A practice in the Isle of Wight area

4. Mrs K complains about the care and treatment she received from the medical centre between October and November 2024.

5. Specifically, she complains: • the medical centre did not act on the initial discharge notes from a hospital Emergency Department (ED) in September, which explained she was at risk • it did not refer her to the Tissue Viability Team (TVT), as suggested in the hospital’s ED discharge notes from mid-November • receptionists at the medical centre did not allow her to book an appointment with a GP as they did not feel it was necessary • the treating nurses responsible for dressing her wound in mid-November did not listen to her concerns or escalate her condition to a GP, despite her feeling that her leg wound required further attention.

6. The TVT is a specialist nursing service for wounds that are slow to heal, such as surgical wounds, leg ulcers, or pressure sores.

7. Mrs K says the lack of care she received from the medical centre, and its staff, caused her prolonged pain and suffering and ultimately led to surgery on her leg.

8. She says the delay in her care contributed to her experiencing a transient ischaemic attack (TIA) following her admission for surgery and meant she had to move downstairs in her home and use a walking stick because of reduced mobility following her discharge.

9. A TIA is a temporary disruption in blood supply to the brain, also known as a ‘mini stroke’.

10. Mrs K also says this experience has had a significant emotional impact as she has lost confidence when socialising or going out, and also felt she needed to change medical centre as she no longer trusted the care provided.

11. She says her daughters cared for her for four months, and the situation has been distressing and emotionally challenging for her and her family.

12. In bringing the complaint, Mrs K is seeking service improvements to ensure similar issues do not happen again.

13. In September, Mrs K underwent a biopsy on her left leg because of concerns about suspected melanoma. After the removal of her stitches, she developed cellulitis, which was treated with antibiotics. Cellulitis is a spreading skin infection, most commonly of the lower leg.

14. At the end of September 2024, while showering, Mrs K slipped and caught her left leg behind the shower screen. She went to the hospital with leg pain, swelling, and difficulty bearing weight. They admitted her for two nights and discharged at the beginning of October, considered medically fit to return home.

15. The hospital asked the medical centre to monitor Mrs K for any signs of infection once she had completed her antibiotics.

16. The following day, a nurse at the medical centre reviewed Mrs K’s wound as part of a fortnightly wound review. It was noted that Mrs K had knocked the wound that morning, causing swelling, a small laceration, and a large haematoma. The nurse treated and dressed the wound. A haematoma is a kind of bruise that happens when an injury causes blood to collect and pool under the skin.

17. Between mid-October and the beginning of November, Mrs K received regular nursing care appointments.

18. In early November, a family friend, who is a plastic surgeon, reviewed photos of her wound and expressed concerns about how it was healing. They advised Mrs K to see her GP or return to hospital, suggesting removal of dead skin and antiseptic dressings applied.

19. Following their advice, Mrs K contacted the medical centre with her daughters to request a GP appointment. A GP saw her the same day, and a nurse examined and dressed the wound and provided safety netting advice on what to watch for.

20. Later the same day, Mrs K also attended the ED as her daughters were concerned about her wound. The hospital found no signs of infection and advised her to continue attending her regular appointments at the clinic and medical centre. It also stated in its discharge comments that it had referred Mrs K to the TVT.

21. The following day, a nurse treated and redressed Mrs K’s wound. They noted she had an upcoming clinic appointment next week, after which her next nursing team appointments would be arranged.

22. The following week, a dermatology service examined Mrs K’s wound. They treated it and referred her to general surgeons to consider the surgical removal of the dead tissue (debridement).

23. The day after, her daughter contacted NHS 111, as she said Mrs K had developed a high temperature, her wound had opened, and her dressing had soaked. The call handler discussed treatment options, including attending the ED, and noted the family’s preference for a face-to-face appointment with the GP, and so provided safety netting advice.

24. Later that day, Mrs K and her daughter visited the medical centre. It prescribed her antibiotics and advised to attend the ED because of concerns about her wound and suspected cellulitis. They also provided safety netting advice.

25. On the same day, Mrs K went to ED. The hospital diagnosed worsening cellulitis and treated her with antibiotics. They advised her to continue this treatment at home and noted for the GP to make a referral to the TVT.

26. In mid-November, Mrs K attended an appointment with a nurse at the medical centre. The nurse noted her recent ED visit, where she received intravenous and oral antibiotic treatment, that it had already referred her to the TVT, and she was on the leg ulcer care pathway.

27. The nurse treated her wound, changed the dressing, and agreed on a daily change until the wound oozing reduced. They provided safety netting advice and noted Mrs K had already been added to the waiting list for surgical debridement.

28. Mrs K continued to receive nursing care for her leg. In late November, she and her family contacted the TVT and shared photos of her wound. The team saw her following review of the photographs and later admitted her for surgery which took place at the end of November.

Did not act on the ED discharge notes 32. Before we decide if we should investigate 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 we have not found any indications that something has gone wrong.

33. Mrs K complains that the medical centre did not act on the initial discharge notes from a hospital’s Emergency Department (ED) in September, which explained she was at risk.

34. She says this is because when she received a copy of her medical notes from the hospital, she saw a clinician had noted, ‘Even if there is no sign of compartment syndrome, this is a continuum, and that [Mrs K] is at risk as this evolves’ when they transferred her from the ED to a ward.

35. Mrs K believes this meant the medical centre should have monitored her more closely after her discharge. We understand how worried Mrs K felt about her condition and the care she received.

36. In considering this, we reviewed the hospital discharge notes, the guidance provided to the medical centre, and GMC standards for good medical practice.

37. The GMC’s ‘Good medical practice’, paragraphs 7c and e, says doctors should: promptly provide (or arrange) suitable advice, investigation or treatment where necessary, and propose, provide or prescribe effective treatment based on the best available evidence.

38. We can see from the hospital discharge letter in November, following Mrs K’s admission in September, included specific recommended actions for the medical centre. These were for it to monitor Mrs K for any signs of infection in her leg after she completed her antibiotics.

39. We can see no evidence in the discharge summary that the hospital referenced the ED notes or asked the medical centre to take any other specific action beyond monitoring the infection.

40. Our advisor explained a clinician made the notes in the ED records as part of Mrs K’s handover to the hospital ward for in-patient treatment, intending them for hospital staff to use during her care. The notes did not direct the medical centre to take any follow-up action or provide guidance for her community care.

41. The advisor also noted that the medical centre followed appropriate steps to ensure Mrs K received the necessary care after her discharge.

42. The medical records show that several medical professionals, including the medical centre and community nurses, were involved in monitoring and treating Mrs K’s wound.

43. In our view, the notes Mrs K referred to were internal hospital notes intended for hospital staff and not for the medical centre to act on. The GP would not have been aware of these notes on Mrs K’s discharge from the hospital.

44. Based on the evidence, we consider that the medical centre acted in line with the GMC’s Good Medical Practice guidance and the recommendations included in the hospital discharge letter. There was no indication that the medical centre needed to take any further action beyond the care already being provided.

45. While we recognise Mrs K’s concerns and the anxiety this situation caused her, we are satisfied that the medical centre provided appropriate care and monitoring following her discharge and that no action was overlooked based on the information available. We hope our explanation gives some reassurance about what happened.

No referral made

46. Before we decide if we should investigate a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. We have done this and found the medical centre has already taken appropriate steps the address what went wrong.

47. Mrs K complains that the medical centre did not refer her to the TVT as suggested in the hospitals ED discharge notes from min-November. She says this caused her prolonged pain and suffering, and she is seeking service improvements as a result.

48. Our Complaint Standards say when mistakes happen, organisations should openly welcome complaints, take responsibility, apologise and be honest when things have gone wrong.

49. Our Standards also say, organisations should acknowledge and explain why things went wrong and identify suitable ways to put things right. Additionally, it should also look at what action it will take to learn from the experience to continuously improve services and help support staff.

50. In reaching our decision, we have not reviewed the hospital actions, as our focus is solely on the actions taken by the medical centre regarding the referral to the TVT.

51. The medical centre explained in its responses that it had reviewed the records and saw correspondence from both the dermatology service and ED. These letters indicated that they had already made referrals to the relevant specialist teams, including the TVT and general surgeons. It explained these letters did not ask the GP to take any action regarding a referral.

52. It did however note a second ED discharge summary in mid- November had asked the GP to make a referral, which caused confusion. It explained upon further review, the medical centre confirmed with the TVT that it had not received a referral from the ED.

53. To improve its service, the medical centre explained it has instructed its secretaries and admin staff to check onward referrals from secondary care to ensure they have been completed. It said it had also conducted discussions with Practice Managers, the clinical team, and reception staff to strengthen understanding of its wound and leg ulcer pathway.

54. We can see from the medical records, when the ED discharged Mrs K at the beginning of November, and the dermatology service saw her in mid-November, both services stated they had referred Mrs K to the TVT and general surgeons respectively for further treatment.

55. The records also show that the ED discharge summary mid-November, asks for the GP to make a referral to the TVT. Although through family contact, we can also see the TVT saw and admitted Mrs K for surgery around one week later.

56. Our advisor noted that when GPs receive a request for follow-up from secondary care, it is common for administrative staff to check previous correspondence and actions to ensure there is no duplication. They also explained that there is usually a shared understanding between primary and secondary care that any referral or recommendations will be carried out, as advised in the correspondence.

57. Our advisor explained that as the initial correspondence had indicated that the referrals had already been made, there was no clear indication that the GP needed to make an additional referral.

58. Our advisor gave their view that the medical centre acted reasonably based on the information it had at the time. However, the unclear content of subsequent ED correspondence led to administrative confusion.

59. From its responses, we can see that the medical centre took Mrs K’s complaint seriously and recognised where its handling of the referral fell short. It acknowledged the gaps in its processes and committed to service improvements, including auditing referral requests from secondary care providers and regularly reviewing its processes.

60. These actions align with our Complaint Standards, which expect organisations to learn from complaints, make service changes, and support their staff in improving practice. The medical centre also apologised to Mrs K directly for not meeting her expectations and shared details about the steps it is taking to prevent similar issues in the future.

61. We understand how difficult this time must have been for Mrs K while waiting for further treatment, and we appreciate why this complaint is so important to her.

62. While there appeared to be some administrative confusion caused by the content of the hospital’s referral correspondence, our view is that the medical centre recognised and took responsibility for the issues in its processes. It apologised sincerely, implemented changes to address these gaps, and took steps to learn from this experience.

63. In addition, we have conducted a precedent check of our systems to look for similar cases or trends that might indicate a systemic issue and we have not identified any. Therefore, we will take no further action.

64. We hope our explanation reassures Mrs K that the medical centre and its staff have learned from this experience and taken steps to improve and follow best practices moving forward.

Receptionist did not allow her to book an appointment

65. Before we decide if we should investigate a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. We have done this and found the medical centre has already taken appropriate steps the address what went wrong.

66. Mrs K says at the beginning of November, both she and her daughter contacted the medical centre seeking a GP appointment because of concern about her leg and her feeling unwell. Mrs K says that receptionists at the medical centre did not allow her to book an appointment with a GP, as they did not feel it was necessary.

67. Mrs K says the receptionist advised that if there was a problem, the attending nurse would flag any issues. She also mentions it initially refused a further appointment request in mid-November, however it later provided her with an appointment to see a nurse later that morning.

68. Our Principles of Good Administration says, organisations should provide services that are easily accessible to their customers, behave helpfully, deal with people promptly, and take responsibility for the actions of their staff.

69. Similarly, our Complaint Standards highlight that organisations should support and encourage staff to be open and honest when things have gone wrong or where it can make improvements. Staff should also be accountable for their actions, identify learning opportunities, and clearly outline how it will use this learning to improve services and support staff.

70. In its response, the medical centre acknowledged Mrs K’s concerns and apologised for the difficulty she experienced accessing a GP appointment in a timely manner. It explained its Practice Managers reviewed the circumstances surrounding the complaint with both its clinical and reception team to help its staff understand their role in ensuring access to GP appointments when requested.

71. The medical centre further explained that its staff are aware of the processes in place to provide appropriate triage and ensure patients are promptly see the most appropriate healthcare professional, including GPs. It expressed confidence in its clinical and administrative staff, who it said are open to learning and reflecting when issues arise, and it hoped this reassured Mrs K.

72. From the records we can see that at the beginning of November, the receptionist noted Mrs K had contacted the medical centre to explain that she had tried several times to book a GP appointment because of concerns about her leg and could not do so.

73. The records also show that following Mrs K’s complaint, the Practice Managers held a case discussion with its staff, including administrative and clerical staff, to review and address the issues raised. This included highlighting the importance of facilitating GP appointments, particularly in cases where patients or their relatives are insistent. The medical centre also informed us it uses the discussion as a learning opportunity to prevent similar issues in the future.

74. In our view, it appears the actions taken by the medical centre were in line with our Principles and Complaint Standards. It responded to Mrs K’s concerns promptly, took responsibility for the actions of its staff, and identified and implemented learning opportunities. Having reviewed the circumstances of the complaint thoroughly and reinforced the importance of ensuring access to GP appointments where needed, the medical centre has taken appropriate steps to address the issues raised and to achieve the outcomes Mrs K wanted.

75. We understand how concerning and upsetting it must have been for Mrs K to no be able to book an appointment when she needed one. We hope it is reassuring for her to know that the medical centre has recognised her concerns, discussed this with staff, and used this as a learning opportunity to improve its services. Based on what we have seen, we will take no further action.

76. Additionally, we want to reassure Mrs K that her complaint is recorded in our system, and we can use the information gathered from her complaint to monitor any systemic issues in the future. By systemic, we mean complaints we may receive of a similar nature or about the same organisation.

Did not listen to concerns of her wound or escalate to a GP

77. Before we decide if we should investigate 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 we have not found any indications that something has gone wrong.

78. Mrs K complains the treating nurses responsible for dressing her wound in mid-November, did not listen to her concerns or escalate her condition to a GP, despite her feeling that her leg wound required further attention.

79. Mrs K says the lack of care resulted in her experiencing prolonged pain and suffering and required her to undergo surgery on her leg.

80. The medical centre explained in its response that its nursing team, including community nurses, are the mainstay of its team for managing and reviewing chronic leg wounds and ulcers of all types. It explained they are competent and experienced in this area, with the knowledge of when and how to escalate to specialist secondary care providers or, if in doubt, to the in-house GP for an opinion.

81. According to the NMC’s ‘Professional Standards of Practice and Behaviour’ guidance, paragraphs 8.1, 8.5 and 8.6, nurses must: respect the skills, expertise, and contributions of your colleagues, referring matters to them when appropriate, work with colleagues to preserve the safety of those receiving care, and share information to identify and reduce risk.

82. Paragraphs 13.1, 13.2 and 13.3 also says nurses must: accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care, make a timely referral to another practitioner when any action, care or treatment is required, and ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence.

83. The records show that prior to Mrs K’s appointment in mid-November, the medical centre had already identified that her leg wound would require specialist intervention in order to heal. It had noted that ED stated it had already submitted a referral to the TVT, and dermatology confirmed it had made a referral to specialist surgeons to consider surgical debridement.

84. The records also show that Mrs K had seen her GP and was taking a course of antibiotics prescribed for the wound.

85. We can see from the medical records, during the mid-November consultation, the nurse documented that the wound appeared ‘unchanged’ and that the oedema (build-up of fluid in the tissues) had reduced.

86. The records also show the nurse also conducted a full set of observations in line with NEWS2, which included pulse, temperature, oxygen saturation and respiratory rate. Our advisor explained these readings were within the expected range and there was no indication of acute deterioration that would require immediate further investigation, such as intravenous antibiotics or escalation to secondary care.

87. According to NMC standards, nurses must be competent to manage and review chronic wounds and work collaboratively with other healthcare colleagues to ensure the safety of patients under their care.

88. The medical centre described its nursing team as experienced in treating complex wounds and appropriately trained to recognise when an escalation to a GP or specialist care is required. Our clinical adviser highlighted that, at the time of the mid-November consultation, there were no indications of acute deterioration in the wound, or clinical evidence that Mrs K needed to be escalated to a GP or other practitioners.

89. It is also clear from the records that Mrs K was on an appropriate referral pathway well before the mid-November appointment, and that she had been referred to the TVT and a surgical team, both of whom were better placed to assess and plan for any surgical interventions required for her wound.

90. Based on the evidence, it appears that the actions of the nurse during the mid-November consultation were reasonable and aligned with the standards expected of competent healthcare practitioners outlined in the NMC Code.

91. Their decision to monitor and document the status of Mrs K’s wound and physiological observations, without immediately escalating to a GP or other service for additional intervention, was appropriate in the clinical circumstances presented at the time.

92. Specifically, the wound documented as "unchanged," indicating no acute deterioration, the reduction in oedema suggested some improvement, physiological observations, including pulse, temperature, respiratory rate, and oxygen saturation, were within normal limits according to NEWS2 guidelines, showing no signs of acute illness, and referral arrangements for specialist intervention already made to address Mrs K’s wound through the TVT and surgical review.

93. Our view is that the nurses had no clinical reason to escalate care immediately to a GP or other service at the time of the consultation in mid-November. Their actions showed adherence to professional standards outlined in the NMC Code, which include prioritising people, practising effectively, preserving safety, and promoting professionalism and trust.

94. By monitoring Mrs K's condition, documenting her progress, and ensuring appropriate referrals for specialist care, the nurses took reasonable and proportionate steps to address her health needs in the circumstances. Therefore, we find no evidence to suggest that the standard of care provided fell below what would reasonably be expected, and we will take no further action.

95. We were also pleased to see that the medical centre meets regularly for care reviews and learning reflection and had made it a priority for their next clinical supervision session to be dedicated to the medical centre policy on leg ulcers and wound management pathways.

96. We are very sorry to hear of the circumstances of Mrs K’s complaint and do not wish to underestimate the significant impact this has had. We recognise that Mrs K was extremely concerned about her leg wound and wellbeing. It is clear this was a very difficult period for her and her family, and we wish them all the best.

1. We have carefully considered Mrs K’s complaint about the medical centre (the medical centre). We are sorry to hear about her concerns regarding the care and treatment she received for her leg wound and understand how worrying the healing process must have been for her.

2. We have seen no indication that anything was wrong in the treatment provided by the medical centre. Where the medical centre did make mistakes, it appears it has already done enough to put things right. We will explain our decision in detail below.

3. We hope this will help Mrs K to understand our decision and give some reassurance about what happened.