A practice in the Chelmsford area

7. Miss R complains about the care provided to her and her daughter, Miss L, by the Centre between July and October 2024.

8. Miss R complains that the Centre:

• misdiagnosed her daughter with pompholyx in July 2024 and did not perform any further investigations into her symptoms • misdiagnosed her with eczema and body lice in October 2024 and December 2024 • did not provide consistent treatment, despite them suffering the same symptoms.

9. Miss R says that as a result of this herself and her partner had to seek private treatment and were diagnosed with scabies in December 2024. They had caught scabies from Miss L, and the whole family suffered physically and emotionally for 6 months before they received the correct treatment.

10. Miss R would like:

• an apology for the misdiagnosis and lack of investigations into their symptoms • a financial remedy of around a level three.

11. On 1 July 2024 Miss L had an e-consultation with the Centre and attached a photo of a rash on her skin. She was advised to seek treatment from her pharmacy.

12. On 26 July 2024 Miss L contacted the Centre about the rash again. It asked her to come into the Centre on the same day for an appointment. At this appointment she was diagnosed with pompholyx (a type of eczema that causes itchy blisters on the hands or feet).

13. On 14 October 2024 Miss R sent the Centre a photo of a rash that had appeared on her arm. The Centre advised that it was likely eczema, and to treat it accordingly.

14. On 28 October 2024 Miss R had an in-person appointment with a nurse at the Centre. Miss R raised the possibility of scabies to the nurse however was dismissed. Miss R was told at this appointment that the rash was an allergy, despite her telling the Centre that her whole family was suffering from the same symptoms.

15. On 4 November 2024 Miss R’s partner was also suffering with symptoms and decided to seek private treatment. They were immediately diagnosed with scabies and offered a steroid cream as treatment. Miss R was also diagnosed with scabies at the time and offered a steroid cream.

16. On 21 November 2024 Miss R returned to the Centre as she had run out of the cream she had been prescribed. She was told that she had a ‘post scabies rash’. She requested more steroid cream on 2 December 2024.

17. On 9 December 2024 Miss R had another appointment with a nurse at the Centre. Her medical note recorded at this appointment stated that she had body lice.

18. On 13 December 2024 Miss R attended the Centre again and prescribed her with more steroid cream.

Miss L’s misdiagnosis in July 2024 and lack of further investigations

22. Miss R complains that the Centre misdiagnosed her daughter Miss L with pompholyx in July 2024.

23. She also complains that the Centre did not offer any further investigations into Miss L’s symptoms. We understand that it will be frustrating for Miss R and Miss L to feel that Miss L’s scabies could have been diagnosed and treated sooner.

24. 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 seen any indications that something has gone wrong.

25. On 1 July 2024 Miss L had an online consultation with the Centre as she had itchy spots on her hands and feet. The records show that photos of Miss L’s rash were sent to the Centre.

26. The Centre advised Miss R to seek over the counter antihistamines and steroid creams as treatment for Miss L.

27. On 26 July 2024 Miss L had a telephone consultation with the Centre. She explained that she had itching on her legs and arms for several weeks which was sometimes keeping her awake at night. The Centre confirmed with Miss L that she had been taking the antihistamines and using the steroid cream.

28. The Centre therefore arranged for Miss L to have a face-to-face appointment with it on the same day. The records indicate that on examination at this appointment, there was no rash on Miss L’s skin. The Centre then arranged blood tests for Miss L to look into the reason for her itching.

29. In its complaint response the Trust apologised for not diagnosing Miss L sooner. It explained that scabies is difficult to diagnose and can be frequently misdiagnosed as other similar conditions such as allergies or eczema. It explained that the clinicians at the Centre reviewed the photos that they had initially examined and concluded that the treatment they offered at the time was correct.

30. We asked our adviser if the Centre were correct to not offer Miss L a face-to-face appointment when she first raised concerns on 1 July 2024 and only examine her via photographs.

31. The GMC guidance explains that ‘if you access, diagnose or treat patients, you must: adequately assess the patient’s conditions’. Our adviser explained that in order for the Centre to have adequately assessed Miss L’s condition, it could have examined her either by photographs or in person. We can see on Miss L’s medical records that it received photographs of the rash.

32. The Centre advised Miss L to use an over-the-counter steroid cream and an antihistamine. It did not prescribe anything to treat Miss L on this occasion.

33. We consider in line with the GMC guidance, the Centre appropriately assessed Miss L through photographs. We discussed with our adviser if the advice given to Miss L to use over the counter steroid cream and antihistamines was appropriate.

34. Our adviser explained that when a patient presents with a rash it can be difficult to diagnose it as anything specific in the first instance as the same rash appearance can be caused by many different conditions.

35. The scabies diagnosis guidance explains that a diagnosis of scabies is made by taking the history and performing an examination of the affected person. It then lists multiple other ‘differential’ diagnosis of scabies, including body lice, eczema, contact dermatitis and insect bites.

36. Our adviser said the advice from the Centre would have been the appropriate treatment for conditions such as eczema or itchy insect bites. As Miss L was presenting with symptoms that may also have been indicative of such conditions, it was appropriate for the Centre to offer her this advice in the first instance.

37. On 26 July 2024 Miss L had a face-to-face consultation with the Centre as she had ‘itching on her legs and arms for several weeks’. Miss L was examined at this appointment, and it was recorded that there was no rash present on her body. The Centre arranged for Miss L to have a blood test to further investigate the cause for the itching.

38. Our adviser explained that scabies could not have been diagnosed at this appointment as there was no obvious rash present. They told us that itching is a very common symptom of many conditions, such as liver or thyroid problems and it was therefore appropriate for the Centre to refer Miss L for a blood test, as the blood test would be able to identify these.

39. The GMC guidance says that in providing clinical care doctors should carry out a physical examination where necessary and promptly provide (or arrange) suitable advice, investigation or treatment where necessary.

40. The records show that the Centre examined Miss L and then referred her for a blood test when no rash was present. We consider this was in line with the GMC guidance as it physically examined Miss L and referred her for further investigations.

41. We recognise that it will be frustrating for Miss R and Miss L to feel that her scabies could have been diagnosed sooner.

42. We consider the Centre appropriately, and in line with the GMC guidance, assessed Miss L via photographs on 1 July. We consider it was appropriate for the Centre to have made a diagnosis of pompholyx based on Miss L’s initial symptoms, and due to that, the advice to use over-the-counter medication was appropriate and in line with the GMC guidance.

43. We also consider the Centre appropriately assessed Miss L in person and arranged further investigations in line with the GMC guidance on 26 July. As such we have seen no indications of failings in this aspect of her complaint.

Miss R’s misdiagnosis in October 2024

44. On 14 October 2024 Miss R submitted an e-consultation about a rash that had appeared on her arm. In this e-consultation she did not mention that her family were experiencing similar symptoms. The Centre advised her that it was likely eczema and to treat it accordingly.

45. On 28 October 2024 Miss R had an in-person appointment with a nurse at the Centre as the rash on her arm was continuing to spread. Miss R told us that she raised the possibility of it being scabies at this appointment however she was dismissed. The records show that she explained that her whole family was suffering from similar symptoms at this time.

46. On 4 November 2024 Miss R was seen in-person at the Centre. At this appointment scabies was diagnosed and the relevant treatment was prescribed for Miss R and her daughter, Miss L.

47. Our adviser explained that when a patient presents with a rash it can be difficult to diagnose it as anything specific in the first instance as the same rash appearance can be caused by many different conditions. The GMC guidance says that ‘if you access, diagnose or treat patients, you must: adequately assess the patient’s conditions’.

48. As Miss R did not mention that her family were experiencing the same symptoms, and as this was her first contact about this, our adviser said it was appropriate on 14 October for the Centre to have considered eczema as a cause of her rash.

49. The scabies diagnosis guidance says that scabies diagnoses are made from the history and examination of the affected person, and a history from their family and close contacts.

50. Miss R told the nurse on 28 October that her whole family was suffering with similar symptoms. There is no evidence on Miss R’s medical records that the Centre considered this information.

51. Our adviser said that in order for the Centre to be acting in line with the GMC guidance and the scabies diagnosis guidance, it should have considered the information Miss R provided to it about her family and close contacts at her 28 October 2024 consultation. It did not and we consider this is an indication of a failing. We need to assess the impact of this on Miss R and Miss L.

52. We have found that the Centre should have considered the possibility of Miss R having scabies and treated her accordingly on 28 October 2024. The records show that on 4 November 2024 the Centre identified that Miss R and her daughter, Miss L, were likely suffering from scabies, they were prescribed permethrin cream. Permethrin is a cream that is used to treat scabies.

53. We have established above that the Centre were correct to not diagnose Miss L with scabies when she contacted it with symptoms in July 2024. Following her blood test on 8 August 2024, Miss L did not contact the Centre again with symptoms until 2 September 2024.

54. Miss L’s medical records show that on 2 September 2024 she explained to the Centre that she had finished the course of antihistamines that it prescribed her and since then, her symptoms were returning. The Centre prescribed her a repeat of the course of antihistamines.

55. The GMC guidance says that the ‘investigation or treatment you propose, provide or arrange must be based on this assessment, and on your clinical judgement about the likely effectiveness of the treatment options’.

56. Miss L told the Centre that since she stopped taking her antihistamines her symptoms were returning. The Centre therefore made the decision to prescribe her antihistamines again as they had worked for her previously. This is in line with the GMC guidance as it assessed the likely effectiveness of antihistamines as a treatment option and prescribed them accordingly.

57. Miss R or Miss L did not contact the Centre to discuss Miss L’s symptoms again until Miss R attended the Centre on 28 October 2024. Had the Centre taken into consideration the information about the rest of the family suffering with the same symptoms on 28 October, it would have identified that she likely had scabies and would have treated both her and her daughter accordingly. It did not do so until 4 November 2024, this is a delay in starting the correct treatment of 1 week.

58. Miss R explained to us that she experienced continuous itching that affected her sleep throughout this time period. Miss R also told us that her daughter, Miss L was suffering from similar symptoms.

59. We contacted the Centre to discuss the indications of failings we identified. We asked the Centre if it would be willing to provide Miss R with a financial remedy and a written apology to remedy the impact caused to Miss R and Miss L.

60. Our NHS Complaint Standards say organisations should openly identify instances when things have gone wrong, or where services have had an unfair impact, and take responsibility for these. They should make sure staff can offer a range of ways to put things right for the individual.

61. Our ‘Guide to Financial Remedy’ sets out our ‘severity of injustice scale’ (our scale). This is a guide which helps us decide an appropriate amount of financial remedy, depending on the injustice the person has suffered. The scale has six bands ranging from levels one and two lower-level injustices of frustration and pain up to level six where often loss of life or profound effects on a person being able to live a normal life.

62. In this instance, we recognise the impact caused to Miss R and Miss L to be at a level two on the scale. This is because Miss R and Miss L experienced itching and a loss of sleep for a period of around a week when the correct treatment could have prevented this. Our scale explains that cases where there is ‘minor pain lasting from a few days to a month or severe pain lasting no more than a week’ we usually recommend a financial remedy of between £120 - £550.

63. We also conduct precedent checks to look for similar themes to help inform our thinking on remedy and checks on similar sorts of awards made to ensure consistency. As part of this process, we contacted the Centre to discuss our findings with it.

64. The Centre acknowledged the mistakes that it made in Miss R’s treatment and the subsequent effect it had on Miss L’s treatment. It agreed with our findings and said that it will make a payment of £120 to Miss R in recognition of the discomfort and distress that its failings caused them. It has also agreed to send Miss R a letter of apology.

65. Taking this into account, we are satisfied that this apology and financial payment is in line with our NHS complaint standards and our severity of injustice scale and is enough to remedy the impact caused. Therefore, we will not be recommending any further action.

Miss R’s misdiagnosis in December 2024

66. Miss R’s records show that she attended an appointment at the Centre on 2 December 2024. At this appointment she explained to it that her symptoms were still ongoing, despite the treatment. On 9 December 2024 Miss R contacted the Centre again with the same issues. The Centre advised her to continue to use the permethrin cream that it had previously prescribed her.

67. On 13 December 2024 Miss R had another appointment at the Centre. Miss R told us that the Centre told her that it was ‘body lice’. It prescribed her steroids at this appointment.

68. The GMC guidance says you must give patients the information they want or need in a way they can understand, and you must make sure that the information you give patients is clear, accurate and up to date, and based on the best available evidence.

69. Miss R did not have body lice on 13 December, so it is not clear why the Centre told Miss R that she had body lice, when she had already been diagnosed with scabies and provided with treatment for this. This communication with Miss R was unclear and inaccurate and is therefore not in line with the GMC guidance.

70. The scabies diagnosis guidance says to treat scabies with permethrin cream. It says once treatment is finished, if symptoms persist or reoccur, to advise retreatment with permethrin cream.

71. In line with this, Miss R was prescribed permethrin cream by the Centre and it continued to recommend that she was treated with this when she attended with continuing symptoms in December 2024. It also prescribed her further steroids following her 13 December 2024 appointment. Our adviser told us that this was an appropriate treatment for scabies.

72. We recognise that it will have been frustrating for Miss R to have had the Centre tell her that she had ‘body lice’ at her appointment on 13 December 2024. Our adviser explained to us that the treatment that Miss R received would have been the same treatment that she would have received for recurring scabies.

73. Although we recognise that Miss R had scabies at this appointment and it was incorrectly recorded as her having ‘body lice’, we do not consider this had any impact on Miss R as she received the correct treatment for scabies at this time. Therefore, we will not consider this issue any further.

Lack of consistent treatment

74. Miss R complains that herself and the rest of her family did not receive consistent treatment for their similar symptoms.

75. We have established earlier in this report that it was appropriate for the Centre not to initially diagnose Miss L with scabies when she first contacted the Centre with a rash. We have also established that the treatment she was provided with at this time was appropriate.

76. As previously mentioned, our adviser explained to us that when a patient presents with a rash it can be difficult to diagnose it as anything specific in the first instance as the same rash appearance can be caused by many different conditions.

77. The scabies diagnosis guidance explains that a diagnosis of scabies is made by taking the history and performing an examination of the affected person. It then lists multiple other ‘differential’ diagnosis of scabies, including body lice, eczema, contact dermatitis and insect bites.

78. We can see in the records that when the Centre did make the diagnosis of scabies on 4 November 2024 it prescribed permethrin cream to both Miss R and Miss L. Permethrin cream is a parasiticide used to treat scabies and lice. The scabies diagnosis guidance recommends permethrin cream as the first line of treatment for cases of scabies.

79. When Miss R and Miss L first attended the Centre with symptoms they were both advised of similar treatment. When the diagnosis of scabies was made, the Centre also provided the same and appropriate treatment for both Miss R and Miss L.

80. We understand that it will have been frustrating for Miss R to feel that herself and Miss L were not receiving consistent treatment. We have found that the treatment for both Miss R and Miss L was in line with the scabies diagnosis guidance, appropriate and consistent.

81. We would like to thank Miss R for taking the time to bring this complaint to us. We understand that it will have been difficult for her and her family to be suffering from scabies for such a long period of time. We hope that this report offers her some closure on this matter.

1. We have carefully considered Miss R’s complaint about a Healthcare Centre in the Chelmsford area (the Centre).

2. We would like to thank Miss R for taking the time to bring this complaint to us. We recognise that herself and her daughter had difficult experiences whilst under the care of the Centre.

3. Miss R complains that the Centre misdiagnosed her daughter, Miss L, with pompholyx in July 2024 and did not perform any further investigations into her symptoms. We have found that the Centre did examine Miss L via photographs on July 2024 and recommended her appropriate treatment.

4. Miss R also complains that the Centre misdiagnosed her with eczema and body lice in October 2024 and December 2024. We have found that the Centre should have considered scabies on 28 October 2024 when Miss R contacted the Centre and explained her symptoms, it did not.

5. We have undertaken further conversations with the Centre. It has agreed to take further steps to put things right and has offered £120 and an apology to recognise the impact that its failure to consider scabies as a diagnosis had.

6. Miss R also says that the Centre did not provide consistent treatment for herself and Miss L, despite them suffering the same symptoms. We have found that the treatment provided to both Miss R and Miss L was consistent.