A practice in the Southwark area

3. Miss A complains about the care and treatment her daughter, M, received in an appointment at the Practice on 4 July 2024. Miss A specifically complains that:

• staff who attended to M showed a lack of consideration and understanding of her severe autism and did not accommodate her individual needs • the GP asked Miss A to physically carry M to be weighed on a scale, which caused M further distress and exacerbated her symptoms • the GP did not consider using an estimated weight for the medication • the GP raised safeguarding concerns about Miss A in an inappropriate and insensitive way.

4. Miss A says the events have caused both her and M severe distress.

5. Miss A would like the Practice to make service improvements and a financial remedy.

6. Miss A contacted the Practice on 3 July 2024 as her daughter had symptoms of an itchy and sore vagina, and a vaginal discharge.

7. M had previously attended the Practice in April 2024 with a similar issue which the Practice had diagnosed as vulvovaginitis (a swelling or infection of the vulva and vagina), and prescribed Metronidazole to treat it. Miss A asked for a telephone appointment but due to M’s symptoms the Practice decided a face-to-face appointment would be more suitable.

8. During the appointment M, who has severe autism and is non-verbal, became distressed at being in a clinical environment. The physician associate who was attending requested some assistance from a GP because there was an issue establishing M’s weight for the correct dose of medication that she needed.

9. The GP then suggested that Miss A physically carry M onto the scale so that she could be weighed, which Miss A was unwilling to do because of M’s distress.

10. The GP then decided to use the same weight from the previous consultation from April 2024 and asked Miss A to weigh M at home instead. The GP then arranged a follow up appointment the next week.

11. The Practice also discussed safeguarding concerns with Miss A due to the sensitivity of M’s symptoms.

16. 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.

Appointment on 4 July 2024

17. Miss A complained about the actions of Practice staff during M’s appointment on 4 July 2024. She specifically said:

• staff who attended to M showed a lack of consideration and understanding of her severe autism and did not accommodate her individual needs • the GP asked Miss A to physically carry M to be weighed on a scale and refused to use an estimated weight for the prescription.

18. Miss A said she originally wanted a telephone consultation as she knew M would struggle with a physical examination and so she wanted to minimise the amount of time spent in the Practice.

19. The Practice said it appreciated that M has autism and always has difficulties with physical examinations in a clinical setting. It said given the symptoms that M was suffering, staff found it necessary to examine her to determine the cause. The Practice apologised if this came across as inconsiderate and inflexible.

20. The Practice apologised that Miss A found the suggestion to have M physically weighed impractical. It said it needed to do this because the medication dosage for Metronidazole syrup depends on the child’s weight.

21. According to the British National Formulary (BNF), the recommended dose for Metronidazole in a child between the ages of 2 months and 11 years, is 7.5mg per the child’s weight in kilograms every 8 hours, usually treated for 7 days.

22. Our adviser said it was essential for the GP not to under or over prescribe the medication, and it was therefore very important to establish M’s weight so the medication could be safely prescribed.

23. The adviser said that considering M was presenting with symptoms in an intimate area of the body, and that these were recurrent symptoms she had already suffered with months earlier, it was correct for the GP to request to see M in person rather than conduct another telephone consultation.

24. We recognise Miss A was concerned about M being in an unfamiliar environment due to the severity of her autism, and how this would affect her. We appreciate Miss A wanted to reduce the risk of M suffering distress.

25. GMC Good medical practice says doctors must consider the needs and welfare of people who may be vulnerable.

26. The records show that Miss A had previously reported similar symptoms in April 2024 and the Practice had prescribed M with Metronidazole but had been unable to physically examine her at the time to establish a root cause.

27. We consider the Practice had shown sensitivity towards M’s individual circumstances originally by prescribing the medication without a physical examination, however as this had not been successful and the symptoms had returned, it became necessary to see M face-to-face to investigate further.

28. We appreciate it then became challenging for the GP to establish M’s weight to safely prescribe the medication.

29. Our adviser said as the responsible clinician, it was the GP’s discretion as to how best to ensure the medication could be administered safely.

30. GMC Good medical practice also says doctors ‘must recognise and work within the limits of their competence’.

31. Our adviser said the GP had to work with the information that was available, as they were unable to establish a definitive weight. It was therefore important in line with M’s best interests for the GP to be able to prescribe the medication. The GP reasonably decided to use the same dose that had previously been prescribed in April 2024 as there had been no safety concerns raised with this. This was a safer option than using an estimated weight.

32. We consider this decision to be in line with GMC Good medical practice. We have seen no indications the Practice failed to take M’s autism into account when arranging the appointment and prescription.

Safeguarding conversation

33. Miss A said the GP raised safeguarding concerns about her in an inappropriate and insensitive way.

34. The Practice apologised if the safeguarding discussion caused Miss A distress and made her feel unfairly judged. The Practice clarified that there was no intention to suggest that any inappropriate behaviour was occurring at home, and said its inquiries were solely focused on ensuring M’s wellbeing.

35. It explained that the nature of M’s symptoms in a sensitive area of the body, and her being a vulnerable patient due to her autism, requires the GP to act in line with their safeguarding responsibilities. The Practice said it discussed this openly and transparently with Miss A rather than raising any alert secretly.

36. NICE guidelines state that children and young people who meet the EquLty Act 2010 definition of disability, namely those who have a physical or mental impairment that has a substantial and long-term negative effect on their ability to do normal daily activities, are especially vulnerable.

37. Our adviser said that in line with these guidelines, it was appropriate for the GP to discuss safeguarding concerns with Ms A in a sensitive manner. The adviser said that clinicians have a responsibility to young and disabled children to ensure their wellbeing. The adviser said this was an informal conversation and did not progress to making a safeguarding referral.

38. We understand Miss A has said the GP raising the issue of safeguarding was distressing and made her feel unfairly judged, and she felt this could have been handled more sensitively.

39. We did not witness the conversation that took place and so we cannot comment on how sensitively the GP addressed the safeguarding issue. In the Practice’s response the GP has apologised for coming across as inappropriate, even if this was not the intention.

40. Our principles of good administration say organisations should always deal with people fairly and with respect. They should be prepared to listen to their customers and avoid being defensive when things go wrong.

41. We have not seen indications that the actions of the GP were wrong, as it was correct in line with relevant guidelines to raise the issue of safeguarding. We are satisfied the Practice has listened to Miss A’s concerns and has reflected on how it dealt with this issue, and the distress this caused.

1. We have carefully considered Miss A’s complaint about the Practice. We recognise the appointment at the Practice caused Miss A and her daughter some distress.

2. Having considered the available evidence, we have seen no indications the Practice did anything wrong.