A practice in the Merton area

2. Mr A complains about the care and treatment provided by the Practice to his mother, Mrs B. He says the Practice:

• Did not send her for an Xray when she saw the doctor with pain in her ribs on 29 September 2024 • Did not arrange transport for Xray on 13 May 2025 • Refused the family a copy of the Xray report • Provided an inappropriate combination of pain relief medication following her Xray of 13 May 2025 • Did not prescribe antibiotics for the chest infection identified in the Xray of 13 May 2025 • Inappropriately attributed her vertigo to inner ear infection rather than aneurysm • Inappropriately reported him and his brother to safeguarding and did not inform the family of this decision or retract the referral after the diagnosis of bone cancer

3. Mr A says if his mother’s rib pain had been investigated after she reported it in September 2024 her recurrent cancer may have been diagnosed and treated sooner. He says if her vertigo had not been misdiagnosed as an inner ear infection her aneurysm could have been identified sooner and treated.

4. Mr A says his mother may not have died when she did, in the circumstances she did if it were not for the failings of the Practice. He says the late diagnosis of her conditions had a devastating impact on his mother, him and his family. He says the inappropriate safeguarding referral was very traumatic for the family and caused them a great deal of distress and reputational damage. He would like the Practice to acknowledge the failings, apologise and improve its service.

5. Mrs B had a previous history of breast cancer and mastectomy. During the period of care in question she was seen several times by doctors from the Practice due to pain in her ribs. During this period the Practice made a referral to adult safeguarding due to the concerns it had about her health and wellbeing. Mrs B was later diagnosed with recurrent cancer. She sadly died on 4 September 2025 from an unrelated brain haemorrhage.

9. The GMC guidance says:

‘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, 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

In providing clinical care you must:

• provide effective treatments based on the best available evidence • consult colleagues where appropriate’

Did not send Mrs B for an Xray when she saw the doctor with pain in her ribs on 29 September 2024

10. The NHS rib injury guidance says:

‘Bruised or broken ribs can be very painful but usually heal by themselves. Symptoms of bruised or broken ribs include:

• strong pain in your chest area, particularly when you breathe in or cough • swelling or tenderness around the affected ribs • sometimes bruising on the skin • feeling or hearing a crack if it's a broken rib

There's often no need for an X-ray. Broken or bruised ribs usually get better by themselves within 2 to 6 weeks. Things you can do to help ease pain and speed up healing include:

• use painkillers, such as paracetamol or ibuprofen gel (or ibuprofen tablets if needed) • hold an ice pack (or a bag of frozen peas) wrapped in a tea towel to the affected ribs regularly in the first few days to bring down swelling • rest and take time off work if you need to • breathe normally and cough when you need to – this helps clear mucus from your lungs to prevent chest infections • hold a pillow against your chest if you need to cough • walk around and sometimes move your shoulders to help you breathe and clear mucus from your lungs • regularly take slow, deep breaths to help clear your lungs • try to sleep more upright for the first few nights.’

11. The NICE chest pain guidance says:

‘For people not requiring admission to hospital, or referral to a specialist:

• Arrange appropriate investigations if the cause of chest pain cannot confidently be established by clinical features alone.

• Manage the underlying cause: Musculoskeletal chest pain — consider prescribing analgesia (for example paracetamol or a nonsteroidal anti-inflammatory drug).’

12. The records show the first assessment took place on 30 September 2024 and a doctor from the Practice saw Mrs B in her home after she had reported a sharp pain in her left lower ribs that had been present for approximately two weeks. The record of the consultation notes she had recently been lifting heavy items in her kitchen and felt she had ‘overdone it’. The record of the consultation notes Mrs B had not suffered any recent falls or any other injury.

13. The doctor identified tenderness over her left lower ribs but no bruising or deformity. Our adviser said the notes of her other clinical observations showed no cause for concern, her oxygen saturation level was 97%, her heart rate was 87 beats per minute and her chest was clear on auscultation (the medical technique in which healthcare providers listen to internal body sounds, typically using a stethoscope). The doctor advised her to take paracetamol regularly and use hot or cold packs to help ease her pain.

14. Our adviser said the clinical findings noted by the doctor in the records are consistent with a musculoskeletal rib injury and there are no features to suggest a more serious underlying condition. The records indicate the doctor provided appropriate safety netting advice asking Mrs B to contact them again if her symptoms persisted.

15. The records indicate a doctor from the Practice discussed Mrs B’s rib pain with her and her family again on 4 October 2024. The note of the discussion states she suffered a fall two nights earlier, resulting in increased rib pain, although Mrs B reported some improvement in her rib pain by the day of the call.

16. The doctor said her symptoms were consistent with a rib bruise, fracture, or intercostal muscle strain (strain of the muscles between the ribs) and the management for such an injury would be the same management they had recommended previously, regular pain relief medication and hot or cold packs to help ease her pain. The doctor arranged a follow up call for a week later to review her progress.

17. The records indicate the follow up telephone consultation took place on 11 October 2024. Mrs B said she was taking paracetamol only two to three times a day for her pain by this time. During the call the doctor noted she had a cough which she said she had been present for around a week, although she denied any shortness of breath and did not display any difficulty with her breathing during the discussion.

18. The records indicate the doctor felt her symptoms were consistent with an upper respiratory tract infection such as a cold. The doctor advised Mrs B of the importance of adequate pain control to encourage normal breathing and reduce the risk of her symptoms worsening and recommended she take paracetamol regularly, up to four times a day, to help manage both her rib pain and cold symptoms.

19. We carefully considered Mr A’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we have received. We found the Practice acted in line with the NHS rib injury guidance, the GMC guidance and the NICE chest pain guidance during the assessment of 30 September 2024 and the follow up telephone consultations.

20. We found no evidence to indicate the Practice should have referred Mrs B for an Xray at this time given the symptoms she displayed, the findings of the assessments and the improvement in pain she reported.

Did not arrange transport for the Xray on 13 May 2025

21. Mrs B was reviewed by the out of hours doctor on 12 May 2025 due to her reports of severe chest pain at the site of her previous mastectomy. The doctor advised she go to a local NHS health centre for an Xray. Mr A contacted the Practice on 13 May 2025 to request transport for his mother to attend the Xray at the local NHS health centre but the Practice sad they could not arrange this for him. Mr A borrowed a wheelchair and took his mother to the private hospital on the same road as their home where the Xray was performed on 13 May 2025.

22. The NHS transport guidance says patients attending hospital are expected to arrange their own transport if it is not an emergency. It says support may be available to patients whose condition means they need additional medical support during their journey or causes them mobility problems, however patient transport services may noy always be available in all areas. In its response to Mr A’s complaint the Practice said as this was a walk-in service at the NHS health centre it did not have the capacity or the means to arrange transport for Mrs B.

23. Our adviser said, in line with the NHS transport guidance, GPs do not usually arrange transport for patients to go into hospital or other services for investigations. The patient (or their family/carer) is normally responsible for arranging their own transport to and from hospital appointments, whether by private car, taxi, public transport, or with assistance from relatives or friends.

24. We carefully considered Mr A’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we have received. We found the Practice acted in line with the NHS transport guidance. We found no evidence to indicate it was a failing on the part of the Practice not to arrange transport for Mrs B’s Xray on 13 May 2025.

Refused the family a copy of the Xray report

25. Mr A says the Practice refused the family access to a copy of the Xray report. In its response to Mr A’s complaint the Practice said it received the Xray report on 14 May 2025 and the practice manager called to advise it would be posted to Mrs B and a copy made available for the family to collect from reception if they wanted to see it sooner. The Practice said as Mrs B had not previously provided consent to send her medical information to Mr A’s personal email address it was unable to do this.

26. The GMC guidance says appropriate information sharing is an essential part of the provision of safe and effective care. However information must be shared within the framework provided by law and ethics. It says information should be shared with due consideration to those close to the patient and organisations should be sensitive and responsive in giving them information and support, while also respecting the patient’s right to confidentiality.

27. We carefully considered Mr A’s complaint and the supporting information he has provided. We also considered the information in the records and the guidance. We cannot say the Practice refused the family a copy of the report, the records indicate a copy was posted to them and a further copy held at reception to collect.

28. The evidence in the records indicates the Xray report was shared with Mrs B and made available to her family promptly and in line with the GMC guidance. We found no evidence to indicate it was a failing on the part of the Practice not to send a further copy to Mr A’s personal email address as there is no explicit consent on record from Mrs B to enable the Practice to share her medical information in this way.

Provided an inappropriate combination of pain relief medication following her Xray of 13 May 2025

29. Mr A says the Practice provided an inappropriate combination of pain relief medication to his mother as it suspected a hernia which she did not have. In its response to Mr A’s complaint the Practice said the only change it made to his mother’s treatment after the Xray was to prescribe a buprenorphine patch to ensure she received regular and sustained pain relief. 30. The Practice held a telephone consultation with Mrs B on 14 May 2025 and the note of the consultation says ‘probable large hiatus hernia, probable combination of acute, subacute and presumed established rib fractures causing some deformity. Agree trial low dose Bu Trans and paracetamol.’

31. The BNF guidance confirms buprenorphine is an opioid analgesic medication for chronic severe pain. It is not specifically to treat hernia but all types of chronic severe pain. The records indicate the Practice prescribed this medication in combination with regular paracetamol as her pain relief requirements were not being adequately met.

32. The BNF sets out the contra-indications for buprenorphine (the conditions and circumstances under which it should not be used) and its interactions with other medications (the effect it can have when used in combination with another medication). Our adviser said there is no evidence in the BNF to indicate it is not appropriate to prescribe buprenorphine patch for severe pain, such as that reported by Mrs B in her assessments at this time. Our adviser said the BNF does not recommend against prescribing buprenorphine alongside paracetamol and it does not note any interactions.

33. The NHS buprenorphine guidance says:

‘Taking buprenorphine with other painkillers

It's safe to use buprenorphine with paracetamol, ibuprofen or aspirin.

Do not take any painkillers containing codeine, such as co-codamol or combined ibuprofen and codeine (brand names Nurofen Plus or Solpadeine) when you're using buprenorphine. You'll be more likely to get side effects if you take any of these while using buprenorphine.’

34. We carefully considered Mr A’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we received. We found no evidence to indicate the Practice provided an inappropriate combination of pain relief medication to Mrs B following her Xray of 13 May 2025.

Did not prescribe antibiotics for the chest infection identified in the Xray of 13 May 2025

35. Mr A says the Practice did not prescribe antibiotics despite the Xray of 13 May 2025 reporting that his mother had a chest infection. In its response to Mr A’s complaint the Practice said as she had no cough and good oxygen saturation levels (95%) at this time the plan was to perform blood tests to see if she had any raised inflammatory markers and a repeat chest Xray in 6 weeks time.

36. The Practice said Mrs B was prescribed antibiotics on 16 May 2025 for a suspected lower respiratory tract infection after the doctor reviewed her symptoms during a home visit. However there were no indications antibiotics were required before this review was carried out.

37. Our adviser said the report of the Xray of 13 May 2025 indicates multiple possible causes for Mrs B’s chest problems and one aspect it refers to is ‘opacity in the right mid zone (which is) nonspecific but could represent infection/inflammation’. The Xray report recommends a repeat study in 6 weeks for further evaluation. Our adviser said the Xray report does not confirm Mrs B had a chest infection.

38. The chest infection guidance sets out the symptoms of chest infection. It says clinicians should check for indications of a cough, wheezing, sweating, fever as well as other chest symptoms such as aches and pains, unusual or laboured breathing patterns.

39. Our adviser said the records indicate the Practice acted in line with the GMC guidance in reviewing Mrs B’s symptoms when it received the Xray report on 14 May 2025 before deciding on the appropriate plan of care. The records confirm she did not have a cough or a fever and her oxygen saturation levels were good. Our adviser said the records support the view she did not display any of the acute signs associated with a chest infection during this assessment and there is no evidence to indicate antibiotic treatment was indicated at this time.

40. The records indicate Mrs B was seen face to face by the doctor 2 days later during a home visit to review her symptoms. The doctor listened to her chest and identified crepitations (crackling sounds) in her chest. The doctor diagnosed lower respiratory tract infection and prescribed antibiotics.

41. Our adviser said there is no evidence in the records of any clear indications of a chest infection until this assessment. Our adviser said there is no evidence to suggest Mrs B suffered a clinical deterioration during the period between the Xray scan of 13 May 2025 and the diagnosis of lower respiratory tract infection on 16 May 2025.

42. We carefully considered Mr A’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we received. We found no evidence to indicate the Practice failed prescribe antibiotics following the result of the Xray of 13 May 2025. We found the Practice acted in line with the GMC guidance and the chest infection guidance.

Inappropriately attributed her vertigo to inner ear infection rather than aneurysm

43. Mr A says the Practice failed to identify his mother had an aneurysm and instead attributed her symptoms of dizziness to an inner ear infection. In its response to Mr A’s complaint the Practice said: ‘Mrs B had a longstanding history of labyrinthitis. It was most likely that her dizziness was due to this as her symptoms improved with medication (Mrs B had been prescribed betahistine medication for her dizziness). The CT scan for her cerebral bleed reported that the haemorrhage could have been from an aneurysm or a lesion, this was certainly not conclusive. Furthermore if there was an aneurysm this would only cause catastrophic symptoms after it had burst, they are generally completely asymptomatic, but to reiterate there was no confirmed diagnosis of an aneurysm.’

44. Mrs B was admitted to hospital on 3 September 2025 after she collapsed at home. A CT scan on 4 September 2025 found a large brain haemorrhage. The report of the scan said ‘large right sided predominantly intraparenchymal frontoparietal haemorrhage, the majority of which is within white matter. Given the focal nature of this and lack of traumatic findings, this suggests a bleed from a ruptured aneurysm or underlying lesion, however trauma does remain a possibility.’ Mrs B sadly died a short time later on 4 September 2025.

45. Our adviser said there is no evidence to support the view the Practice incorrectly attributed any of the symptoms Mrs B displayed during this period of care to an inner ear infection rather than an aneurysm. As stated in the hospital records her cause of death was a brain haemorrhage. An aneurysm was not confirmed as the cause of the brain haemorrhage, only suggested as one possibility.

46. Our adviser said if Mrs B had been complaining of frequent, persistent episodes of dizziness during the months prior to her brain haemorrhage, it would have been appropriate for the Practice to arrange investigations into what may have been causing this to either identify or rule out possible neurological conditions. However there is no evidence in the records which would indicate this was the case.

47. Mrs B was taking medication for her symptoms of dizziness as and when they occurred. However our adviser said the records do not indicate Mrs B complained of frequent, persistent episodes of dizziness in the months prior to her brain haemorrhage. There are very few references to her suffering dizziness in the records that cover the period of care we have investigated (one in September 2024, one in February 2025, one in March 2025 and two in May 2025).

48. Dizziness is only mentioned twice in the records that cover the six month period of care prior to her brain haemorrhage. These are very brief references during concurrent consultations on 29 and 30 May 2025. There are no further reports of dizziness following this. The notes from these consultations say:

‘29 May 2025 - Problem – Labyrinthitis – Dizziness, worse on movement.

30 May 2025 – She has had 4 dizziness pills so far and says she is still dizzy but seems better and they will take a while to work.’

49. We carefully considered Mr A’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we received. We found no evidence to indicate the Practice inappropriately attributed symptoms of an aneurysm to either labyrinthitis, vertigo or an inner ear infection.

50. We acknowledge Mrs B suffered a sudden and catastrophic brain haemorrhage and we acknowledge how distressing this was for Mr A. Having reviewed the information in the records and the hospital notes we found no evidence to indicate this was something that could have been identified sooner by the Practice or that it was something that it overlooked due to misdiagnosing her symptoms.

Inappropriately reported him and his brother to safeguarding and did not inform the family of this decision or retract the referral after her diagnosis of bone cancer

51. Mr A says the safeguarding referral was vexatious. He says the cause of his mother’s rib pain was identified as recurrent cancer that had reached her bones within a few days of the safeguarding referral and the Practice should have shared this information with the safeguarding team and retracted the referral.52. In its response to Mr A’s complaint the Practice said: ‘When the doctor called Mrs B with the result (of the Xray), it had been made clear to him that you (Mr A) did not want him to talk to you and therefore the doctor requested to speak with Mrs B, his patient. Despite your insistence that you are PoA for Health and Welfare this was in fact incorrect. It was also irrelevant as the doctor had no reason to doubt that Mrs B had capacity.

The doctor was, however, starting to grow concerned for her wellbeing, given the Xray findings of multiple rib fractures of varying age, without a clear mechanism of injury, and the behaviour of yourself since our first consultation on 12 May 2025. Without Mrs B’s expressed consent, the doctor was not going to inform you of any medical results without Mrs B being present on the phone. It soon transpired that the plan agreed previously had not been implemented and she had not received any analgesia since 10 May 2025 nor had either you or your brother even collected her prescription for a proton-pump inhibitor, all the while she was continuing to suffer with pain.The X-Ray confirmed what had been elicited by both the OOH Dr from his visit (rib fractures) and the doctor’s history on the phone (hiatus hernia causing dyspepsia). It was on the back of this follow up telephone consultation that the doctor determined it necessary to refer Mrs B to adult safeguarding due to:1. Unclear mechanism of injury for multiple, multi-aged rib fractures.2. Non-compliance with an agreed treatment plan for Mrs B which was dependent on her sons/carers support.3. Her sons increasingly presenting a barrier to care for Mrs B with regular vexatious complaints and subsequently threatening behaviour4. Concern that Mr A is imposing his non-evidence based health beliefs on Mrs B preventing her from getting the appropriate care she requires.’

53. Mr A complained to the General Medical Council (GMC) about the decision to refer his mother to adult safeguarding. The GMC said:

‘Regarding the concern that the doctor made a vexatious referral to safeguarding, there does not appear to be any information to show that the referral by the doctor was inappropriate. It appears there was information to indicate unexplained rib fractures in an elderly and vulnerable patient and if the doctor felt concerned, we could not criticise them from initiating safeguarding procedures. It is part of a doctor’s role to identify safety risks, and while concerns may be raised had the doctor failed to act when they believed it appropriate to have done so, the fact that no subsequent concerns were identified following the referral would not necessarily indicate that the doctor acted inappropriately.’

54. The GMC guidance says: ‘Safeguarding adults who are at risk of harm

You must consider the needs and welfare of people (adults, children and young people) who may be vulnerable and offer them help if you think their rights are being abused or denied. You must act promptly on any concerns you have about a patient – or someone close to them – who may be at risk of abuse or neglect or is being abused or neglected.’

55. Our adviser said in line with the GMC guidance it is part of a doctor’s role to identify potential safety risks, and it would be inappropriate for a doctor not to act if they believed a patient was at risk. Our adviser agreed with the view provided by the GMC that although no subsequent concerns were identified following the referral, this does not indicate it was inappropriate for the doctor to make the referral.

56. Our adviser said in most circumstances, it would be in line with the GMC guidance for the Practice to discuss their concerns with the patient, seek their consent to share information where appropriate, and explain that a safeguarding referral is being made.

57. However, there are important exceptions. The GMC confidentiality guidance says a doctor may make a safeguarding referral without informing the patient or their family if doing so would place the patient or another person at increased risk of serious harm or undermine the purpose of the safeguarding enquiry. Our adviser said in such circumstances, the duty to protect an adult at risk overrides the usual expectation to seek consent or notify those involved.

58. We acknowledge the safeguarding referral did not identify any concerns. We also acknowledge the referral and subsequent safeguarding investigation caused Mr A and his family a great deal of distress and inconvenience.

59. We found it was appropriate for the doctor at the Practice to refer Mrs B to adult safeguarding given the concerns they had. We do not think the Practice should have retracted the referral once the diagnosis of cancer was confirmed as we can see the referral was based on additional concerns and not only the potential rib fractures reported in the Xray of 13 May 2025. We found the Practice acted in line with the GMC guidance when making the safeguarding referral.

1. We have decided to not uphold this complaint as we found no evidence of failings in the action taken or care provided by the Practice.