A practice in the North Somerset area

3. Mrs O complains from 16 August to 13 November 2023 the Practice did not treat her symptoms of neck pain, numbness in her hands, numbness in her feet and loss of balance appropriately. Mrs O also says the GP Practice did not arrange for a cervical MRI scan.

4. Mrs O subsequently had an operation to remove two cervical discs, and a stent was fixed to her spine. She says the GP Practice’s inaction caused a delay of three months, and because of the delay Mrs O says her condition worsened and left her with permanent damage which includes pain and pins and needles in her arms and hands.

5. Mrs O would like to achieve a financial payment for the GP Practice’s failings and the permanent damage she has been left with.

6. On 4 August 2023, Mrs O had a fall while on holiday. Following this, Mrs O had various appointments at the Practice, the fracture clinic, with the physiotherapist, and at the pain clinic. She also attended at A&E on a couple of occasions.

7. On 13 November, Mrs O attended for an appointment at the Practice. Mrs O was unhappy with the care she had received from the Practice so she deregistered from the Practice and registered with a new GP Practice.

8. In December 2023 Mrs O had a brain and cervical spine MRI (MRI of the neck). On 12 March 2024 Mrs O had an operation on her cervical spine C5/C6.

13. Mrs O complains from 16 August to 13 November 2023 the GP Practice did not treat her symptoms of neck pain, numbness in her hands, numbness in her feet and loss of balance appropriately. Mrs O also says the GP Practice did not arrange for a cervical MRI scan.

14. Mrs O had a fall while on holiday and when she returned to the UK she had a consultation with her GP on 16 August 2023. Mrs O says she should have been referred for an MRI scan on her neck at this appointment.

15. The GP Practice says it treated her for a whiplash injury and an MRI was not clinically indicated when she presented in August 2023. It explained at their practice GPs are generally not able to organise MRI scans, and it is done by a specialist.

16. To see if the GP Practice acted in line with applicable guidelines and standards in the way it conducted the consultations, we sought independent advice from a clinical adviser (our GP Adviser).

17. The relevant guidance is NICE Whiplash Guidance, which says the signs of whiplash are (in summary): •neck pain •headache •a reduced range of neck movements •muscular spasm.

18. The NICE Neck Pain guidance is also relevant as Mrs O showed clinical features of non-specific neck pain which include: •‘pain that is aggravated by particular movements, posture, and activities.

•pain that radiates in a non-segmental distribution down the arm, up into the head, into the shoulder, or across the shoulder blade.

•pain associated with paraesthesia (skin tingling/burning or numbness) or hyperaesthesia (extreme sensitivity in sense of touch), but with no objective loss of sensation or muscle strength.

•positional asymmetry, limited range of movements often asymmetrically •tenderness in intervertebral (spine) joints and/or stiff muscles that may be palpable as nodules or tender bands.’

19. Both sets of guidance say Mrs O should not have been referred for further investigations into her neck pain unless she was displaying reg flag symptoms.

20. The NICE Neck Pain guidance and the NICE whiplash guidance both detail red flag symptoms and both highlight the same issues. These are if the patient is showing symptoms of malignancy, infection, inflammation, osteoporosis and cervical myelopathy. The NICE Neck Pain guidance describes symptoms of cervical myelopathy as: • paresis (muscular weakness) • sensory changes or loss of sensation • altered muscle tone • clumsy or weak hands • gait disturbance • flexion of the neck which causes electric shock-type sensation that radiates down the spine and into the limbs.

21. More severe symptoms may include profound weakness of the hands, bowel or bladder dysfunction, altered cognitive state and inflammatory arthritis.

22. We have considered Mrs O’s consultations to understand if she had been properly treated in line with the relevant guidance and whether she should have been referred for an MRI scan.

23. Mrs O’s previous medical history is relevant as she has had a diagnosis of fibromyalgia. Fibromyalgia causes a lot of symptoms, and the main symptom is widespread pain, pain sensitivity and allodynia, which is when pain is felt from something that should not be painful at all, such as a very light touch.

24. Mrs O was also being treated by the MSK services for lower back pain and investigations into this were ongoing during the treatment period we are looking at.

16 August 2023

25. Mrs O had a consultation with the GP, Mrs O told the GP she had a fall 12 days prior while on holiday. She presented with no feeling in both hands, aches all over, limited neck movement, off balance, very sensitive body sensation with electric shocks through the body and she was a bit disorientated. Mrs O was examined and had pins and needles in her hands. Her neck was examined which showed a reasonable range of motion, but it was stiff and painful.

26. We can see Mrs O presented with some of the symptoms of a neck injury as she had a stiff and painful neck.

27. She did report electric shocks throughout her body which can indicate cervical myelopathy, however, increased sensitivity is also a symptom of fibromyalgia. Our GP adviser explained Mrs O’s existing diagnosis of fibromyalgia could have skewed the GP’s view of her clinical presentation making it very difficult to determine what symptoms could be attributed to fibromyalgia, existing lower back pain, and what could have been caused by a neck problem.

28. The GP diagnosed a whiplash type injury and bruised nerves which would account for the pins and needles in her hand. We consider this diagnosis was reasonable and in line with the NICE whiplash guidance. Our GP adviser agrees. Mrs O did present with sensory changes (pins and needles), but our GP adviser said it is not unreasonable to attribute that to bruised nerves.

29. Mrs O did not present with any red flag symptoms such as fever, night sweats, muscle weakness, or bladder dysfunction.

30. The NICE whiplash guidance explains for treating and managing a whiplash injury doctors should ‘provide reassurance recovery from whiplash-associated disorder usually occurs within the first 2 to 3 months’. The guidance says symptoms are a normal reaction to being injured, maintaining normal activities and staying active are important factors in recovery.

31. The Practice issued Mrs O with a two-week fit for work note and recorded it would look into the matter further if Mrs O needed more time off work.

32. We consider a watch and wait approach is appropriate and in line with the NICE whiplash guidance, and we have not seen any evidence something went wrong with this consultation.

4 September

33. Mrs O had an A&E attendance on the 4 September. The discharge summary sent to the Practice says she had a severe back spasm and pain, and she struggled to pass urine. A&E attributed this to the multiple large disc prolapses Mrs O had in her lower back. They asked the GP to review for further management of back pain disc prolapses and consider a physiotherapy referral.

5 September

34. Mrs O had a telephone consultation and advised she recently had a fall and went to A&E (the discharge summary was already on Mrs O’s records). Mrs O presented with all over body pain, and muscle spasm. They discussed a letter from the MSK services which suggested a potential referral to the pain clinic for steroid injections. Analgesia was discussed, and the GP was not sure if gabapentin was suitable long term, and said they would discuss with another clinician the following day.

35. Due to Mrs O’s complex history, we do not consider it unreasonable for the clinicians to discuss her treatment. The GMC guidance says treating doctors are to ‘consult colleagues or seek advice from your supervising clinician, where appropriate’. Mrs O did not have any red flag symptoms at this appointment which would indicate cervical myelopathy, and we consider the GP’s approach to asking for advice about the analgesia to be appropriate and in line with the GMC guidance.

6 September

36. Another clinician reviewed Mrs O’s situation and recorded their notes in Mrs O’s medical record. They also spoke with Mrs O late on 5 September producing the call note on 6 September. The note in Mrs O’s records say Mrs O was under the care of (MSK) who booked an MRI of her lower back which showed degenerative changes and L4 nerve root impingement. She had a fall on holiday in August and another fall shortly after where she damaged her wrist.

37. It is noted Mrs O has long term complex symptoms which require involvement of the pain clinic. The GP noted during a telephone call with Mrs O she reported she did not feel safe to drive, she was very upset and in pain, and she felt her episodes of back spasm could happen at any time.

38. The GP prescribed Gabapentin in response to the request for increased analgesia.

39. The GMC guidance says doctors should ‘refer a patient to another suitably qualified practitioner when this serves their needs’.

40. The GP noted this matter was difficult and they would ask MSK to follow up. As Mrs O was already under the care of a specialist, we consider the GP requesting this follow up to be an appropriate response and considered the earlier ED’s request. This was in line with the GMC guidance.

41. We have also reviewed the GP consultancy records and we cannot find anything during this appointment which indicated an issue solely with her neck.

42. We have not found indications anything went wrong at this consultation.

11 September

43. Mrs O had a consultation at the GP Practice where she said she started with chronic pain 25 years ago and was suffering with chronic pain over her entire body. Mrs O had attended a fibromyalgia group in 2011, recently had physio, had acupuncture and had seen a chiropractor.

44. On examination the GP noted Mrs O had a jumpy right and left leg. Mrs O reported numbness in her right hand and arm which was intermittent, on examination Mrs O was able to move it normally and had normal grip strength.

45. The GP suspected a functional disorder (conditions where neurological symptoms like weakness, tremors, or seizures are present, but they're not caused by damage to the brain's structure) and so made a referral to the pain clinic. Referring to other specialisms is a requirement of GMC guidance, Good Medical Practice 15(b) which says: In providing clinical care you must: promptly provide (or arrange) suitable advice, investigation or treatment where necessary’. We consider this referral was in line with GMC guidance.

46. Mrs O presented with hand numbness, but she had normal movement and grip strength, typically in cervical myelopathy the guidelines say expect to see weakness in limbs and grip strength.

47. We do not consider anything went wrong with this consultation and the Practice made an appropriate referral.

20 September

48. Mrs O’s medical notes show the GP spoke to the physiotherapist who was treating Mrs O to discuss the request for peripheral nerve conduction studies. The physiotherapist was going to do a formal neurology examination the following day.

49. The clinicians agreed Mrs O’s presentation was atypical which meant her symptoms were not wholly representative of any particular condition. They discussed the possibility of a functional disorder and agreed to do peripheral nerve conduction studies to help clarify the clinical picture. A referral for nerve conduction studies was completed the following day.

50. The GP and the physiotherapist worked together to try and reach a diagnosis for Mrs O. We consider this to be good medical practice and in line with GMC guidance which says doctors should ‘work with colleagues in ways that best serve the interests of patients’.

2 October

51. Mrs O had a consultation with the Practice and said she did not believe she had FND (functional neurological disorder) and was not well enough to attend a mental health nurse appointment. Mrs O advised she had hand numbness and tingling in both hands. Mrs O reported lower back pain, neck pain and left wrist pain.

52. The GP considered if it was a fibromyalgia flare. On examination Mrs O had spinal neck pain. The GP recorded she had good range of neck motion, but all movements caused spasms around her neck and arms. Mrs O had power in her hands and normal sensation/tone but was tender over her left wrist.

53. Mrs O was seeing an orthopaedic consultant for her wrist which was arranged at previous A&E visits. The GP noted she was awaiting a pain clinic appointment and nerve conduction studies.

54. Mrs O had some red flag symptoms during this consultation such as numbness and tingling in her hands. Our GP adviser said her presentation was not typical of cervical myelopathy and was more in keeping with the symptoms described in the NICE neck pain guidance as she still had muscle strength.

55. Mrs O was awaiting nerve conduction studies. Our GP adviser said her symptoms had not significantly changed therefore it was appropriate to wait until the nerve conduction studies were completed.

56. We have seen no evidence anything went wrong at this consultation.

13 November

57. Mrs O attended the Practice for a consultation and needed to use walking aids as mobility was incredibly difficult for her. She was in pain and had jumping of the legs. Mrs O reported she felt like her arms and legs were floating above her and her neck was crunching when she extended her neck. Mrs O asked to be referred for an urgent MRI.

58. On examination she was unable to do a head impulse test as it was too painful. A head impulse test checks to see if the eyes can maintain eye position when the head is turning.

59. The GP discussed the results of the upper limb nerve conduction studies which were normal. As Mrs O’s hand numbness did not corelate with this clinical finding, the GP concluded the cause could possibly be fibromyalgia or FND. Mrs O became distressed and asked why she was not referred for an MRI in August. Mrs O was upset and was asked to leave the Practice.

60. The GP provided a statement which says that last appointment had significantly overrun and they had to see other patients. The GP typed the clinic notes and set a task to do a referral the next day. The GP had intended to do a referral to MSK to ask them to reconsider doing an MRI on her neck. The GP says they advised Mrs O they would do this. The next day the GP went to do the referral and saw Mrs O was no longer registered at the Practice.

61. We can see this last appointment would have been very difficult for Mrs O, she was experiencing significant pain and has a complex medical history.

62. We can understand why the results of the nerve conduction studies would have been disappointing for Mrs O.

63. We do not consider anything went wrong in this last appointment as the GP would have made the referral for an MRI in line with the GMC guidance if Mrs O had not de-registered from the Practice.

64. We have considered Mrs O’s treatment history and have seen significant input from physiotherapy. Both the Practice and physiotherapy were working to try to understand the cause of Mrs O’s pain and she was referred for appropriate testing in line with GMC guidance.

65. Mrs O did not present as a typical patient with cervical myelopathy as her fibromyalgia caused considerable difficulties when clinicians were trying to get a clear picture of her situation.

66. We understand this would have been an incredibly frustrating time for Mrs O especially as she was in such significant pain.

67. On 24 November 2023, Mrs O had a consultation at a new GP Practice where she was referred for an MRI scan. Mrs O says the new GP identified she needed an MRI straight away and the Practice should have identified an MRI was needed back in August 2023.

68. While we can appreciate Mrs O’s view, we consider the new GP Practice had the benefit of all the testing which had taken place during August to November, therefore both situations are not the same and are not comparable.

69. We cannot see anything went wrong with the treatment the Practice gave Mrs O and we thank Mrs O for bringing her complaint to us.

1. We have carefully considered Mrs O’s complaint about the GP Practice. We have seen Mrs O had a very difficult period of investigations and appreciate this caused her considerable frustration and distress.

2. We have carefully looked at the complaint brought to us by Mrs O and we have not seen anything went wrong with the care provided by the GP Practice.