A practice in the Somerset area

3. Dr O complains about aspects of care the Practice provided after she experienced shingles in November 2024. Specifically, she says the Practice:

• left her without appropriate pain relief despite requesting help • prescribed incorrect pain relief given her medical history including too many serious opioids • did not allow an in-person GP consultation despite telling staff she needed an abdominal examination.

4. Dr O says she experienced unnecessary pain for longer than she should have, and her breathing was affected given the location of the pain high up in her abdomen. She says she was prescribed medication (co-codamol) that is contraindicated given her history of a gall bladder removal. She says she experienced unnecessary distress with the medication prescribed due to a worry of it damaging her bowel or pancreas.

5. She says she was unable to eat properly, and she needed to see a GP for an abdominal examination. She says the lack of care she received from the Practice has left her with a loss of trust and anxiety about care she may need to access in the future, and the events have exacerbated her existing mental health and PTSD.

6. Dr O is seeking an apology, service improvements, and a financial remedy as an outcome to the complaint.

7. On 28 October 2024 Dr O’s local hospital diagnosed her with shingles.

8. On 30 October, Dr O sent an online query to the Practice about her pain relief. The Practice prescribed amitriptyline (used to treat various types of pain).

9. Dr O spoke with the Practice on 5 November about ongoing pain. The Practice increased the dose of amitriptyline and reduced the dose of co-codamol.

10. On 8 November Dr O sent another online request to the Practice to change her medication.

11. Dr O called the Practice on 13 November to request an urgent appointment with a GP.

12. On 14 November, Dr O attended a minor injuries unit due to ongoing discomfort and pain.

Pain relief

15. Dr O says the Practice left her without appropriate pain relief despite requesting help. She says it gave her incorrect pain relief given her medical history and too many serious opioids.

16. NICE guidance on pain management for shingles said:

• ‘For adults with mild pain, [NICE emphasis] offer a trial of paracetamol alone or in combination with codeine or a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen.

• If this is not effective, or the person presents with severe pain, consider offering amitriptyline (off-label use), duloxetine (off-label use), gabapentin, or pregabalin.

• Consider oral corticosteroids in the first 2 weeks following rash onset in immunocompetent adults with localized shingles if pain is severe, but only in combination with antiviral treatment.’

17. Dr O was diagnosed with shingles in A&E on 28 October 2024. It discharged her with a prescription for acyclovir (an antiviral medication), prednisolone (a corticosteroid) and cocodamol (an opioid containing 30g codeine and 500g paracetamol). It gave her advice to contact the Practice to consider additional medication for neuropathic pain.

18. She contacted the Practice on 30 October saying her pain was not under control with the medication given to her in A&E.

19. The Practice prescribed amitriptyline 10mg to increase gradually to 30mg. This is in line with NICE guidelines to start neuropathic medication when patients with shingles are experiencing more severe pain.

20. Dr O next spoke to the Practice on 5 November saying she remained in severe pain. The Practice called her the same day and increased her dose of amitriptyline to 25mg. It reduced her co-codamol dose.

21. NICE guidance on the use of amitriptyline for neuropathic pain says:

‘The initial dose is 10 to 25 mg amitriptyline a day (taken at night), gradually titrated up in 10 to 25 mg steps every 3–7 days in one to two divided doses to an effective dose or the person's maximum tolerated dose (no higher than 75 mg a day).’

22. The Practice started amitriptyline at a dose in line with the NICE guidance. It also continued to assess and evaluate the amitriptyline dose upwards when Dr O contacted the Practice on 5 November.

23. The guidance also says:

‘Consider trialling amitriptyline for 6–8 weeks, with at least 2 weeks at the maximum tolerated dose, before deciding it is not effective.’

24. It was in line with that guidance for the Practice to keep Dr O on amitriptyline following the increase in the dose to allow for an adequate assessment to see if this was effective.

25. Dr O next contacted the Practice on 22 November. She said the pain relief was not effective for her pain levels.

26. The Practice prescribed gabapentin the same day. This is recommended as an alternative neuropathic medication in NICE guidelines on the management of shingles pain and was the appropriate next step. The prescription of Dr O’s pain relief was timely and in line with NICE guidelines on the management of shingles pain.

27. Dr O expressed concern over a prescription for codeine given her history of gallstones and a previous cholecystectomy. She also expressed concern that codeine had been prescribed for longer than three days.

28. Dr O was first given a prescription in A&E on 28 October for co-codamol containing 30mg of codeine and 500mg of paracetamol. The Practice issued a further prescription for 60 tablets of a lower dose of co-codamol containing 15mg of codeine and 500mg of paracetamol on 5 November to last a whole week when taking the full dose.

29. NICE guidance on the use of codeine for mild to moderate pain says codeine can be prescribed for short-term treatment of acute moderate pain.

30. It advises against the prolonged use (over three months) because of a risk of dependence and addiction if taking codeine long term. Dr O had been taking the medication for a much shorter period and therefore these risks did not apply to Dr O.

31. NICE guidelines advise caution in prescribing or taking codeine when there is a history of gallstones. This is not given as a contra-indication (when medication should be avoided) and codeine can still be prescribed. There is no information in the guidelines about prescribing codeine specifically following cholecystectomy, only if there are gallstones.

32. We have seen no indication the prescriptions for codeine and the Practice’s management of Dr O’s pain relief was outside of the relevant NICE guidance.

Request to see a GP

33. Dr O spoke with the Practice on 13 November due to concerns of complications of taking pain medication with narcotic bowel syndrome and said she was symptomatic with this. She said she was experiencing abdominal pain and bloating which was different to her shingles pain and requested an emergency appointment to see a named GP.

34. GMC guidelines on good medical practice say:

‘In providing clinical care you must: • adequately assess a patient’s condition(s), taking account of their history, including • symptoms • relevant psychological, spiritual, social, economic, and cultural factors • the patient’s views, needs, and values • carry out a physical examination where necessary • promptly provide (or arrange) suitable advice, investigation, or treatment where necessary

35. On offering remote consultations the GMC guidelines say:

‘You must provide safe and effective clinical care whether face to face, or through remote consultations via telephone, video link, or other online services. If you can’t provide safe care through the mode of consultation you’re using, you should offer an alternative if available, or signpost to other services.’

36. When Dr O rang to request an urgent face-to-face appointment for her abdominal symptoms on 13 November, her symptoms were not assessed by a clinician that day, either remotely or face-to face. That appears not to be in line with the GMC guidance above.

37. Instead, the Practice signposted her to other services in a text message with advice to attend alternative services if she had not been contacted by the Practice and if she felt her symptoms were urgent.

38. Dr O subsequently attended a minor injuries unit the following day while waiting for triage where she was reviewed and given advice regarding ongoing nerve pain. No abdominal problem was identified.

39. Our GP adviser said GMC guidance means that in this scenario the Practice should have reviewed Dr O’s request for an urgent appointment the same day and, in this case, for her to be contacted about her symptoms.

40. Symptoms of abdominal pain can require examination for a full evaluation. However, if a clinician is satisfied via a telephone assessment that symptoms do not indicate a potentially serious condition, then a face-to-face consultation and physical examination may not be necessary.

41. The Practice’s triage system at the time did not enable safe triage of urgent clinical requests after it’s cut-off time for submission of triage forms. This meant serious conditions could have been missed.

42. Although we cannot say Dr O definitely needed an abdominal examination, an urgent request for an appointment was not reviewed by the Practice the same day. This is outside of GMC guidance to adequately assess a patient’s symptoms.

43. We discussed this with the Practice. The Practice says a recent nationwide change in the way in which appointment requests are triaged has been put in place. That means any on the day requests are triaged the same day with a clinician follow up and/or appointment. That should prevent the issues Dr O experienced from happening again.

44. The Practice recognises the distress the events had on Dr O. It has agreed to apologise to Dr O. in addition to the national change in appointment triage, it has agreed to implement several service improvements to prevent a recurrence.

45. The Practice told us multiple clinicians now triage requests throughout the day to ensure patients get the right care at the right time.

46. It has also reviewed communication on its askmyGP platform when patient requests are clinically deemed routine or non-urgent to ensure patients understand the next steps and/or timeframes. Its online platform is now open during core surgery opening hours to allow patients to submit requests throughout the day.

47. It said learning from complaints and incidents is shared with the individuals involved, the Practice team, and organisationally for continuous learning and development and Dr O’s complaint will be taken to the next Practice clinical meeting for discussion.

48. We consider this is enough to remedy the impact the events had on Dr O and prevent a recurrence. The distress Dr O experienced was limited to one day, as she was seen in the minor injuries unit the next day. Our guidance on financial remedy says an apology is usually sufficient remedy for distress of short duration.

49. We recognise the frustration Dr O experienced in the clinical care and treatment she received for symptoms of shingles. We acknowledge the distress this caused her. We are grateful to Dr O for bringing her concerns to our attention.

1. We have carefully considered Dr O’s complaint about her GP Practice. We understand the events that caused Dr O to complain are important to her. We recognise how distressing it was for her to feel like she did not receive the correct care.

2. We acknowledge Dr O’s concerns that the Practice did not treat her appropriately for symptoms of shingles. We have seen no indication the clinical care Dr O received was incorrect. We identified a failing in the way the Practice triaged urgent requests from patients for them to be assessed or seen by a clinician the same day. We have decided the Practice has already done enough to put right the impact of these events on Dr O.