A practice in the Manchester area

3. Mr D complains the Practice failed to properly investigate his back pain between 22 September 2022 and 24 November 2023.

4. He states the Practice’s inaction delayed his diagnosis of disc protrusion and annular tear. Disc protrusion is where part of the spinal cushioning bulges out. An annular tear is a tear in the disc’s outer layer.

5. Mr D told us this delay has left him unable to sit, stand, or walk for long periods. He says he suffers constant pain that disrupts daily life, work, and social activities. This has caused his mental health to suffer, and led to ongoing physical, emotional, and financial challenges.

6. Mr D is seeking acknowledgement, an apology, service improvements and a financial remedy at level six on our severity of injustice scale.

7. Mr D first visited the Practice with back pain on 22 September 2022. During a phone consultation, he described worsening muscle cramps and spasms, which felt like electric shocks.

8. The GP checked his symptoms, ordered blood tests to measure electrolytes (salts in the blood that help control muscle and nerve function), and arranged a face-to-face appointment later that day. They also told him to watch for red flag symptoms (serious warning signs, such as limb weakness or difficulty with bowel/bladder control).

9. At the face-to-face appointment, Mr D reported worsening pain in his neck and lower back. The GP examined him, identified tense trapezius muscles (muscles across the upper back/neck) and tenderness in paraspinal muscles (muscles next to the spine), but noted no spinal tenderness.

10. The GP referred him to physiotherapy, prescribed co-codamol 30mg/500mg (a strong painkiller combining codeine and paracetamol), and asked him to come back if the pain continued.

11. The Practice carried out blood tests on 28 September, which showed normal results.

12. On 5 October, Mr D returned to the Practice and described electric shock-like nerve pain across his body. The GP examined him, noting tender spots in his soft tissue (the tissue supporting organs like fat and muscle) but detected no signs of joint swelling.

13. The GP suggested fibromyalgia (a long-term condition causing widespread pain and tenderness) as a possible diagnosis. They referred him to the musculoskeletal (MSK) clinic to rule out other conditions affecting bones, muscles, and joints and advised him to call 111 if the pain worsened.

14. Mr D attended physiotherapy on 10 October and reported nerve pain in all four limbs and pain in the cervicothoracic junction (where the neck meets the upper back).

15. The physiotherapist assessed him and found no abnormalities in his lumbar spine (lower back), limb neuro function (nerves in arms/legs), or cervical ROM (range of motion in the neck). They confirmed he was Romberg negative (no balance issues from spinal nerves) and prescribed exercises.

16. On 20 February 2023, Mr D visited the Practice again, reporting neck pain and continuing cervicothoracic pain during a physiotherapy appointment.

17. The physiotherapist examined him and noted mild mid-thoracic scoliosis (sideways curve of the spine), mild laxity in the left shoulder (looseness or instability), weakness in his posterior rotator cuff (shoulder stabiliser muscles), and a positive Jobe’s relocation test (indicating shoulder instability). They detected no ROM abnormalities in his cervical or thoracic spine and prescribed exercises.

18. On 6 November, Mr D had a phone consultation with a GP and described weeks of shooting pains in his legs. The GP scheduled a face-to-face appointment for the next day.

19. On 7 November, Mr D described pain radiating from his back into both legs, trouble urinating, and occasional leg weakness. The GP examined him, suspected bilateral sciatica (nerve compression affecting both legs), and raised concerns about possible cauda equina syndrome (a rare condition where spinal nerve compression affects bladder/bowel control).

20. The GP directed Mr D to visit the emergency department for an urgent MRI to investigate further.

24. 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.

25. Mr D complains the Practice failed to properly investigate his back pain between 22 September 2022 and 24 November 2023.

26. In its response the Practice stated it had conducted a clinical review and found no reasonable way for any clinician to have predicted the events of November 2023. The Practice explained its review had concluded the symptoms Mr D exhibited in October 2022 and February 2023 were separate from those he presented with in November 2023.

27. GMC Good Medical Practice paragraph 15 states: You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:

• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.

28. NICE CKS lower back pain says, ‘Do not routinely arrange a spinal X-ray or other imaging to diagnose non-specific low back pain in primary care.’ NICE NG59 1.1.4 also says, ‘Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica.’

29. NICE CKS lower back pain says to consider offering physiotherapy to treat lower back pain. NICE NG59 1.2.2 also recommends exercise for lower back pain and says to take people’s specific preferences and capabilities into account.

30. NICE CKS lower back pain ‘assessment’, lists red flag symptoms for potentially serious conditions causing back pain. For example, for Cauda equina syndrome, the red flag symptoms include:

• new, sudden pain radiating down both legs or starting in one leg and spreading to both • new trouble starting to urinate or losing the ability to feel the flow of urine.

31. NICE CKS lower back pain ‘management’ states, ‘Arrange emergency hospital admission or specialist referral, the urgency depending on clinical judgement, if:

• There are red flag symptoms or signs suggesting a potentially serious underlying cause.’

32. We can see from Mr D’s records that on 22 September the Practice carried out two consultations with Mr D. It initially completed a telephone consultation, then followed this up with a same day face to face consultation.

33. Mr D’s records show the GP took a thorough clinical history, ordered blood tests and completed a thorough examination to rule out red flags. It is our view that this is in line with GMC Good Medical Practice paragraph 15a and 15b. Our adviser agrees with this view.

34. We understand from our adviser that Mr D’s records from 22 September show that no red flags were present at that time. Therefore, the GP acted in line with NICE CKS lower back pain and NICE NG59 when they referred Mr D to the Practice physiotherapist and did not order a scan of Mr D’s back at this point.

35. Mr D next presented to the Practice on 5 October. His records show there were still no red flag symptoms. We can see from the records the GP referred Mr D to the musculoskeletal clinic for consideration of any underlying issues such as fibromyalgia. We understand from our adviser that this is in line with GMC Good Medical Practice 15b and 15c.

36. On 10 October 2022 and 20 February 2023, Mr D attended physiotherapy consultations at the Practice. We can see Mr D’s records show the physiotherapist took a detailed history and carried out a physical examination on both occasions. Our adviser explained these records show no red flags were identified during these consultations.

37. Mr D next contacted the Practice eight months later, on 6 November 2023. We can see the Practice carried out a telephone consultation during which Mr D informed the GP that he had experienced reports ‘a few weeks of shooting pains down the legs.’ Shooting pains are considered red flags as per NICE CKS lower back pain.

38. NICE CKS lower back pain says to arrange emergency hospital admission or referral depending on clinical judgement. We can see from Mr D’s records that his telephone appointment was 4.25pm on 6 November and his face-to-face took place at 11.58am on 7 November, meaning the Practice reviewed him in under 24 hours.

39. Our adviser explained to us that as Mr D’s symptoms were not new onset this was appropriate use of clinical judgement in line with this guidance.

40. During Mr D’s 7 November consultation, he reported shooting pains radiating to both legs and difficulty passing urine as normal. These are both red flags as per NICE CKS lower back pain. The GP advised Mr A to attend the emergency department. Our adviser explained this was appropriate sign posting in line with NICE CKS lower back pain red flags.

41. Overall, we have seen no indications the Practice has not acted in line with guidelines. Therefore, we are taking no further action on Mr D’s complaint.

42. We are very sorry for the difficulties Mr D has faced with his back and the impact this has had on his day-to-day life. We hope this statement provides him with reassurance regarding the Practice’s care.

1. We have carefully considered Mr D’s complaint about a practice in the Manchester area (the Practice). We are very sorry to hear about the ongoing physical, emotional and financial challenges Mr D is experiencing since his back pain begun.

2. We have seen no indication that anything went seriously wrong with the Practice’s investigation of Mr D’s back pain. We will therefore be taking no further action on Mr D’s complaint.