A dental practice in the Stroud area

4. Mrs B complains about the care and treatment provided by the Practice between August 2023 and January 2024.

5. Specifically, she said the Practice: • persistently questioned her and contacted a hospital about her blood tests without her believing her account • did not believe her account of her medical history and contacted a hospital about her medication dosage to verify this • did not communicate with her or show interest about her symptoms and wellbeing when it should have • incorrectly recorded her medication had been stopped and this action was not in its remit • printed her diagnosis on a dispensing label and refused to remove it • made a referral without her consultation or consent • removed her from the Practice without an explanation or warning.

6. Mrs B says that she was denied appropriate treatment.

7. She also said she experienced loss of sleep and anxiety for a period of four months and still suffers from anxiety when she receives a letter from a general practice.

8. She said she felt demeaned by the Practice because it did not believe her accounts and asked her consultants for information without her permission.

9. Mrs B says that she no longer feels confident attending GP appointments alone.

10. Mrs B is seeking an acknowledgment and apology, service improvements and a financial remedy.

11. In August 2023, the Practice wrote to Mrs B about her fexofenadine (an antihistamine medication that treats allergy symptoms and hives) dosage and what she was taking. Mrs B went to the Practice the next day and confirmed what dosage she was taking.

12. Also in August 2023, the Practice recorded a change to Mrs B’s medication adalimumab (a medication used to reduce inflammation in treating various conditions).

13. In October 2023, a practice pharmacist had a conversation with Mrs B about her blood monitoring. Mrs B’s rheumatologist subsequently wrote to her to notify her they had been contacted by the Practice about her blood tests.

14. In November 2023, Mrs B’s rheumatologist wrote to the Practice to confirm what it should prescribe her.

15. Also in November 2023, the Practice wrote to Mrs B inviting her to a face-to-face meeting to discuss the issues she had raised. Mrs B declined the offer and asked for guidance on how to change practices. The Practice subsequently wrote to Mrs B acknowledging she had declined to have a face-to-face meeting and sent her information about changing practices.

16. In December 2023, Mrs B wrote to the practice about concerns with having her diagnosis on her prescription label. The Practice agreed to remove this the same month.

17. On 8 March 2024, the Practice sent a patient removal request form to Primary Care Support England.

18. On 11 March 2024, Primary Care Support England emailed the Practice confirming Mrs B would be removed from the Practice list on 19 March 2024. It said a letter had been sent to Mrs B to explain this.

22. 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.

The Practice’s questions about blood tests

23. Mrs B said the Practice repeatedly questioned her over the need for regular blood tests when these were undertaken and reviewed by her rheumatology consultant. Mrs B said the questioning was aggressive and the Practice pharmacy staff did not believe her and contacted her consultant without her permission to verify the testing requirements. Mrs B she provided the Practice with a letter with the information, which is on her medical records, so the Practice’s questioning was unnecessary.

24. We are sorry Mrs B found the Practice’s questioning inappropriate and aggressive. We recognise her frustration that she felt the Practice already had the information it needed.

25. The Practice said it received a letter in August 2023 from Mrs B’s rheumatologist which was unclear and implied the Practice may be responsible for the monitoring. It also said due to the hospital not being able to access local blood results and being an out of area, and therefore an unfamiliar provider, it would be usual for a Practice to transfer care locally to maintain appropriate safety.

26. Section 16 of GMC Good Medical Practice guidance says a doctor should only prescribe drugs or treatment, including repeat prescriptions, when: • they have adequate knowledge of the patient’s health and are • satisfied that the drugs or treatment serve the patient’s needs.

27. GMC Good Medical Practice also says doctors must consult colleagues where appropriate.

28. Our clinical adviser said the letter from the rheumatologist to the Practice in August 2023 did not make it clear whether they were asking the Practice to arrange blood monitoring, or whether the rheumatology department was doing it. Our clinical adviser said blood monitoring in this situation would usually be done under a shared care arrangement where the hospital and Practice’s responsibilities are clearly set out. This was not in place so the Practice needed to clarify its responsibilities.

29. Our clinical adviser also said the Practice did not need Mrs B’s permission to contact her rheumatologist to confirm about the blood tests. They said a practice cannot practically provide medical care to patients if they have to obtain consent every time they contact a specialist who is also providing care to them. Our clinical adviser explained patients imply this consent when they register with the practice.

30. We do not see indications of failings when the Practice contacted Mrs B and the rheumatologist to clarify about Mrs B’s blood tests. The Practice acted in line with GMC Good Medical Practice guidance by clarifying the blood test and monitoring arrangements to ensure it was giving safe care to Mrs B.

The Practice’s questions about medication

31. Mrs B said the Practice consistently did not follow her consultant’s instructions regarding the dosage of fexofenadine in November 2023. She said the Practice also intentionally misinterpreted the consultant’s guidance to justify not prescribing the required dose.

32. Mrs B said one of the GPs at the practice bullied her by avoiding prescribing the doses that the specialist had advised. She said even when they said they would do so, they then prescribed an inadequate quantity of the medicine. She said they indicated she had been managing on the lower dose that they had prescribed. She said they were incorrect and she was having to supplement with over-the-counter alternatives that were not the correct doses and therefore having to go under or over the advised dose.

33. We are sorry Mrs B was frustrated by the Practice’s actions about her medication and worried the Practice was trying not to prescribe her what her consultant her recommended. We understand this caused some inconvenience as she had to supplement with over-the-counter alternatives.

34. The Practice said the dose requested by Mrs B fell outside of that recommended in the British National Formulary (BNF). Therefore, it sought clarity from a specialist in November 2023 regarding the appropriateness and safety of this higher level of prescribing, which is in keeping with good safe practice.

35. Our clinical adviser said the maximum licensed dose for fexofenadine according to the BNF is 180mg once a day. The records show Mrs B wrote to the Practice and said she was able to manage her symptoms with one fexofenadine 180mg daily but occasionally had to increase to two per day 180mg. We can see this in line with a letter from Mrs B’s consultant dated 23 August 2023 which said the fexofenadine dose was ‘180mg daily or increased if need be’.

36. Our clinical adviser said the Practice was following GMC Good Medical Practice guidance when it contacted the specialist on 20 November 2023 to clarify the higher dose recommendation. This was in line with section 16 of the guidance as the dose was outside usual prescribing guidelines and the Practice had to be sure this was correct and safe before issuing the prescription.

37. Our clinical adviser also said the Practice did not need to get Mrs B’s permission for this, for the same reasons as outlined in paragraph 29.

38. We do not see indication of failures when the Practice contacted a specialist to confirm the correct prescription dosage for Mrs B’s fexofenadine. It was in line with the relevant standards and guidance and it did not need to get Mrs B’s permission.

Communication about Mrs B’s symptoms

39. Mrs B said the Practice did not enquire about her wellbeing between September 2023 and December 2024. She said the Practice should have been proactive in contacting her to enquire about her wellbeing as she had sent them multiple correspondences that indicated how she was being impacted by the GP’s actions regarding her blood tests and medication.

40. She also said she told the Practice she was suffering from insomnia and the Practice offered no help for this. She said this also caused her anxiety and loss of trust in the Practice. She said she felt she could not go to the Practice as staff always questioned her.

41. We understand why Mrs B expected the Practice to be more proactive in asking about her welfare and we are sorry she felt unsupported and that she could not go to the Practice.

42. In its complaint response 5 December 2024, the Practice said it had invited Mrs B to meet with the GP face to face on several occasions. The Practice said Mrs B had declined these invitations.

43. Our clinical adviser said patients normally interact with GP practices by booking an appointment when they want to discuss a medical issue. They said there was no requirement for the Practice to proactively contact Mrs B based on what she had written in her letters to the Practice. There is no guidance or standard which says GPs should do this.

44. We understand Mrs B expected the Practice to be more proactive in asking about her wellbeing. We hope we have clearly explained why there was no requirement for the Practice to do this and we cannot see any indications of failings.

Recording medication had been stopped

45. Mrs B said in August 2023 a practice pharmacist removed adalimumab from her medical records which is not within the pharmacist’s remit. She said the Practice made changes made to her prescriptions without consultation.

46. The Practice said the drug was taken off the system and re-added due to a change of brand. It said none of Mrs B’s medication was stopped. It said the system it uses appears to show the medication is ‘stopped’ due to a brand change, however, this is automatic on the system. It said this is normal procedure when changing brands on repeat prescriptions.

47. Section 21 of GMC Good Medical Practice guidance says clinical records should include: • relevant clinical findings • the decisions made and actions agreed, and who is making the decisions and agreeing the actions • the information given to patients • any drugs prescribed or other investigation or treatment • who is making the record and when.

48. Our clinical adviser said the Practice followed this guidance when it recorded Mrs B’s adalimumab brand change on the system. Our clinical adviser also noted the Practice was not actually prescribing adalimumab, as this medication was prescribed and administered in hospital.

49. There is no evidence in the medical records that the Practice incorrectly ended nor stopped Mrs B’s prescription for adalimumab.

50. We understand Mrs B’s concern when she saw her records said this prescription had been stopped. We hope Mrs B is reassured the medication was not actually stopped. We have seen no indications of failings when the Practice recorded the brand change for Mrs B’s medication as it did this within the relevant standards and guidelines.

Printing of diagnosis on dispensing label

51. Mrs B said in December 20023 the Practice was wrong to print her diagnosis ‘urticaria’ on her prescription label for famotidine and fexofenadine as it was a breach in confidentiality. We understand why Mrs B was concerned to see her diagnosis on the prescription label and would have preferred for this information to remain private.

52. The Practice said it is common practice to put a diagnosis on prescriptions, especially where there may be a number of indications for a drug, or prescribing falls outside of usual practice or BNF dosage levels. It said this improves safety and reduces queries to the pharmacy and is in keeping with good practice. The GP agreed to remove the diagnosis on 22 December 2023.

53. Our clinical adviser said there is no standard or guideline regarding the inclusion of diagnoses on prescription labels. They said it is common practice to add the diagnosis to the directions line of a prescription so the patient knows what the medicine is for.

54. We do not see any indications of failings when the Practice included Mrs B’s diagnosis on her prescriptions for famotidine and fexofenadine as this did not breach any standards or guidelines and our clinical adviser said it is common practice. We also note the Practice agreed to remove the diagnosis in December 2023 at Mrs B’s request, which would have been an appropriate remedy if the Practice had done anything wrong.

Referral and consent

55. Mrs B said the Practice made a referral without her consultation or consent, and she still does not understand what the referral was for.

56. The Practice said the referral dated 22 August 2023 was an advice and guidance (A&G) request for clarification of the fexofenadine prescribing. It said this was a dermatology consultant that the complainant had seen in 2022.

57. GMC good medical practice says doctors should consult colleagues when appropriate. There is no requirement for doctors to seek the patient’s consent before doing so.

58. Our clinical adviser said there is no evidence the Practice made any referrals for which it should have consulted Mrs B about beforehand, based on the medical records. The purpose of A&G referrals is for primary care services to have access to specialist clinical advice to strengthen shared decision making and avoid unnecessary outpatient activity. It was appropriate for the Practice to use A&G for clarification of Mrs B’s treatment plan, without first seeking her consent.

59. We therefore do not see any indication of failings when the Practice made an A&G referral without Mrs B’s consent.

Removal from Practice list

60. Mrs B said the Practice removed her from the practice list without an explanation or warning in March 2024.

61. On 24 November 2023, Mrs B wrote to the Practice and said she would seek a change in practice and wanted a response to the issues she had raised. In this letter, Mrs B said ‘it is difficult to regard this as anything but a fundamental breach of trust and confidence between us. I do not feel that I would be able to rely upon you as a clinician to have my clinical and personal interests as your first priority and as such would be unable to feel confident in relying upon you as my primary care physician.’

62. On 27 November 2023, the Practice wrote to Mrs B offering a face-to-face meeting with her GP and the practice manager to discuss the issues that she had raised.

63. On 28 November 2023, Mrs B wrote to the Practice and declined the offer to have a face-to-face meeting with the Practice. She asked for guidance on how to change practices. The Practice replied on 30 November 2023 and provided information on how Mrs B could find a new GP practice.

64. Following this, Mrs B did not change her GP practice. She continued to send letters to the Practice about the concerns she had raised previous in January and February 2024. The Practice responded on 1 February saying the team would discuss the issues and get back to Mrs B shortly.

65. On 26 February, Mrs B complained about the Practice to Gloucestershire Integrated Care Board.

66. On 8 March 2024, the Practice sent a patient removal request form to Primary Care Support England. On the form, the Practice said it had tried numerous times to meet with Mrs B to resolve the concerns, but Mrs B had refused to do this.

67. It said the accusations of clinical misconduct that Mrs B had made to the ICB had left the GP feeling vulnerable and at risk if they treated her any longer. It said Mrs B’s behaviour had caused a lot of upset at the Practice and the complaint to the ICB was harming the GP’s reputation. It said the reason for removing Mrs B from the practice list was due to the breakdown of the relationship with her.

68. On 11 March 2024, Primary Care Support England emailed the Practice confirming Mrs B would be removed from the Practice list on 19 March 2024. It said a letter had been sent to Mrs B to explain this.

69. Section 3.2.7 of NHS England guidance says a practice can remove a patient from its list if there has been an irrevocable breakdown in the relationships between the patient and the practice.

70. Section 3.2.9 says it is justified for a practice not to give the patient a warning in certain circumstances, including it is, in the opinion of the practice, not otherwise reasonable or practical for a warning to be given. It also says the practice must record in writing the reason why no such warning was given.

71. The Practice recorded the reason for not giving Mrs B a warning in its patient removal request form, including the breakdown of the relationship between Mrs B and the practice. Primary Care Support England accepted the Practice’s request as it removed her from the list in March 2024.

72. We therefore do not see indications of failings the Practice did anything wrong when it removed Mrs B from the practice list. Mrs B requested information to change practices, which the Practice responded to with the relevant information. The Practice also followed the relevant standards and procedures to remove her from the patient list.

73. We hope our explanation provides Mrs B some reassurance on what happened during her care and treatment, and that we have reached this decision following careful consideration.

1. We have carefully considered Mrs B’s complaint about the Practice. Mrs B raised several concerns about different aspects of the care the Practice provided between August 2023 and January 2024. She also complains about the Practice’s decision to remove her from the patient list.

2. Having considered the evidence available, we have not seen any indications of failings in the Practice’s actions.

3. We want to thank Mrs B for bringing the complaint to us. We were saddened to hear of the events Mrs B complains about and recognise the distress she experienced. Our decision does not take away from her experience.