A practice in the Bolsover area

3. Mrs L complains about aspects of the care and treatment received from the Practice in December 2022.

4. She complains she was:

• not properly assessed when she attended the Practice • misdiagnosed following assessment • not referred for a magnetic resonance imaging (MRI) scan • not offered physiotherapy.

5. Mrs L says she has been left with permanent damage to her left arm and three fingers on her left hand. She says she has continuous nerve pain in her left side.

6. She says physiotherapy was delayed due to the misdiagnosis and, had this been provided earlier, she would not now need a hip replacement.

7. Mrs L would like a proper explanation as to why she was misdiagnosed and why she was not found to have suffered a full stroke sooner.

8. She would like assurances that the Practice will take learning from this and improve its services.

9. Mrs L is in her early fifties.

10. She has known type 2 diabetes and had a myocardial infarction (a heart attack where blood flow to a part of the heart is blocked) in 2015.

11. In November 2022, her GP asked that she monitor her blood pressure for a week, sending readings into the Practice due to concerns about this being high.

12. At the end of December 2022, Mrs [name redacted] lost consciousness at home and was taken to the ED (emergency department at the hospital).

13. She had a head CT, but this did not find anything wrong, and she was referred to her GP with possible migraine.

14. Mrs L saw the Advance Nurse Practitioner (ANP) at the Practice two days letter and said she thought she may have had a transient ischaemic attack (TIA). The ANP referred her to the TIA clinic at her local hospital.

15. Following an MRI scan in March 2023, this showed an established infarction (an area of where tissue has died due to an ischaemic incident). The consultant was unable to say when this had occurred.

19. We have considered the four points of Mrs L’s complaint together as these are tightly interlinked.

20. Mrs L says the Practice did not properly assess her when she attended in early December, two days after attending the ED at her local hospital. She says she was misdiagnosed as having had a TIA without examination when she had suffered a full stroke.

21. In addition, she says she repeatedly asked to be referred for an MRI scan, but this did not happen. She says was not offered physiotherapy which has resulted in a need for a hip replacement.

22. In its response to Mrs L’s complaint, the Practice says there was no wrongdoing and that it took appropriate action based on her symptoms and the information provided by the ED. It did not respond to Mrs L’s concerns about physiotherapy.

23. 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.

24. In reaching our decision, we have considered NICE guidance on suspected transient ischaemic attack which says:

‘Refer for specialist assessment as soon as possible within 7 days’

25. We have also considered GMC requirements in respect of good medical practice. This says in section 15:

• ‘b - promptly provide or arrange suitable advice, investigations or treatment where necessary

• c - refer a patient to another practitioner when this serves the patient’s needs’.

26. From the medical records we can see the ED sent a letter to the Practice at the beginning of December 2022 in respect of Mrs L. It says she attended because she had collapsed at home whilst cooking.

27. She presented with a left side facial droop, left sided weakness, a mild headache, no vomiting, no vertigo (a spinning sensation that affects balance), no dysphasia (loss of ability to speak) or sensory impairment, did not have chest pain but did have heart burn and was experiencing stress.

28. A CT scan did not find anything of concern with the report of this saying there was ‘no sign of acute ischaemia, no intracranial haemorrhage (bleeding within the skull), a small old focal lacunar infarct (a type of stroke) in the right corona radiate (a group of nerve fibres in the brain)’.

29. After overnight monitoring, the medical notes say Mrs L was seen to be drinking coffee normally but that the numbness in her face had moved to the right side now and she was still experiencing weakness in her left side. She was discharged that morning after being advised to contact her GP if her symptoms continued. The medical notes said this was unlikely to be a stroke, and that the symptoms were possibly linked to a ‘hemiplegic migraine’ (a rare type of migraine causing temporary one-sided weakness mimicking stroke symptoms).

30. Mrs L contacted the Practice the day after being discharged from hospital. The medical records say that during a telephone appointment she said her blood pressure was high and her arms tingling.

31. She was offered a face-to-face appointment but declined this. The GP advised her to call an ambulance if her symptoms worsened, but Mrs L said there was too long a wait for ambulances. The notes say the GP reiterated their opinion that she should do this if she got worse.

32. The following day, Mrs L was seen at the Practice by an ANP. The medical records show the ANP considered Mrs L’s clinical history, including the myocardial infarction (heart attack) seven years earlier, the previous day’s telephone appointment and the letter from the ED. The notes say the ED had carried out blood tests, an electrocardiogram (ECG) and a computed tomography (CT) scan and these did not show anything of concern.

33. The records go on to say the ANP prescribed Mrs L losartan (used to treat high blood pressure) and asked that she come back in two weeks as there were concerns about her blood pressure. In addition, the ANP referred Mrs L to the TIA clinic. There is no reference to the ANP making a diagnosis at this time.

34. Looking at the medical records, there is no reference to Mrs L asking for an MRI or any reference to physiotherapy.

35. We discussed this with our clinical adviser to establish what should have happened when Mrs L spoke with the Practice the day after being discharged from the ED.

36. They said the medical records show the GP considered the letter from the ED when speaking with Mrs L and this said, ‘not advised for further investigation’. As Mrs L declined a face-to-face appointment, the GP could not give further advice other than that given in respect of going to the ED should her symptoms worsen.

37. In respect of the appointment with the ANP the following day, our clinical adviser said they were correct in referring to the letter from the ED as this contained information in respect of the tests Mrs L had undergone. From this, there were no indications of Mrs L having suffered a stroke.

38. They went on to say the ANP went over and above requirements in that they referred Mrs L to a TIA clinic as a precaution despite the ED tests indicating this was not necessary.

39. In respect of not being referred for an MRI, our clinical adviser said where a patient shows signs of having suffered a TIA, the GP (or ANP in this instance) should refer to a specialist clinic for further consideration. The consultants at the clinic will then decide on next steps, which may include an MRI.

40. As the ANP was concerned Mrs L may have suffered a TIA, something our adviser said was not indicated from the ED letter, we consider they acted appropriately in referring her to a specialist clinic.

41. This shows the Practice met the requirements of both GMC and NICE guidance in making the referral for specialist advice.

42. We asked our adviser about referral for physiotherapy as Mrs L had complained of weakness in the left side of her body, particularly her arm. They said as she had not been diagnosed with having a TIA (or stroke) at the time of her appointments, it was not appropriate to refer for physiotherapy without a diagnosis.

43. They went on to say when Mrs L moved to another GP Practice at the end of 2022, a GP suggested she self-refer for physiotherapy. Mrs L did not do this.

44. From this, we have not seen any indication of the Practice not following guidance or failing to provide the correct level of care and treatment to Mrs L.

45. This is because the medical records show Mrs L was offered face to face appointments when she contacted the Practice and that it considered her previous history alongside the letter from the ED before making decisions about her care.

46. In addition, the ANP referred Mrs L to the TIA clinic despite the information from the ED suggesting this was not necessary. There is nothing to show the ANP made a diagnosis at this time.

47. In respect of an MRI scan and physiotherapy, there is nothing in the medical records to show Mrs L asked the Practice for either of these. In addition, our adviser said it is the responsibility of the TIA clinic to arrange an MRI scan if they consider it needed, not the GP, with their responsibility being to refer to a specialist when needed, something the ANP had done.

48. In addition, as Mrs L did not have a diagnosis of a TIA or stroke at the time of the appointment, a referral to physiotherapy was not appropriate. The ANP did not know the root cause of her symptoms, having referred her to the TIA clinic for further investigation.

49. As we have not found any indication of failings in the care and treatment provided by the Practice, we will not be taking this further.

50. We can see this has been a distressing and upsetting experience for Mrs L and are sorry to learn she continues to experience problems with movement in her left arm and left-hand fingers. We wish her well in her future health and thank her for bringing her complaint to us.

1. We have carefully considered Mrs L’s complaint about a medical practice in the Chesterfield area (the Practice). We are saddened to read of her experience and concerns about suffering an undiagnosed stoke and the impact this has had on her.

2. After our consideration, we have seen no indication that anything went seriously wrong in the treatment and care provided by the Practice in December 2022.