed with ‘suspected paronychia.’ This is a bacterial infection of the skin around the nail.

32. The Primary Care Dermatology Society (PCDS), November 2022, guidelines advises that patients with acute paronychia:

• soak the affected digit in warm water several times a day • be given topical antiseptics, e.g. Fucidin cream the minor infection • an oral antistaphylococcal (a type of bacteria) antibiotic for more severe or prolonged bacterial infection • surgical incision and drainage may be required for abscess formation

33. The NICE paronychia - acute guidelines, January 2021, say most cases of acute paronychia tend to clear up within a couple of days with treatment. An untreated infection may lead to chronic paronychia or complications, such as damaged tendons and nail loss.

34. The GP noted, on 23 November 2022, Miss K’s thumb had been ‘throbbing for the last two weeks.’ Miss K had not injured it and there was no pus discharge, red line, or fever present. The GP requested photographs of her thumb and correctly prescribed Flucloxacillin. This was an antistaphylococcal antibiotic and so complied with PCDS and NICE guidelines for treating paronychia.

35. The GP has documented they advised her of what to look out for and told Miss K to come back if the thumb did not improve. This action complied with the General Medical Council (GMC) good practice guidelines on safety netting.

36. On 9 December 2022, Miss K spoke to the GP for the first time since 23 November 2022. The record shows Miss K was ‘systemically well’ (well in herself) but she had swelling and tenderness in her right thumb.

37. The GP changed Miss K onto Co-amoxiclav. Our adviser says the GP was correct to change Miss K on to an alternative antistaphylococcal antibiotic and this complied with NICE guidelines. They were satisfied no further action needed to be taken during this appointment as the GP had prescribed new antibiotics to treat the infection.

38. Thirteen days later, on 22 December 2022, Miss K visited the Surgery again. The records show the nail infection was not significantly improving, and her nail bed was discharging fluid. Our adviser explained this indicated her infection had changed, worsened, and needed more treatment. The GP referred Miss K to the emergency department so surgeons could incise and drain her thumb. This action complied with NICE and PCDS guidelines for abscess formation in paronychia.

39. We understand Miss K is concerned the GP failed to recognise the severity of her infection on 9 December 2022. Having carefully reviewed the evidence; it appears the GP correctly assessed Miss K’s symptoms and diagnosed her with paronychia. Following this, it appears the GP followed NICE guidelines and provided appropriate oral antibiotics to treat the infection. When Mrs K thumb infection got worse, the GP urgently referred her to A&E to have her thumb drained. This is the recommended treatment plan in line with NICE guidelines. On this basis, it appears there are no indications of failings for this part of the complaint.

1. We have carefully considered Miss K’s complaint about a practice in the Bromley area (the Surgery). We are sorry to hear Miss K had to have part of her thumb amputated in December 2022 due to a bone infection. We do not underestimate how upsetting and painful this must have been. We appreciate this continues to have a massive impact on her life, as she has lost some fine motor skills and is now sensitive to the cold. We recognise she has suffered significant worry as she feels the Surgery could have prevented this by identifying the bone infection sooner.

2. On balance, it appears the Surgery lost Miss K’s nail sample in February 2022, which it needed to test for a fungal infection. We would like to reassure her this nail sample would not have identified her bone infection earlier. This is because she later developed a bacterial infection which caused the bone loss. Sadly, a bacterial infection would not have shown in the sample, so we do not feel the error would have changed Miss K’s treatment.

3. We also consider the Surgery correctly assessed her thumb and gave her appropriate advice and treatment in her appointment on 9 December 2022. These actions were in line with the relevant clinical guidelines.

4. We explain our rationale for each part of this complaint in more detail below.