A practice in the Leeds area

4. Miss M complains the Practice failed to monitor her low thyroid and vitamin D levels following her attendance with headache symptoms in February 2024. She says the Practice was rude and dismissive in its communication with her and did not inform her of a referral to the Non-Specific Symptom (NSS) clinic for her weight loss. She also says the Practice did not manage her complaint correctly as she experienced delays in receiving a response.

5. Miss M says she continues to experience issues relating to her thyroid and weight loss with no clear diagnosis. She says her headaches are sporadic now which she manages herself as she has lost faith in the Practice and is fearful of future care. She wants an acknowledgement of failings, an apology, service improvements and financial remedy.

6. Miss M had a diagnosis of hypothyroidism (low thyroid levels) since 2010. She was taking medication to manage this.

7. In mid-February 2024, Miss M attended the Practice with headache symptoms. The Practice organised for her to have bloods taken and to discuss the results with her. Miss M refused pain medication at this point.

8. Three days later, the Practice noted Miss M had attended the emergency department (ED) where it had given her a working diagnosis of Polymyalgia Rheumatica (PMR) which is an inflammatory condition which can cause muscle stiffness and pain and Giant Cell Arteritis (GCA) which is inflammation of the arteries particularly around the head and neck.

9. The Practice spoke with rheumatology and arranged for the service to see her the following day. The Practice called Miss M to tell her about the appointment and to arrange for her to have C-reactive protein (CRP) blood tests on the same day. CRP is a protein produced by the liver in response to inflammation. The Practice also told Miss M to contact it if she had any visual changes.

10. The Practice contacted Miss M at the beginning of March to discuss her headaches. It noted that rheumatology had ruled our PMR and GCA and had informed her that her headache was possibly thyroid related as her thyroid stimulating hormone (TSH) levels were low. It advised her to take her thyroxine medication regularly and if headaches did not improve, it would arrange a CT scan. It also arranged for further repeat blood tests in a months’ time. She had the blood test in June.

11. The Practice informed Miss M to continue taking her thyroxine medication daily following the results of her blood test. It stopped prescribing Vitamin D in September.

Monitoring of thyroid levels 14. Miss M complains the Practice failed to monitor her hypothyroidism (low thyroid levels) following her attendance with headache symptoms in February 2024. She told us the Practice organised blood tests and following the results of these, advised her pain was due to low thyroid levels and would resolve once she took her medication daily. She says this was not the case and the pain continued and the Practice failed to continue monitoring her thyroid levels.

15. NICE guidance on prescribing for hypothyroidism says the dose of medication should be individual based on clinical response and thyroid function test (TFT) results. It says treatment require regular monitoring to determine an adequate dose and to avoid under and over-treatment. BNF guidance on the medication prescribed to Miss M says a practitioner should consider measuring thyroid stimulating hormone (TSH) levels every three months until stabilised then yearly thereafter.

16. Miss M had a diagnosis of an underactive thyroid since 2010. She was taking medication to manage this. She attended the Practice in mid-February with a severe headache. The Practice organised blood tests which showed her thyroid levels were low which it considered may be the cause of her pain, so it increased the dose of her medication.

17. Three days after Miss M’s initial appointment, the Practice received further information about Miss M attending the ED with worsening symptoms. As the ED had given Miss M a working diagnosis of PMR and GCA, the Practice made a referral to rheumatology to investigate her ongoing symptoms.

18. The Practice then contacted Miss M in early March to discuss her headaches noting that during her ED attendance, the Trust had informed her that her headache was possibly thyroid related. It advised her during this appointment to take her thyroxine medication regularly and if headaches did not improve, it would arrange a CT scan. It also told her to arrange a repeat blood test in a month’s time and gave her advice on what to do if her symptoms got worse in the meantime.

19. From what we have seen, Miss M did not arrange her blood test the following month, so the Practice contacted Miss M in early June to remind her that the blood test was overdue and to arrange them. This was also in line with BNF guidance that says a clinician should check the levels of TSH every three months.

20. Our clinical adviser explained that the results of this blood test showed that Miss M’s TSH levels were in the normal range. We can see that the Practice advised Miss M of this in early July and to continue taking her medication daily and that if she remained well the next blood test would be within the next year.

21. We have not seen any evidence that Miss M attended the Practice after this date and therefore consider the Practice did not get anything wrong in monitoring her thyroid levels following her attendance with a headache in February. It organised blood tests to monitor her levels and increased her medication when they came back low. It also arranged follow up blood tests to ensure her levels were stable. We will therefore not take any further action on this part of the complaint. We recognise that her experience caused Miss M some distress and hope this will give her reassurance the Practice followed guidance in the management of her care.

Treatment 22. Miss M complains the Practice failed to monitor her vitamin D levels from early 2024 when she attended the Practice with ongoing headaches. She is also concerned it did not act on information from the NSS clinic who she says told her to stop taking vitamin D as her levels were too high.

23. It appears the Practice prescribed Miss M with calcichew D3 forte tablet which contains both calcium carbonate and vitamin D in 2010.

24. Miss M first attended the Practice in February 2024 with headaches which as we discussed earlier, the Practice carried out investigations and referrals to secondary care to determine the cause.

25. In July 2024 she attended the NSS clinic and following blood tests the nurse told her to stop taking her calcichew D3 forte tablet. The NSS clinic informed the Practice of this decision in August when it discharged Miss M from its service. The Practice stopped prescribing the medication to Miss M in early September 2024. It appears Miss M stopped taking the medication before this date in early August.

26. BNF guidance on the medication colecalciferol (vitamin D3) says it is not a requirement to routinely monitor the prescription of vitamin D concentration. The exception is in some cases such as when patients with symptomatic vitamin D deficiency or malabsorption, those taking antiresorptive therapy, or where there may be poor compliance.

27. Our clinical adviser explained that Miss M did not meet the criteria for routine monitoring of her vitamin D. They said following the advice from the NSS clinic in August, the Practice completed a medical reconciliation for Miss M in early September where it acknowledged she had stopped taking this medication.

28. We were pleased to see that following the stopping of the vitamin D medication, the Practice arranged a further blood test for Miss M in January 2025 to ensure her levels of vitamin D were back within normal range. Our clinical adviser confirmed that this test showed Miss M’s her levels were sufficient.

29. It therefore appears the Trust acted in line with BNF guidance in that there was no need for regular monitoring of Miss M’s Vitamin D levels following her prescription in 2010. However, when the NSS clinic advised that the medication should stop, the Practice acted on this advice by stopping the prescription and by monitoring her levels through a follow up blood test a few months later to ensure her levels were stable.

30. It appears the Practice did not get anything wrong in its actions relating to this and therefore we will not take any further action on this part of the complaint. While we have found no evidence of fault in the Practice’s actions, we recognise the distress these concerns may have caused and thank you for bringing them to our attention.

Communication 31. Miss M says the Practice was rude and dismissive in its communication with her during her appointments in February and March 2024 and did not inform her of a referral to the NSS clinic for her weight loss.

32. We have firstly considered Miss M’s concerns regarding the attitude of the GP towards her during her appointment in February and March. Miss M told us that during her consultations with the Practice in mid-February and early March she felt thar the GP dismissed her concerns over her symptoms and spoke to her in combative manner.

33. We have seen evidence in the medical records for both appointments the Practice acknowledge some challenges in relation to these appointments. The Practice also apologised in its final response for how these interactions made Miss M feel.

34. We can sympathise with the experiences Miss M told us about, and how it made her feel at the time. We were not present during these interactions so we cannot say the Practice was dismissive or rude in its behaviour to her. We are unable to judge what the Practice might have said or in what context. But it is clear she was unhappy with how it spoke to and treated her.

35. We would like to be able to conduct a meaningful investigation of this complaint, but we would not be able to reach a decision as there is no objective evidence and the Practice has already apologised. Therefore, we will not take any further action on this part of the complaint. We are sorry for any further upset this may cause.

36. We have gone on to look at Miss M’s concerns the Practice did not inform her of a referral to the NSS clinic for her weight loss. Miss M says it was a shock to both her and her family when it became clear the appointment was to investigate her risk of cancer.

37. We have seen evidence in medical records, the rheumatology team at the Trust was responsible for Miss M’s referral to the NSS clinic, not the Practice. It appears the Trust sent Miss M a letter in early June to advise of the referral. We have seen the letter from the Trust and although it did mention investigations into her weight loss, it did not give any detail on investigation into her cancer risk.

38. We were sorry to hear of Miss M’s experience and recognise how shocked and upset she was when she became aware of the reason for her clinic appointment. However, it was not the responsibility of the Practice to provide Miss M with this information and therefore we cannot not see that the Practice got anything wrong in its actions in relation to this. We will not take any further action on this part of the complaint.

Complaint Handling 39. Miss M says the Practice did not manage her complaint correctly as she experienced delays in receiving a response. Miss M told us she initially raised her concerns with the Practice in March 2024 which she says she followed up in May. She has told us that the Practice did not respond to complaint which resulted in her sending a further email in October.

40. NHS England’s complaint policy says an organisation should provide a full response to the person raising the complaint within 40 working days. Unless it has agreed a longer timescale with the person raising the complaint within the first six months, it will inform them if it cannot conclude the investigation and issue a final response within six months.

41. We can see Miss M contacted our service due to a lack of response from the Trust in October and following two intervention letters from our service, the Practice responded to her complaint in January 2025. This was ten months after the original complaint and four months over NHS guidance on managing a complaint.

42. We can see from what she told us how this delay and lack of communication from the Practice added to the lack of faith she told us she now has in the Practice following her experience.

43. Our Principles for Remedy says where failings have had an impact, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise. An appropriate range of remedies will include an apology, explanation, and acknowledgement of responsibility.

44. In the final response, the Practice acknowledged and explained the delay in its complaint process to Miss M. It has also apologised to Miss M for the delay and for any upset caused. This appears to be a human error which the Practice has reflected on as part of the complaints process.

45. We consider the actions taken by the Practice in its final response are enough to put right the distress and lack of faith she has in the Practice Miss M told us about in relation to how the Practice has managed her complaint. We were pleased to see the Practice has provided Miss M with an explanation as to why there was a delay in it providing her with a response. It has also apologised for her experience. We will therefore not take any further action on this part of the complaint.

46. We were sorry to hear of Miss M’s experience and recognise the difficulties she continues to have with ongoing symptoms. We hope this will give her reassurance that we have not found the Practice got anything wrong in its actions relating the monitoring of her thyroid and vitamin D levels and in its communication with her. We are also satisfied it has done enough to address the impact caused by the failing in its complaint handling. We will therefore take no further action on the complaint.

1. We have carefully considered Miss M’s complaint about the Practice. We were sorry to hear about her experience and the difficulties she continues to face with her ongoing symptoms. We have looked at all the evidence provided to us by Miss M and the Practice. We have seen that the Practice followed relevant guidance in relation to how it monitored her thyroid and vitamin D levels and in its communication with her in early 2024.

2. We have also looked at how the Practice managed Miss M’s complaint and have found that this was not in line with NHS guidance on complaints. We saw the Practice acknowledged and apologised to Miss M for her experience and took learning to improve, in line with relevant complaint standards. We are satisfied this is enough to remedy this part of complaint and we will therefore take no further action on the complaint.

3. We are sorry for any additional upset this may cause, and we hope our explanations below explain how we have fully considered this.