A practice in the City of Leicester area

5. Mrs P complains about the Practice’s care and treatment of her son A’s constipation between January and February 2023. She complains the Practice:

• did not take A’s constipation issues seriously and were dismissive of his symptoms at each of his appointments between January and February 2023 • did not proactively refer A to hospital at the earliest opportunity in January 2023.

6. Mrs P says as a result of the Practice’s actions, her son was hospitalised for eight days to unblock his bowel. She says A’s bowels do not work, and he requires adult supervision to use the toilet. She says his mental health has been adversely affected and he now struggles with hospital visits.

7. Mrs P would like an apology and service improvements.

8. On 25 January 2023, Mrs P had a telephone consultation regarding A who had been constipated for over a week. The Practice said an urgent referral to paediatrics should be made however due to A’s upcoming appointment on 18 February 2023, a cover letter was sent to the community paediatrics team instead.

9. On 7 February 2023 A had a face-to-face appointment at the Practice and had not opened his bowels for 12 days. The Practice recommended a stimulant laxative, twice weekly.

10. On 9 February 2023 Mrs P had a telephone consultation to discuss A’s ongoing constipation. The GP discussed A’s symptoms with a paediatric on-call doctor at a hospital in the East Midlands area and Mrs A was advised to continue with the stimulant laxative regime. They also recommended increasing A’s laxative dosage incrementally from six sachets to eight.

11. On 13 February 2023 A had not opened his bowels for around 18 days and during a telephone consultation, Mrs P was advised to increase the stimulant laxative to eight sachets as advised by paediatrics and to review in approximately five days. Mrs P contacted NHS 111 on the evening of 13 February 2023, and A was subsequently admitted to a hospital in the East Midlands Area that night.

12. A was admitted to hospital from 13 February 2023 and was discharged on 21 February 2023. He had eight days of enemas (inserting liquid into the rectum and colon, primarily for the purpose of relieving constipation) and seven Klean preps (a strong laxative).

Appointment on 25 January 2023

16. Mrs P complains that A’s constipation issues were not taken seriously from the outset starting with the telephone consultation on 25 January 2023. Mrs P says she made it clear that A had been constipated for eight days even though he had been taking laxatives and glycerine suppositories, but the Practice did not take his symptoms seriously.

17. The records show that A had previously had issues with constipation and was taking laxido and sennosides (laxatives) daily. He had previously been referred to Gastroenterology but was discharged in June 2022 however, the problem was ongoing.

18. The records show during the consultation on 25 January 2023, Mrs P told the Practice that A was eating minimal amounts, was drinking more, was not vomiting, was passing wind, but complained of stomach pain.

19. The NICE guidance says:

‘Refer children and young people with idiopathic constipation who do not respond to initial treatment within 3 months to a practitioner with expertise in the problem.’

20. The Practice explained that during A’s appointment on 25 January 2023, it agreed to make an urgent referral to paediatrics. However, it decided not to make the urgent referral because A already had an upcoming appointment on 18 February 2023 with the Community Paediatrics Team. It decided to send a cover letter to the community paediatrics team on 27 January 2023 instead, ahead of the upcoming appointment.

21. The Practice said it encouraged Mrs P to attend A&E in the meantime if there was no response to the laxatives or if A was in discomfort.

22. The records show that the letter to community paediatrics details the concerns raised by Mrs P during the telephone consultation on 25 January 2023 and it asks for the issues to be addressed in the upcoming appointment on 18 February 2023.

23. We have considered the role of the community paediatric team and have looked at its website. The community paediatric team’s website is clear in stating that it does not offer support for constipation issues. It refers to a hospital in the area that can offer support.

24. Our adviser said it was not appropriate to refer A to the community paediatric team in light of the support services it offers. In line with the NICE guidance, as A had long term issues with constipation that was not responding to treatment, the Practice should have instead made an urgent referral to paediatrics with an expertise in the problem, as it was originally planning to do. The Practice did not do this, and we consider this is an indication of a failing.

25. Mrs P says the Practice’s actions led to her son’s hospitalisation in February. We are sympathetic to A’s experience in hospital and understand Mrs P’s frustration that the Practice referred her to a service that did not focus on A’s particular symptoms which were affecting him daily.

26. Our adviser explained that the waiting time for an urgent referral is several weeks and is largely dependent on local waiting times. As discussed below, A received advice from a specialist on-call doctor in one of his subsequent appointments on 9 February 2025; this was just two weeks after the appointment on 25 January 2025. A was also unfortunately hospitalised on 13 February, so the appointment scheduled for 18 February 2023 with the Community Paediatric Team did not take place.

27. If the Practice had made the urgent referral at or after the appointment on 25 January 2023, we cannot say that A would have been seen before 9 February (when specialist advice was received from a paediatric on-call doctor) or 13 February 2023, when he was hospitalised.

28. Even if A had received a timely appointment following an urgent referral to paediatrics, we cannot determine whether his hospital admission would have been avoided. Furthermore, our adviser said, if A had been seen quickly and within two weeks of the referral, i.e. by 8 February 2023, it is very likely that the team would have provided the same advice that was provided by the specialist on-call doctor on 9 February 2023.

29. Taking into account the relevant guidance and the views of our adviser, we have concluded that we cannot investigate this matter further as we cannot determine that the indicated failing had any impact on A. We cannot say that the treatment provided would have been different, or that his hospitalisation could have been avoided.

Appointment on 7 February 2023

30. Mrs P told us that she attended the Practice because A had not opened his bowels for 12 days, was not eating well, having overflow diarrhoea, not passing as much urine as normal, and his symptoms were not taken seriously enough at this appointment.

31. The records show that the GP examined A. On examination, it was documented that A’s abdomen was soft, distended (swollen), and bowel sounds present. Mrs P was advised to add in sodium picosulphate (a stimulant laxative), twice weekly.

32. The NICE guidance says to offer Polyethylene glycol 3350 + electrolytes, using an escalating dose regimen, as the first-line treatment. It says to add a stimulant laxative if polyethylene glycol 3350 + electrolytes does not lead to disimpaction after 2 weeks.

33. According to the guidance polyethylene glycol 3350 + electrolytes should be prescribed in the first instance and if this proves ineffective then a stimulant laxative should be prescribed.

34. Our adviser explained that A had already been appropriately prescribed Laxido which contains polyethylene glycol 3350 + electrolytes and according to the records, an escalating dose regimen was subsequently prescribed from four sachets, to six and then eight sachets in his following appointments. Our adviser said A was also appropriately prescribed sodium picosulphate (which is a stimulant laxative) at the appointment on 7 February 2023 as he had not opened his bowels for nearly 2 weeks.

35. We can see that this was a difficult time for A and for Mrs P as A had been constipated for 12 days and would have been in a lot of discomfort.

36. We consider the advice and medication given on 7 February 2023 was in line with the NICE guidance. As such, we cannot see any indication of failings on the part of the Practice in relation to the treatment given at this appointment.

Appointment on 9 February 2023

37. Mrs P complains that during her telephone consultation with the Practice to discuss A’s ongoing issues with constipation, she was advised to increase his medication, and this advice was not proactive enough and did not demonstrate that it was taking A’s symptoms seriously.

38. Within the Practice’s complaint response, it said it discussed A’s presenting symptoms with a paediatric on-call doctor at the hospital in the area for advice. The hospital advised to continue with Laxido and to use the faecal impaction regime to increase to six sachets per day for a few days and then to eight sachets. The hospital also advised not to give sodium picosulphate at that time.

39. The Practice said at this appointment, it followed the hospital’s advice and told Mrs P that she should arrange an appointment for A to be seen if he experiences abdominal pain, vomiting or became unwell. The records indicate that she was happy with this plan.

40. As previously noted, the NICE guidance says polyethylene glycol 3350 + electrolytes should be prescribed in the first instance using an escalating dose regimen.

41. The GMC guidance says to promptly provide (or arrange) suitable advice, investigation or treatment where necessary.

42. Our adviser said, the Practice’s decision to seek further advice from the paediatric on call doctor at the hospital, who is a specialist in constipation issues in children, was appropriate given A’s ongoing issues with constipation. Furthermore, the hospital’s advice, adopted by the Practice, to follow an escalating dose regime with Laxido was in line with the NICE guidance.

43. Our adviser explained that the advice given at this appointment demonstrates that there is not just one pathway for patients with constipation as the advice from the hospital differed slightly, in that it advised not to give A sodium picosulphate. Our adviser said this is not uncommon as there are several different laxatives and different clinicians will select different regimes tailored to the needs of the patient.

44. We consider the Practice acted in line with the GMC guidance by contacting the hospital and seeking further specialist advice. The Practice implemented this advice. Therefore, we cannot see any indication of a failing here.

Appointment on 13 February 2023

45. Mrs P complains that the advice she was given at this appointment did not take into consideration A’s worsening symptoms. She says A’s stomach was not soft at this appointment as the Practice alleged and he was not soiling and drinking. Mrs P also refutes the Practice’s claim that it offered hospital admission for A at this appointment.

46. We note that at this appointment A had not opened his bowel for approximately 17 days which understandably would have been very distressing for A and Mrs P.

47. We can see from the records that A had a face-to-face appointment at the Practice on 13 February 2023 and the Practice assessed him. The Practice noted that whilst A had not passed a proper stool for 17 days and was also off his food, A was passing wind, had no abdominal pain or vomiting and looked well in himself. It was also noted that his abdomen was soft and bowels sounded positive with no mass or guarding.

48. The Practice advised Mrs P to give A eight sachets of Laxido and to ring the Practice if A does not open his bowels in four to five days. It is also recorded in the notes that the Practice offered hospital admission, but Mrs P was not keen.

49. The GMC guidance states that doctors should adequately assess a patient’s condition taking account of their history, and symptoms and carrying out a physical examination where necessary. It also states that doctors should only propose, provide or prescribe drugs or treatment only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs.

50. Our adviser said the Practice appropriately assessed A’s symptoms and performed a physical examination at the appointment on 13 February 2023. Our adviser said it was appropriate to encourage the continuation of the faecal impaction regime and to advise Mrs P to contact the Practice if A’s symptoms did not improve in four to five days.

51. According to the medical records, A was not in any distress, including no abdominal pain or vomiting. Our adviser said these are important signs to look out for when considering whether a situation required escalation. In addition, A was already on the faecal impaction regime.

52. We note that Mrs P says she was not offered hospital admission even though it is recorded in the Practice’s notes for the consultation on 13 February 2023. As there are two conflicting accounts of what happened here, and there is no further evidence we could obtain to show whether this was offered during this appointment, we cannot say, even on the balance of probabilities whether this was offered or discussed during this appointment.

53. We note Mrs P’s comments that A does not complain openly when in pain but shows discomfort in his face. We can understand why Mrs P would question the advice she received at this appointment as A was hospitalised on the same day and was admitted for eight days.

54. We have carefully considered the guidance alongside our adviser’s comments. We can see that the Practice assessed A based on the information it had at the time of the appointment, performed a physical examination, and recommended continuing with the medication already prescribed and recommended by the on-call paediatrician on 9 February. We consider its actions were in line with the GMC guidance. We have not seen any indication of a failing at this appointment.

Conclusion

55. Having carefully considered the Practice’s actions at each of the appointments between January and February 2023, we have seen no evidence to suggest that the Practice did not take A’s constipations issues seriously or dismissed his symptoms.

56. Whilst we consider the Practice should have made an urgent referral to paediatrics on 25 January 2023 instead of referring A to the community paediatrics team, which did not deal with constipation issues, we cannot say that this would have led to A being seen by the paediatrics team before he was admitted on 13 February. Therefore, we cannot say that this led to his deterioration and his hospitalisation.

57. Our adviser explained there is no recommendation in the NICE guidance for when a child needs to be admitted to hospital immediately for severe constipation. Our advised said if, on examination, A was in severe pain, vomiting or his abdomen was very tender on examination then that would be reasonable grounds for immediate admission. However, A did not present with these symptoms at any of his appointments.

58. We are sorry to hear of how distressing this time was for A and Mrs P and the severe discomfort A was in leading up to and during his hospital admission. We hope our decision provides Mrs P with assurance about what happened with her son’s care.

1. We are sorry to learn of Mrs P and A’s experience with the Practice. We acknowledge the difficult circumstances around this complaint and the impact this has had on A.

2. We have carefully considered Mrs P’s complaint about a GP Practice in the East Midlands Area (the Practice). We have decided that we cannot investigate this complaint further. This is because we have seen no indications of failings in the Practice’s care and treatment of A’s chronic constipation.

3. We have seen an indication of a failing at the appointment on 25 January 2023 as we consider the Practice should have made an urgent referral for A rather than sending a letter to the community paediatrics team. However, we could not link it to the claimed impact.

4. We understand this was, and continues to be, an upsetting time for Mrs P and her son. Our decision is not made without recognition of the upsetting circumstances around the events. We have explained the reasons for our decision below.