A practice in the Cumberland area

4. Mr P complains about the care and treatment provided to him by a GP Practice in the Cumberland area (the Centre) between June 2023 and February 2024.

5. He says that the Centre:

• failed to provide the necessary information and patient history in a referral sent to urology • did not prescribe pain relief medication or appropriately investigate his hip pain • did not investigate his sudden and unexplained weight loss.

6. Mr P says that as a result of this he experienced problems when he had a catheter fitted after knee surgery on 26 April 2024. He says that this was as a result of him having a hard and enlarged prostate. He says that he subsequently suffered a bladder infection and a bowel obstruction which led to him being incontinent. He says that this has worsened his condition and compromised his future health.

7. Mr P believes that had sufficient information and history been included in his urology referral then the referral would have been marked as urgent. Further, that staff performing his knee operation would have been notified of likely complications.

8. Mr P also says that he experienced pain in his hips for longer than he should have done, and increased worry about his health due to the lack of investigations for this and his weight loss by the Centre.

9. Mr P seeks:

• an apology and explanation from the Centre • a financial remedy.

10. On 6 June 2023 Mr P attended the Centre for an appointment as he was having ‘extreme pain and stiffness’ in multiple parts of his body including his hips. He was prescribed tramadol for this.

11. On 14 November 2023 Mr P attended the Centre for another appointment. At this appointment he had his weight checked. It is noted that he had lost 4% of his body weight in the last year.

12. On 1 February 2024 Mr P had another appointment at the Centre. He explained that he was having ongoing pain in his hips. He said he had been using the tramadol he was prescribed, and voltarol gel.

13. On 16 February 2024 Mr P contacted the Centre to ask it to make a referral to urology for his ongoing urinary problems following his prostate surgery in 2012. He also mentioned his ongoing shoulder pain. Following this appointment the Centre made referrals to urology, musculoskeletal and physiotherapy.

14. On 24 April 2024 Mr P had another appointment at the Centre to discuss his upcoming knee surgery. In this appointment Mr P said he had seen the musculoskeletal team at his local Trust about his hip and shoulder pain. The Centre told Mr P that he would need a referral letter to orthopaedics for potential surgery.

15. On 26 April 2024 Mr P had knee replacement surgery. He explained that following it, he had difficulties after a catheter was inserted. He subsequently suffered a bladder infection and a bowel obstruction which led to him being incontinent. Mr P had to have a resection of his bladder neck in December 2024.

Urology referral

19. Mr P told us that he feels that the Centre did not send the necessary information and patient history in a referral it sent to urology in February 2024. He says that as a result of this, he experienced difficulties which caused him to become incontinent after a Trust inserted a catheter following a knee replacement surgery he had in April 2024.

20. We recognise that Mr P had difficulties following his surgery in April 2024. We understand why this experience will have been distressing for him. 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. We have done this and have not found any indications that something has gone wrong.

21. Mr P explained to us that he had a hard and enlarged prostate and was experiencing difficulties with this which prompted him to ask the Centre for a referral to urology. Mr P says that the Centre did not include sufficient information and medical history in the referral, and that the Trust were therefore not aware that they needed to take care when inserting his catheter.

22. He says that as a result of the catheter being inserted, he suffered a bladder infection and a bowel obstruction that caused him to become incontinent. He told us that this has worsened his existing symptoms and compromised his future health.

23. Mr P believes that had the sufficient information and history been included in his referral it would have been marked as urgent and that staff looking after him following his knee surgery would have been notified of the likely complications and that his incontinence could have been avoided.

24. In its complaint response on 28 May 2024 the Centre said that the examination of Mr P’s prostate and the symptoms that he was experiencing required a routine referral.

25. Mr P’s records show that he had an appointment with the Centre on 7 February 2024 in which he had his prostate examined. The records explain that his prostate was enlarged, smooth, not hard, and non-tender.

26. The records then show that Mr P had a further appointment with the Centre on 16 February 2024 when he asked the Centre for a referral to urology, as he was experiencing ‘new symptoms’ following the surgery he had on his prostate in 2014. Following this appointment, the Centre referred him to urology.

27. The referral documents explain that the Centre referred Mr P to urology as his symptoms had returned since his previous prostate surgery, and that he was needing to get up to go to the toilet multiple times a night. The referral also details Mr P’s recent consultations and his significant medical history.

28. The GMC guidance says doctors should refer a patient to another suitably qualified practitioner when this serves their needs and contribute to the continuity of care by sharing all relevant information about patients with others involved in their care, as required.

29. We discussed the case with our adviser, to understand if the Centre needed to do anything more to ensure that the Trust had the correct information before it performed Mr P’s surgery.

30. Our adviser said that the information provided by the Centre in Mr P’s referral is the standard information that is expected of clinicians for a routine referral such as this. They told us that if the Trust felt not enough information had been provided for it to triage the referral, it would have been the responsibility of the Trust to go back to the Centre to ask for more information.

31. Our adviser told us that there was nothing in Mr P’s medical history that indicated that his referral needed to be sent as urgent rather than routine. They explained that an urgent referral would only be reserved for cases where cancer is suspected or for people who have severe urinary symptoms that require urgent attention.

32. The urological cancer guidance shows that symptoms of urological cancers include unexplained appetite loss or weight loss, persistent urinary tract infections, pain or blood when urinating, a mass felt on prostate examination, raised PSA levels, or a change in a person’s penis or testicles.

33. Mr P’s medical records show that he did not have raised PSA, his recent prostate exam did not show any mass, and he did not have issues with pain or blood when he was urinating.

34. The LUTS guidance explains that clinicians should rule out the serious underlying causes of urinary problems before considering further treatment. In Mr P’s case, the Centre had performed a recent prostate examination and blood test which showed no cause for concern, and he was not suffering from any symptoms that indicated a potential urinary cancer.

35. In line with the LUTS guidance and the urological cancer guidance, the Centre correctly ruled out any serious underlying reasons for Mr P’s symptoms before referring him onwards to urology with a routine referral.

36. Our adviser told us that prior to Mr P’s knee replacement surgery in April 2024, the Trust will have carried out a pre-operative assessment in which it will have discussed Mr P’s medical history with him and looked at his medical records to ensure that it had all the information it needed.

37. The pre-operative guidance explains that the purpose of a pre-operative assessment is to check if a patient has any medical problems that might need special care during or after surgery.

38. We understand that it will have been distressing for Mr P to feel that he experienced problems following surgery that could have been avoided. After consideration, we have seen no indication that the Centre did not provide the correct information in its referral to the Trust. We consider the Centre acted in line with the GMC guidance and shared the relevant information about Mr P in its referral.

39. We have also seen nothing to suggest that the Centre should have categorised his referral as urgent rather than routine. We consider the Centre acted in line with the GMC and LUTS guidance and will therefore not consider this complaint point further.

Management of hip pain

40. Mr P told us that he raised with the Centre on multiple occasions that he was having issues with pain in his hip. He explained that he does not feel that the Centre did enough to address this and did not provide him with the correct pain medication to support him with his pain.

41. The medical records show that Mr P had an appointment with the Centre on 3 May 2023 in which he discussed the pain in his joints. The Centre discussed his existing osteoarthritis with him and performed a blood test, the results of which show nothing abnormal.

42. Mr P’s records show that he had another appointment on 6 June 2023, in which he explained that he was experiencing ‘extreme pain and stiffness’ effecting his hands, wrists, hips and feet. The Centre prescribed Mr P tramadol and chased an existing referral to rheumatology.

43. Mr P’s records show that he had another appointment with the Centre on 1 February 2024, in which he told the Centre that he was using tramadol and voltarol gel to help with the ongoing pain in his joints.

44. The records show that Mr P then had a further appointment on 24 April 2024 in which he said that he had seen the musculoskeletal team at the Trust in relation to his ongoing joint pain.

45. Our adviser explained that as Mr P had an existing diagnosis of osteoarthritis, the Centre needed to consider his pain with this in mind, especially as Mr P never presented to the Centre exclusively with hip pain.

46. They told us that given that Mr P already had an existing referral to rheumatology, and reported in his 24 April 2024 appointment that he had seen the musculoskeletal team, the pain relief prescribed was appropriate and there was nothing more that it could have done for Mr P.

47. The GMC guidance says that clinicians should assess a patient’s condition, taking account of their history and promptly provide or arrange suitable advice, investigation or treatment where necessary.

48. The Centre considered Mr P’s hip pain in the context of him already having an existing diagnosis of osteoarthritis. It assessed his condition during each appointment, ensured that he had the appropriate referrals for treatment, and provided him with an appropriate pain relief prescription. As such, we consider that the Centre acted in line with the GMC guidance in the way it assessed him and managed his complaints about his hip pain.

49. We recognise that it will have been difficult for Mr P to have ongoing pain in his hips and to feel that the Centre were not doing enough to address this. We have seen no indication that the Centre failed in the way that it treated Mr P’s hip pain. We will therefore not consider this complaint point further.

Investigation of weight loss

50. Mr P told us that he did not feel that the Centre investigated his ‘sudden and unexplained’ weight loss.

51. Mr P’s medical records show that on 14 November 2023 he attended the Centre for an appointment in which he had his weight checked. It was noted that he had lost 4% of his body weight in the last year.

52. Our adviser explained that there is a certain threshold for weight loss to be classed as sudden or unexplained and to need further investigation. They explained that a 4% weight loss in a year would not hit this threshold and therefore the Centre would not be expected to do anything further in relation to this.

53. The guidance on weight loss explains that significant unintentional weight loss is classed as 5% or more of body weight lost over a period of 6-12 months.

54. Mr P experienced a 4% loss of body weight over a period of 12 months. In line with the guidance on weight loss, this would not be classed as a ‘sudden and unexplained’ weight loss.

55. We understand why it will have been worrying for Mr P to feel that he had lost weight unexpectedly, and that this was not being addressed by the Centre. In line with the guidance on weight loss, and considering the information provided by our adviser, we have not seen any indication that the Centre should have done more than it did to investigate Mr P’s weight loss. We will therefore not consider this complaint point further.

56. We would like to thank Mr P for taking the time to bring his complaint to us. We understand why it will have been worrying for him to feel that the Centre were not providing him with the correct healthcare. We hope our decision reassures him that the Centre were following the relevant guidance in the care it provided to him.

1. We have carefully considered Mr P’s complaint about the Centre.

2. We would like to thank Mr P for taking the time to bring his complaint to us. We recognise that he has had difficult experiences whilst under the care of the Centre and can understand that it will have been worrying for him to feel that he was not getting appropriate care.

3. We appreciate that Mr P has concerns about the care he received. Having carefully considered the information available, we have not seen an indication that anything went wrong in his care. Therefore, we will not consider his complaint any further. We have set out our reasons for this decision below.