A practice in the Bexley area

3. Mr X is raising a complaint about the service provided by the Practice in November 2024. He complains that the Practice: • did not appropriately prioritise his physical health needs following discharge from hospital after a CT scan showing a stroke • focused inappropriately on his mental health and personal circumstances • made a safeguarding referral to Social Services regarding his children which he believes was unnecessary • included information in the safeguarding referral which he disputes, including references to him being suicidal or crying.

4. Mr X says these actions caused him significant emotional distress, stress to his family, and time off work which he believes affected his career progression.

5. As an outcome, Mr X would like a formal apology, apologies from individual clinicians involved, consideration of financial compensation, and service improvements.

6. On 6 November 2024, Mr X attended the hospital with chest tightness and other symptoms. He was discharged on 7 November 2024 and told that a CT scan showed evidence of a stroke, with advice to follow up with his GP.

7. The Practice contacted Mr X by text message inviting him to book a GP appointment. He initially booked an appointment for 20 November 2024 but later requested an earlier date.

8. Mr X attended the Practice on 15 November 2024. He was seen by a Paramedic. During this consultation a safeguarding referral regarding his children was made.

9. On 18 November 2024, Mr X was contacted by Social Services and informed that there were no safeguarding concerns regarding his children.

10. On 20 November 2024, Mr X saw a GP at the Practice and was referred to a Transient Ischemic Attack (TIA - often referred to as a mini stroke) clinic.

Stroke follow-up care

14. Mr X was discharged from hospital on 7 November 2024. He complains that the Practice should have seen him earlier and made a referral for follow up care after the CT scan showed signs of a stroke.

15. Our adviser said the CT scan carried out on 6 November 2024 showed evidence of an old stroke, which was an incidental finding rather than an acute, recent stroke.

16. Our adviser said the purpose of follow-up in cases of an incidental old stroke is secondary prevention, including management of cardiovascular risk factors. Secondary prevention aims to reduce the impact of a disease or injury that has already occurred, and to prevent recurrence.

17. The prevention guidance sets out the management of patients following a stroke or TIA, including secondary prevention measures such as risk factor management and medication. It does not specify urgent follow-up requirements for incidental findings of an old stroke.

18. The GMC guidance says doctors should refer patients to another suitably qualified practitioner when this serves their needs.

19. Mr X was reviewed by the Practice on 15 and 20 November 2024, and a referral to stroke services was made on 21 November 2024. He was then seen in the clinic on 28 November.

20. Our adviser explains this was not an acute stroke that had just happened and was an incidental finding. In these circumstances, there is no guidance to say how quickly a referral to stroke services should be made. This was made on the 21 November which was 14 days after his discharge. This is in line with the GMC guidance.

21. An MRI scan later confirmed that Mr X had not experienced a stroke, further supporting that urgent stroke follow-up was not required.

22. We have therefore seen no indications of failings in the Practice’s management of Mr X’s stroke follow-up.

Safeguarding referral and consideration of mental health

23. During the appointment on 15 November, the Paramedic made a safeguarding referral relating to Mr X’s children, due to their concerns about Mr X’s mental health. Mr X strongly disagrees with the safeguarding referral and the information recorded within it, such as reference to him being suicidal and crying.

24. The medical records show that Mr X contacted the Practice on 14 November asking for an urgent face-to-face appointment as he was having a recurrence of his depressive symptoms. He reported that he had ‘a mental breakdown at work yesterday’.

25. The records state that he had been previously diagnosed with depression and anxiety in 2019. He explained to the Paramedic that he had been feeling anxious and stressed due to work and home issues, which led to his chest pain, that he attended at A&E for.

26. The records say that Mr X told the Paramedic that he ‘didn’t want to wake up anymore in the morning and prays to god that he dies’. It is noted that Mr X had not told his wife about his mental state and that he had brought his 6-month-old son to the appointment.

27. The Paramedic documented that they had spoken to a GP and agreed to send a family wellbeing referral due to the fact that Mr X had three children at home and he was suffering with depression with thoughts of praying not to wake up in the morning. Mr X was informed of this plan during the appointment.

28. The safeguarding guidance recognises that parental mental health difficulties, chronic stress, and expressions of distress can increase vulnerability for children. The records show that during the consultation Mr X reported significant stress and emotional difficulties.

29. The safeguarding guidance supports identifying potential vulnerability even where there is no immediate safeguarding concern.

30. The NICE guidance also sets out the expected approach to assessing and monitoring people with less severe depressive symptoms, including discussion of concerns, safety-netting, and consideration of follow-up.

31. Our adviser said while there was no evidence of immediate risk to the children, the decision to consider safeguarding was in line with the safeguarding guidance.

32. The safeguarding guidance recognises that factors such as chronic parental stress and mental health difficulties may indicate potential vulnerability, and that the application of professional judgement may result in different approaches in similar circumstances.

33. Therefore, we have not seen any indications of failings in the Practice making a safeguarding referral in these circumstances. As the Practice had concerns about Mr X’s mental health, which he had not disclosed to his wife, it was in line with the Safeguarding guidance for it to consider that the children may be vulnerable and to make a referral.

34. Mr X denies saying that he was ever suicidal or that he cried. The referral states that he said he hopes not to wake up in the morning due to low mood but that he stated he could not harm himself due to his religion. The referral also states that he was tearful in the appointment.

35. There are conflicting accounts of what happened during the appointment and what was said. As there is no independent evidence that we could obtain to say what happened, we are unable to reach a conclusion about whether the information included in the referral was accurate or not.

36. Mr X says the Practice focused inappropriately on his mental health and personal circumstances during this appointment.

37. The GMC guidance says in providing clinical care you must adequately assess a patient’s condition(s), taking account of their history, including symptoms, and promptly provide (or arrange) suitable advice, investigation or treatment where necessary.

38. As above, the records show that Mr X asked for an urgent face-to-face appointment because of a recurrence of his depressive symptoms.

39. The records show that his recent attendance at A&E was discussed and it was noted he had a follow up appointment for a stroke review with a GP on 20 November.

40. From the records of the consultation on 15 November, it appears that Mr X’s main concern was his stress, anxiety, and depression.

41. In line with the NICE guidance (above), and GMC guidance the Paramedic discussed his concerns, provided safety-netting information by sending him information about Crisis Line, and arranged a follow-up on 20 November and 16 December. The Paramedic also sent him information about self-referral for talking therapies.

42. Therefore, we consider it was appropriate for the Paramedic to consider Mr X’s mental health during this appointment as this was listed as the reason for the urgent appointment and was the main symptom that he discussed. The records show that his physical health was not ignored and that a further review was arranged. This is in line with the GMC guidance.

43. We recognise that the safeguarding referral caused Mr X and his family distress and frustration. We have not seen any indications of failings with the safeguarding referral or the action taken during this appointment. As such we will not be taking any further action.

1. We have carefully considered Mr X’s complaint about the Practice. We are sorry to hear about his experience and recognise that the events following his GP appointment in November 2024, including the safeguarding referral, caused him and his family distress.

2. We thank Mr X for taking the time to bring his concerns to us. After reviewing all the evidence, we have not seen any indications of failings in the care provided by the Practice. We have therefore decided to take no further action.