A practice in the Wandsworth area

4. Ms A raises concerns about the Practice’s management of her pregnancy between August and October 2023. Ms A specifically complains that the Practice: • did not properly investigate her persistent symptoms of possible infection, did not carry out a physical examination or a swab, and relied only on urine tests • did not refer her to hospital despite repeated requests and midwife guidance • did not recognise her pregnancy as high-risk given her age, symptoms, and previous miscarriage • most reviews were by telephone or with a Physician Associate rather than a GP • treated her symptoms as urinary infections despite negative cultures and gave antibiotics that did not address her concerns.

5. As a result, Ms A says her waters broke at 18 weeks, and her baby did not survive. She believes an undetected infection may have contributed to this. She says that she, her husband, and their young daughter have experienced severe emotional distress, and she fears she may struggle to conceive again.

6. As an outcome to her complaint, Ms A would like an acknowledgment of failings, service improvements, and a financial remedy to support future fertility treatment.

7. Ms A became pregnant in June 2023 following previous fertility difficulties and a miscarriage in 2022.

8. Between August and October 2023, Ms A contacted the Practice several times reporting symptoms including urinary discomfort, pelvic pain, and abnormal discharge. She had a mix of telephone and face-to-face reviews with a GP and a Physician Associate (PA). The Practice arranged urine tests and prescribed antibiotics for suspected urinary infection.

9. Ms A says her symptoms continued and that she asked for further investigation and a referral to hospital.

10. In October 2023, at 18 weeks of pregnancy, her waters broke early. She was admitted to hospital, and her baby sadly died two weeks later.

11. Ms A believes an undetected infection during pregnancy contributed to this outcome.

Assessment and investigation of symptoms and treated her symptoms as urinary infections 15. Ms A says that between August and October 2023 she repeatedly reported symptoms during pregnancy that may indicate infection, including pelvic pain, urinary discomfort, abnormal discharge and strong-smelling urine. She says the Practice relied mainly on urine testing and did not properly investigate her symptoms.

16. The GMC guidance says doctors must adequately assess a patient’s condition, taking account of their history and symptoms, and provide or arrange appropriate investigations where necessary.

17. The BMJ abdominal pain guidance says abdominal pain in pregnancy is common and can be difficult to diagnose because normal pregnancy changes can alter symptoms. It says clinicians should carry out a careful assessment, consider a range of possible causes, and recognise that some discomfort may be physiological rather than serious.

18. The NICE UTI in pregnancy guidance says that where urinary infection is suspected in pregnancy, a mid-stream urine sample should be sent for culture, and antibiotics may be prescribed if clinically indicated.

19. The NICE renal colic guidance supports arranging ultrasound imaging in pregnant patients where renal causes are being considered.

20. The records show that on 17 August 2023 Ms A was seen face-to-face. A full history was taken, including her pregnancy status and symptoms (tiredness, flu-like symptoms, and discomfort in her lower abdomen). Her observations were normal, and the PA carried out an abdominal examination.

21. The PA arranged urine and blood tests, and provided safety-netting advice. It was noted that Ms A had a scan booked in two days’ time, but the PA advised she could attend at the early pregnancy unit if she wanted to be seen earlier.

22. Our adviser said Ms A did not have any red flag early pregnancy symptoms at this consultation like bleeding, discharge, fever or bowel symptoms. Our adviser said the PA assessed Ms A appropriately and requested appropriate investigations based on her symptoms.

23. We consider the PA acted in line with the GMC guidance as they assessed Ms A’s condition, taking account of her history and symptoms, and arranged appropriate investigations. We also consider they acted in line with the NICE UTI in pregnancy guidance as a mid-stream urine sample was sent for culture.

24. On 21 August Ms A spoke to a GP over the phone as she was concerned about her ongoing lower abdominal discomfort. The GP explained her test results were normal, aside from microscopic blood in the urine, which they explained can be normal in pregnancy. Due to the discomfort and the presence of blood in the urine, the GP referred her for a renal tract ultrasound scan. The GP also advised her to speak to the community midwives if she had ongoing concerns.

25. Again, our adviser said there were no red flag symptoms at this consultation. Our adviser said it was appropriate to consider that renal stones could be the cause of her discomfort, and an ultrasound is an appropriate investigation for this. We consider the GP acted in line with the NICE renal colic guidance as they arranged ultrasound imaging to exclude any renal causes for her ongoing discomfort.

26. Ms A made a face-to-face appointment on 22 August 2023, when she reported ongoing symptoms. The GP arranged further urine testing, and prescribed antibiotics while awaiting the results.

27. Our adviser said based on the information available at the time, it was reasonable for the Practice to assess and manage Ms A’s symptoms as a possible urinary tract infection and to consider antibiotics to see if they settled her symptoms whilst awaiting the results of the further urine test, and the renal tract ultrasound.

28. We consider the GP acted in line with the GMC and NICE UTI in pregnancy guidance during this consultation, as they assessed Ms A and arranged for suitable investigations.

29. The renal ultrasound on 8 September 2023 did not identify any significant abnormality. Ms A was also under obstetric care and she was reviewed by them on 16 September 2023 where she discussed her ongoing abdominal discomfort.

30. Ms A contacted the Practice again on 9 October 2023. She spoke to a PA over the phone and explained that she felt that she had a urine infection as she had pain when urinating, lower abdominal discomfort, and strong-smelling urine. The PA arranged for a further urine test, and safety-netting advice was given.

31. Our adviser said Ms A again showed no red flag symptoms during this consultation. They said as Ms A was still concerned about a urine infection, it was appropriate to arrange a repeat urine sample.

32. We consider the PA acted in line with the GMC and NICE UTI in pregnancy guidance during this consultation, as they again assessed Ms A and arranged for suitable investigations.

33. During this period, Ms A was also having antenatal checks and scans, and no abnormality was detected.

34. The BMJ abdominal pain guidance does suggest that patients can suffer with abdominal pain with no sinister cause throughout the pregnancy. We have seen that throughout this period, the Practice assessed Ms A at each consultation and arranged appropriate investigations, in line with the GMC, NICE UTI in pregnancy, and NICE renal colic guidance.

35. Our adviser said there was no complaints of vaginal discharge in any of the consultations which would have indicated the need for vaginal swabs.

36. We have seen no indications that any red flag symptoms were missed, or that anything further should have happened. As such, we have not identified any indications of failings and for this reason, we will not be investigating this issue any further.

Referral to hospital

37. Ms A says she was denied referral to hospital despite advice from the midwifery team. She says the midwives told her that, because of her stage of pregnancy, her care should be managed by her GP and that the GP was responsible for referring her to hospital if needed. She says that when she raised her concerns, the GP declined to refer her and told her that because she had no fever or bleeding there was no danger.

38. The records show that on 21 August 2023 Ms A submitted an e-consultation request in which she mentioned wanting a hospital referral.

39. She was reviewed by telephone by a GP on 22 August 2023. The GP’s consultation notes from that day do not record that Ms A requested referral during the call. There is no documentation that a referral was discussed or declined. The notes record discussion of her symptoms and the plan for further investigation.

40. No referral was made following that consultation.

41. We have carefully compared Ms A’s account with the clinical records. The records do not document that the referral was discussed, that GP refused a referral request, nor do they record that referral was declined on the basis that she had no fever or bleeding.

42. We can only base our findings on the available evidence. The GP records do not document a request for referral or a refusal. The Practice’s complaint response does refer to any referral request that was rejected.

43. As we have conflicting accounts of what happened, and we do not consider that there is any independent evidence we could obtain to allow us to reach a view on whether the GP refused to refer Ms A to hospital, we are unfortunately unable to reach a finding on this point. As such, we will not be considering this issue any further. We appreciate that this will be disappointing for Ms A.

Recognition of pregnancy risk

44. Ms A says the Practice did not recognise her pregnancy as higher risk between August and October 2023, given her age, previous miscarriage, and ongoing symptoms.

45. The NICE antenatal care guidance explains that most routine pregnancy care is led by midwives in the community. This includes scheduled antenatal appointments, standard ultrasound scans, blood pressure and urine checks, screening tests, and ongoing assessment for pregnancy-related risks. It says women who need additional or specialist care should be identified and referred by the midwives to secondary care.

46. The records show Ms A was under the care of maternity services during this period. She had pregnancy scans confirming a viable intrauterine pregnancy and was reviewed by the obstetric team at 16 weeks.

47. As explained above, when Ms A contacted the Practice, we consider the GP addressed the specific symptoms she reported at the time and arranged appropriate assessment and investigation of those symptoms.

48. Our adviser explained that formal pregnancy risk assessment is usually carried out at the first booking appointment with the midwifery team, and ongoing antenatal care and risk management are led by maternity services. GPs manage specific clinical symptoms when patients present to them but do not lead overall antenatal risk assessment.

49. Our adviser said midwives are specialists to assess the risks of the patient with respect to age and previous history.

50. Therefore, in line with the NICE antenatal care guidance, it would have been for the midwives to assess risk and refer Ms A to specialist care if appropriate at the initial booking appointment, and any further appointments after this. As such, we have not seen any indications of failings with the Practice not assessing her risk and we will not consider this issue further.

Appropriateness of telephone and PA reviews

51. Ms A says that most of her reviews were conducted by telephone or by a PA rather than by a GP, despite her ongoing symptoms during pregnancy.

52. The NHS Modern General Practice guidance explains that GP practices use structured triage systems to assess patients’ needs and allocate them to the most appropriate healthcare professional. This may include telephone, online, or face-to-face consultations and review by different members of the practice team.

53. The records show that Ms A contacted the Practice through its triage system and was reviewed by both GPs and a PA.

54. Our adviser explained that telephone consultations can be appropriate where a patient is clinically stable and there are no red-flag symptoms requiring immediate face-to-face assessment, as in Ms A’s case.

55. Our adviser also explained that PAs are trained clinicians who work within GP practice teams and are supported by GPs. Having reviewed the records, they said they could not identify anything in the PA consultations that would have been managed differently if a GP had carried out the review.

56. Therefore, we consider the Practice acted in line with the NHS Modern General Practice guidance by triaging Ms A’s symptoms and providing her with an appropriate appointment on each occasion for her symptoms. As explained above, we have not seen any indications of failings in the care and treatment provided by the Practice during any of the consultations. For this reason, we will not be taking this part of the complaint further.

57. We are deeply sorry for the loss Ms A has experienced and recognise the lasting impact this has had on her and her family. We understand how important it is for her to have answers. While our role is to consider whether there are indications that the Practice acted below expected standards, nothing in this decision is intended to diminish her grief or the significance of her experience. We extend our sincere sympathy to Ms A and her family.

1. We have carefully considered Ms A’s complaint about the Practice and offer our sincere condolences for her loss. We recognise how distressing this has been for her and her family.

2. We thank Ms A for taking the time to bring her concerns to us. After reviewing all the evidence we have not identified any indications of failings in the care provided by the Practice between August and October 2023.

3. We acknowledge Ms A’s concerns that the care provided by the Practice may have contributed to the outcome she experienced. Based on the information available, we have not identified indications of failings in the GP care that would have caused this outcome. For this reason, we will not be taking further action.