A practice in the Nottinghamshire area

4. Dr O is unhappy with the care and treatment she had from the Practice between 19 and 24 May 2022.

5. She says the Practice missed two opportunities to take a sample of her blood to investigate her symptoms of high blood pressure and swelling to her face, feet and legs.

6. She says due to the failings at the Practice, she had an emergency admission to hospital and was in a critical condition. She says her diagnosis and treatment for stage three AKI was unnecessarily delayed, meaning a longer hospital stay and greater damage to her kidneys.

7. She says she now has a long-term condition which could have been prevented.

8. She says it was extremely distressing for her and her husband to feel the Practice was not taking their concerns seriously and they no longer trust the Practice to give them good care.

9. She says her emergency admission was stressful for them because hospital staff told her they were concerned the swelling might have damaged other organs, including her heart, lungs and brain.

10. Dr O would like the Practice to admit it failed her and to make service improvements to reduce the risk of something similar happening to others.

11. Between 19 and 24 May 2022, Dr O visited the Practice twice due to feeling tired, generally unwell and having swelling. During this time, the Practice did a full examination and arranged for a blood test on 2 June.

12. At first, the Practice thought it was likely Dr O had hypertension (high blood pressure) and it prescribed her with amlodipine (blood pressure medication).

13. As Dr O’s symptoms did not change, the Practice arranged for a blood test to be done sooner. On 26 May, the Practice told Dr O her blood test was abnormal and completed an urgent referral to hospital. Dr O was later diagnosed with stage three AKI.

17. We look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have done this, and we have not seen any signs that something has gone wrong.

18. GMC ‘Good medical practice’ paragraph 15 says doctors must:

‘provide a good standard of practice and care. If [doctors] assess, diagnose or treat patients, [the doctor] must: • adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs’.

19. Our adviser said there is no specific guidance on swelling.

19 May appointment

20. NICE guidelines say:

‘1.2 Diagnosing hypertension • 1.2.3 If clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.

1.3.3 For all people with hypertension offer to: • test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip • take a blood sample to measure glycated haemoglobin (HbA1C), electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol and HDL cholesterol • examine the fundi for the presence of hypertensive retinopathy • arrange for a 12-lead electrocardiograph to be performed.’

21. The records show the Practice noted Dr O’s symptoms as a one-week history of feeling generally tired, her face was a bit swollen, she did not have a cough, she did not have any urine or bowel symptoms and she was eating and drinking but with a bit less appetite.

22. The records show Dr O’s temperature was 36 degrees, her oxygen saturation level was 99 percent, her heart rate was 83 and her blood pressure was 160/95.

23. The records show the Practice diagnosed her with hypertension and prescribed her with amlodipine, with a follow up blood test and repeat blood pressure check in two weeks.

24. The Practice’s actions seem to be in line with the GMC and NICE guidance.

25. We considered whether the Practice should have done blood tests sooner. Our adviser said there are no guidelines for the timing of a blood test after a diagnosis of hypertension. We have seen no sign that the blood tests should have been sooner.

24 May appointment

24 The records show the Practice noted Dr O’s symptoms as her feeling generally unwell, she felt worse than before and more chesty. Dr O had started amlodipine for her blood pressure.

25 The records show Dr O’s temperature was 36 degrees, her oxygen saturation level was 98 percent, her heart rate was 90 and her blood pressure was 160/80. Her urine dip test was clear (no protein), and her chest was clear. There was swelling in her arms but no obvious swelling in her legs.

26 The records show the Practice arranged for Dr O to have an electrocardiogram (a test to check the heart's rhythm and electrical activity) and blood test on 26 May, and to see the doctor again on 27 May. If Dr O’s symptoms worsen, the Practice said she should go to the emergency department.

27 The Practice’s actions seem to be in line with the GMC and NICE guidance.

28 On 26 May, Dr O’s blood test were noted to be abnormal. The Practice called Dr O at around 11pm, requesting she urgently go to hospital because of seriously low sodium levels in her blood sample.

29 This is in line with the GMC guidance.

30 Based on the evidence we have seen, we have not seen any signs of failings in the actions of the Practice. As we have seen nothing to suggest the Practice got anything wrong, we will not be taking any further action on this complaint. We hope our investigation will give Dr O some answers.

1. The Parliamentary and Health Service Ombudsman has carefully considered Dr O’s complaint about a practice in the Nottinghamshire area (the Practice).

2. We are sorry to hear Dr O’s concerns about the care and treatment she received. We recognise she has experienced difficult symptoms and has been diagnosed with stage three acute kidney injury (AKI). We understand this has been a distressing experience for her and her husband.

3. We have reviewed all the relevant evidence. We have seen no sign that anything went seriously wrong. We recognise Dr O may be disappointed by this decision. We hope this statement will help her understand how we reached our decision.