A practice in the Southend-on-Sea area

8. Mrs R complains about the poor service she received from the Practice. She says the Practice sent incorrect and delayed referrals for specialist care and treatment between April 2024 and August 2025.

9. She also complains about the Practice’s poor communication and complaint handling.

10. Mrs R says the failures have caused a significant delay in her getting a diagnosis and treatment for her symptoms and has impacted her physical health.

11. She says the Practice’s poor communication and complaint handling has added to her upset and distress during what has already been a difficult time for her.

12. By bringing this complaint to us, Mrs R would like the Surgery to make changes to improve its service going forward.

13. On 19 April 2024, Mrs R attended the Practice with reports of multiple joint pain. The Practice made a routine referral to rheumatology. This referral was rejected as it was sent to the wrong hospital. The Practice sent a further referral to the correct hospital on 4 July.

14. Mrs R was seen by the rheumatoid specialist on 18 July and 15 October. The specialist felt Mrs R did not have inflammatory arthritis, and her symptoms were more consistent with fibromyalgia. Therefore, they referred her to the chronic fatigue and fibromyalgia service and discharged her from rheumatology.

15. The chronic fatigue and fibromyalgia service referral was rejected with no reason given so the specialist asked the Practice to refer Mrs R to its local fibromyalgia services.

16. In June 2025, due to extensive wait times, Mrs R asked the Practice for a further referral to be sent to an alternative provider. The Practice made a further referral to a rheumatologist outside of its locality to make an onward referral to another fibromyalgia service as it had exhausted its local provision.

17. On advice from the rheumatologist, the Practice also made subsequent referrals to pain management, physiotherapy for a supervised exercise programme, and clinical psychologists for help with pain and sleep management.

Initial referral to rheumatology

21. Mrs R says she attended the Practice on 19 April 2024 with multiple joint pain that had been ongoing for around nine-months. She says the Practice should have referred her urgently to a rheumatologist. She says the Practice initially sent the referral to the wrong hospital and only sent it to the right one when she highlighted the error on 28 June.

22. The Practice says it did not know that it had sent the referral to the wrong hospital until Mrs R raised her concerns on 28 June. This was because the referral was not showing as rejected on its system. It apologised for the error and made a further referral to the correct hospital on 4 July.

23. The Practice explained that, on examination in April, Mrs R had no patterns to her pain, no swelling of joint, no finger joint pain, no signs of inflammation, and had blood test results with only a slightly out of range rheumatoid factor. On this basis, it says it did not think Mrs R had rheumatoid arthritis so sent the referral as routine rather than urgent.

24. NICE ‘Rheumatoid arthritis in adults: management’ guidance says to refer for specialist opinion any adult with suspected persistent synovitis (inflammation causing pain or swelling) of undetermined cause. Refer urgently (even with a normal acute-phase response, negative anti-cyclic citrullinated peptide [CCP] antibodies or rheumatoid factor) if any of the following apply: • the small joints of the hands or feet are affected • more than one joint is affected • there has been a delay of 3 months or longer between onset of symptoms and seeking medical advice.

25. The records indicate that, following Mrs R’s appointment, the Practice made a routine rheumatology referral on 24 April. On 28 June, Mrs R notified the Practice that the referral had been sent to the incorrect hospital, so it made a further one to the right hospital on 4 July.

26. Our adviser says Mrs R had reported more than one joint being affected and that it had been ongoing for more than three-months. Additionally, the records indicate that Mrs R’s rheumatoid factor level was ‘borderline’. The said if rheumatoid arthritis is suspected then an urgent referral should be made. This is because joint inflammation can lead to permanent joint damage if not treated promptly.

27. Mrs R was seen at the hospital for her first appointment on 18 July.

28. The Practice sent the initial referrals as routine. We consider this was not in line with NICE ‘Rheumatoid arthritis in adults: management’ guidance and is an indication of a failing. As the Practice sent the initial routine referral to the wrong hospital and then again as routine to the second hospital, it appears the Practice was responsible for the initial delay Mrs R experienced in waiting for a specialist rheumatoid appointment.

29. When we see an indication of a failing, we go on to look at the impact it had and what needs to happen to put things right.

30. Mrs R was seen by a rheumatoid specialist on 18 July and 15 October. The specialist felt Mrs R did not have inflammatory arthritis but referred her to the chronic fatigue and fibromyalgia service and formally discharged her from its service.

31. As Mrs R was not diagnosed with rheumatoid arthritis, we do not consider this delay had the significant impact that it could have had. That said, we appreciate it meant that Mrs R experienced a delay in receiving the right diagnosis and meant she had to wait longer to be put on the waiting list for a fibromyalgia service.

32. Our adviser explained that there is a national shortage of fibromyalgia services which makes it harder for patients to be seen in a timely manner. We can see this was the case for Mrs R.

33. On this basis, we cannot say that an earlier diagnosis would have meant Mrs R would have received earlier support from the fibromyalgia service or that it impacted her physical health. Albeit we recognise the frustration and upset this caused.

34. Our ‘NHS Complaints Standards’ explain when things go wrong, we expect organisations to apologise and ‘see complaints as an opportunity to develop and improve its services.’

35. We contacted the Practice to discuss our views on the complaint and to allow it to reflect on its service. The Practice has already apologised for sending the referral to the wrong hospital initially, but it has agreed to write to Mrs R to apologise for sending a routine referral on both occasions and for the upset and frustration this caused. It agrees that the referral should have been sent as urgent and will ensure it acts in line with the NICE guidance going forward. It also apologises that this matter was not addressed when Mrs R first raised her complaint.

36. We consider these actions to be in line with Our NHS complaints standards and resolves this part of Mrs R’s complaint. Therefore, we will not be taking any further action.

Further referrals

37. Mrs R says the Practice continued to send incorrect and delayed referrals for specialist care and treatment.

38. GMC ‘Good Medical Practice’ guidance explains that a doctor 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, needs, 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.

39. Following the initial referral, Mrs R was seen by a rheumatoid specialist on 18 July and 15 October. The specialist felt Mrs R did not have inflammatory arthritis but referred her to the chronic fatigue and fibromyalgia service and formally discharged her from its service.

40. In a letter dated 5 December, the specialist wrote to the Practice to inform it that the referral had been rejected with no reason given. The specialist requested the Practice refer Mrs R to local fibromyalgia services instead.

41. On 20 December, Mrs R contacted the Practice to ask about the fibromyalgia referral. Mrs R was upset and frustrated that the Practice had not acted on the rejected referral and the specialists request for local services.

42. The Practice explained that it had not received a letter and Mrs R forwarded it on for action and the Practice added it to her GP records.

43. Our adviser explained that the Practice can only act on information it is aware of. The records indicate that the Practice did not receive the letter from the specialist and was only made aware of its contents when forwarded on by Mrs R.

44. On 28 December, the Practice requested additional blood tests be carried out. The referral to the local fibromyalgia service was made via the orthopaedic pathway on 10 January 2025. However, this referral was rejected.

45. On 24 January, further blood tests were done. The Practice said it wanted to take more to ensure nothing was missed and a further referral was put in via the general medicine pathway.

46. The Practice explained that the pathway referral system is often difficult and confusing to navigate and it is unsure why the initial referral was rejected and the second one accepted. It also apologised for the inconvenience and the delay in the acceptance of Mrs R’s referral.

47. On 12 February 2025, the local fibromyalgia service confirmed Mrs R was on its waiting list.

48. On 4 June, Mrs R contacted the fibromyalgia service to ask when she would be seen. It advised that it was likely she would not receive an appointment until 2027.

49. Mrs R asked the Practice for a further referral to be sent to an alternative provider due to the extensive wait time. The Practice made a further referral to a rheumatologist outside of its locality to make an onward referral to another fibromyalgia service as it had exhausted its local provision. Our adviser confirmed this was appropriate in order to act on Mrs R’s wishes to find an alternative provider.

50. Our adviser confirmed that GP Practices have limited services they can refer directly into and that local pathways can be hard to navigate. Patients are often referred to specialists to make onward referrals to sub-speciality services, such as fibromyalgia, and these are often given more weight than a GP referral.

51. The rheumatologist saw Mrs R on 5 August. The specialist wrote to the Practice and asked it to refer her to fibromyalgia service along with further referrals to pain management, physiotherapy for a supervised exercise programme, and clinical psychologists for help with pain and sleep management.

52. The Practice made the additional referrals but contacted the specialist back requesting them to make the onward referral to the fibromyalgia service as it had already exhausted its local provision and Mrs R wanted an alternative provider due to wait times. Again, our adviser confirms this was appropriate action to take.

53. Our adviser said there are no specific guidelines to determine what is considered ‘prompt’ action. However, our adviser said that the timeliness of the Practice’s actions and referrals throughout this period appears to be reasonable.

54. We understand the pain Mrs R experienced during the period complained about and how distressing it was for her not to be seen by specialist to help alleviate her symptoms. Therefore, we recognise that a delay in accessing services added to her distress.

55. Having taken everything into account, we consider the Practice acted in line with GMC ‘Good Medical Practice’ guidance. We consider it assessed Mrs R’s symptoms, listened to her concerns, and made appropriate onward referrals to specialists to help support with a diagnosis and treatment.

56. We also consider it promptly arranged for blood tests to support the referrals as needed. We understand there were delays at times in making the onward referrals. However, we cannot hold the Practice responsible for making further referrals when it has not received the information to act upon. For these reasons, we do not consider the Practice was responsible for the delays Mrs R experienced during this period complained about.

Communication and complaint handling

57. Miss R complains about the Practice’s poor communication and complaint handling. She complains that the Practice did not explain what was happening during this period. She also complains that she does not feel that the Practice’s complaint handling showed any reflection and accountability and she was not provided with apologies or explanations for the delays she experienced. She says this added to her upset and distress during what was already a difficult time for her.

58. GMC ‘Decision making and consent’ guidance explains the importance of dialogue between doctor and patient. It says this helps the patient understand their role in the process and informs them of their right to choose whether or not to have treatment or care. It also says this helps to ensure patients have the opportunity to consider relevant information that might influence their choice between the available options and to reach a shared understanding of the expectations and limitations of the available options.

59. Our adviser explained that breaking down care or treatment processes into clear steps that patients can follow helps them to be able to fully engage in their care.

60. We can see that the Practice did not always explain the referral pathways or the difficulties with fibromyalgia clinic availability to Mrs R. This is not in line with GMC guidance and is an indication of a failing.

61. We consider this caused Mrs R to feel that the Practice delayed making her referrals and made inappropriate referrals during this time. We consider if the Practice’s communication had been better, this could have potentially alleviated some of the upset and distress caused during this period.

62. During the complaints process, the Practice apologised that it had not always been clear with Mrs R about its processes. It accepts that this caused Mrs R unnecessary distress that could have been avoided.

63. Our NHS Complaint Standards say that Organisations should take accountability for mistakes identified and give sincere apologies that reflect the impact on the person concerned.

64. We can see that the Practice have already acknowledged its poor communication and apologised for the impact this caused. We consider this is in line with Our NHS complaints standards.

65. As we have seen an indication of a failing in the Practice initially sending Mrs R’s referrals as routine, rather than urgent, we consider it missed an opportunity during its complaint handling to acknowledge and apologise to Mrs R for the delay and subsequent upset and distress this caused.

66. Our NHS Complaint Standards say organisations should be open and honest when things have gone wrong. The Practice did not do that here and we consider this is an indication of a failing in the Practice’s complaint handling.

67. The Practice has apologised for not identifying this during its complaint investigation and agreed to write to Mrs R, to apologise for not sending the referrals as urgent and the impact caused. It has also reflected on this and will ensure that all future referrals are sent as urgent when necessary.

68. As the Practice has now agreed to acknowledge the failing and the impact caused, we consider this is in line with our NHS complaints standards and resolves the impact caused here. Therefore, we will not be taking any further action.

1. We are very sorry to hear about Mrs R’s experience. We recognise she has experienced delays in receiving a diagnosis and treatment for her condition which she feels has had both a physical and mental impact on her. Therefore, we understand how important this complaint is to her.

2. We have carefully considered Mrs R’s complaint about a GP Practice in the Southend-on-Sea area (the Practice). We consider the Practice should have sent Mrs R’s initial referral as urgent rather than routine. We consider this meant Mrs R had to wait longer to get a diagnosis. This also meant there was a delay in her being referred to a fibromyalgia service for support with her symptoms.

3. Fibromyalgia is a long-term condition that causes pain all over the body often accompanied by fatigue, sleep disturbances, headaches, and cognitive difficulties.

4. We contacted the Practice regarding the above and the Practice have agreed to write to Mrs R to apologise, and it has reflected on its Practice to ensure it follows the NICE guidance in future. We consider the actions it has agreed to take remedies this part of Mrs R’s complaint.

5. We also recognise that the Practice’s communication with Mrs R, and the handling of her complaint, could have been better. We consider this could have alleviated some of the upset and frustration caused during the period complained about.

6. We can see that the Practice has already apologised for its poor communication during the complaints process. The Practice has now agreed to further write to Mrs R to apologise that it did not acknowledge the referral error in its complaint responses. On this basis, we consider this is in line with Our NHS Complaint Standards.

7. We do not consider the Practice made any incorrect referrals and we do not consider it was responsible for the other periods of delay Mrs R experienced. Therefore, we will not take any further action.