A practice in the Stratford-on-Avon area

4. Miss T complains between March 2024 and January 2025, the Practice:

• did not refer her to a consultant gynaecologist in her area • did not investigate or act on her gynaecological symptoms correctly.

5. Miss T tells us she experiences daily chronic abdominal pain and has recurring irregular vaginal bleeding. Miss T says she experienced unnecessary delays in accessing care for her ongoing symptoms and felt she had no option but to seek care privately abroad.

6. By bringing this complaint to us, Miss T seeks financial remedy to compensate her for her pain and suffering, and to help towards the costs of her ongoing care.

7. Miss T had sterilisation surgery (a procedure to prevent pregnancy) in 2003. She has experienced recurring irregular vaginal bleeding and daily chronic abdominal pain since this surgery.

8. In 2023, Miss T visited her previous GP who conducted blood tests, hormone tests, vaginal swabs and arranged scans. On 10 September 2023, Miss T had an X-ray which showed one of the sterilisation clips (small clamps used to block the fallopian tubes, to prevent a sperm and eggs from meeting) had moved. Miss T’s GP referred her to a gynaecologist, and she told us she had an appointment booked for February or March 2024.

9. Miss T relocated in January 2024 and changed GP. She registered with the Practice in her new area. She said she contacted the gynaecology team in her previous area to inform them she had moved. She said they told her as she had moved out of their catchment area, they would cancel her appointment, and Miss T would need to ask her new GP to refer her to a gynaecologist in her new area.

10. Miss T told staff at the Practice about her symptoms and that she wanted to be referred to a gynaecologist on several occasions. Miss T said the Practice did not investigate or act on her symptoms appropriately and staff always told her they were waiting for her medical records to be transferred over from her previous GP before they could make a new referral.

11. Miss T told us she moved abroad at the beginning of 2025 because she was not getting the support and follow-up she needed from the NHS. She said private health care is cheaper abroad than the UK.

Gynaecology referral

15. 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 compare what should have happened with what did happen. If we see indications something has gone wrong, we then look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we consider the Practice has already done enough to put right the impact of these events

16. Miss T complains the Practice failed to refer her to a gynaecologist in her area. She said she informed the Practice about her symptoms and asked staff to refer her to a gynaecologist on several occasions, including at a face-to-face appointment with a doctor and at her smear test appointment. She said the Practice did not refer her as it was still waiting for her old medical records to be transferred over from her previous GP.

17. Miss T’s medical records show she phoned the Practice on 13 March 2024 at 1.16pm requesting a referral to gynaecology, but the call cut out. The Practice tried to phone Miss T back but had no response. Miss T phoned the Practice again at 2.04pm. The records show she discussed online access to her records and a referral, but the phone line then cut out again.

18. Miss T submitted an online consultation form at 2.19pm and reported experiencing leg pain. Miss T saw a GP at the Practice at 4.02pm who reviewed Miss T’s leg pain and referred her to ambulatory care that evening to review for a possible deep vein thrombosis (a blood clot formed in a deep vein).

19. Our clinical adviser said Miss T did not report an urgent or life-threatening situation in her call to the Practice on 13 March. They said the Practice receptionist made one attempt to phone Miss T back, but Miss T did not respond. They said as with any other customer service, there would be an expectation the customer would call back themselves which is a normal operation for a GP practice. Our Principles of Good Administration say organisations should ensure that decisions and actions are proportionate, appropriate and fair. We can see the Practice acted in line with these principles.

20. NHS England guidance says GP Practices should offer patients a choice of access channels, including phone, online and in-person. We can see the Practice did have these channels available to Miss T. Miss T submitted an online consultation form at 2.19pm about leg pain but did not mention or discuss her gynaecological issues in this form. Our clinical adviser said Miss T missed this opportunity to communicate her request for a gynaecology referral with the Practice.

21. Miss T’s medical records show she submitted an online consultation form on 12 June at 08.39am. Miss T reported she was leaking urine, was thirsty and drinking too much and was experiencing changes to her periods.

22. Following this request, Miss T was seen by a GP at the Practice at 10.31am. The GP documented Miss T’s symptoms and history including that she had a sterilisation and ablation, had been told a sterilisation clip came off and needs a referral back to gynaecology. The GP documented there was an issue with the transfer of Miss T’s previous medical records.

23. GMC Good Medical Practice says doctors must refer a patient to another suitably qualified practitioner when this serves their needs. It also says doctors must provide effective treatment based on the best available evidence and must treat each patient as an individual, not relying on assumptions about the treatment options or outcomes a patient will prefer.

24. Our clinical adviser said because Miss T’s GP did not have access to her previous records at this appointment, they could not refer Miss T to gynaecology. They said Miss T’s GP did not have enough information about why she required a referral, or who to make a referral to. Our clinical adviser said GPs do not expect patients to remember everything correctly, so it is important they can see written records, which would provide them with the best evidence, to provide the best care.

25. Miss T’s medical records show she had an appointment with a practice nurse on 20 June 2024 for a routine smear test. The nurse noted Miss T said she was waiting for a gynaecology referral, but the Practice has not done this because it does not have her records. The nurse documented they contacted the medical records team about this.

26. In its complaint response, the Practice said the nurse created a joint task on its system. This was for the medical records team to locate Miss T’s full medical records and for a doctor to ensure Miss T was followed up. The medical records team completed their part of the task and closed it. The Practice said because it was a joint task, it whole task was closed before the doctor had received it.

27. Our clinical adviser said it is a known operational issue that when a joint task is shut down by one recipient, the entire task is shut down and is then not visible to the other recipient.

28. In its complaint response, the Practice said because of Miss T’s complaint, it had identified an issue with sending joint tasks and would use this as a learning point and discuss this in its managerial meeting.

29. Miss T’s medical records show she submitted an online consultation form on 24 June about ongoing gynaecology symptoms. Our clinical adviser said these symptoms possibly related to menopause. The Practice sent Miss T a text message asking her to book a routine phone call but there is no evidence in the records Miss T did this.

30. Miss T’s medical records show she made no further enquiries to the Practice about a gynaecological referral from June 2024 until January 2025.

31. We asked the Practice to clarify what happened regarding the transfer of Miss T’s medical records from her previous GP Practice. The Practice told us when Miss T registered with the Practice on 20 December 2023, the electronic transfer of her digital and paper records from her previous GP failed. It received a notification the electronic transfer had failed the same day. The Practice still did not identify the issue until 23 January 2024, when Miss T contacted it again to request online access to her records.

32. The Practice said it when it identified the issue, it contacted Miss T’s previous GP and requested a full medical summary of Miss T’s records that day. It said it received a copy of Miss T’s electronic records the same day and copy of her paper records the following day. It did not add these records to Miss T’s current computerised medical records.

33. Following the practice nurse’s query to the medical records team regarding Miss T’s records, the Practice said it contacted Primary Care Support England (an NHS support service which tracks the movement of medical records) on 20 June. It advised it had sent all of Miss T’s previous records to the Practice on 25 January.

34. The Practice said while it had received Miss T’s records in January, it did not act on this correctly until 21 June. On 21 June, the Practice located and summarised Miss T’s full medical records, extracting any relevant or significant information into Miss T’s current computerised medical records.

35. The Practice has not been able to explain us why it was delayed in summarising Miss T’s medical records because of staffing changes and a resignation in the management team un the period of January to June 2024.

36. In its complaint response, the Practice said a practice nurse sent a task to the medical records team on 4 July 2024 to say Miss T was being followed up by a hospital consultant and there was no need to locate Miss T’s records relating to an ultrasound scan. We have not been able to identify why the nurse sent this task. The Practice also said the practice nurse tried to phone Miss T, but she did not answer.

37. In its complaint response, the Practice told Miss T because of her complaint, it had identified an issue with the management of any errors receiving digital medical records.

38. The Practice said this was a learning point and since this time it has put systems in place to ensure records are monitored and summarised more promptly. It said it has implemented the following actions:

• training for all registration and administrative staff on identifying and actioning electronic record transfer errors • clarification of task allocation processes to ensure clear accountability between administrative teams • ongoing monitoring to ensure timely follow-up of failed transfers.

39. We have seen an indication of a failing in the Practice’s management of transferring Miss T’s medical records when Miss T registered with the Practice, so we have looked at the impact this caused Miss T.

40. Miss T told us she experiences chronic abdominal pain daily and has recurring irregular vaginal bleeding. She said this is due to the clip from her sterilisation surgery having moved. Miss T told us because she was delayed accessing care for her ongoing symptoms, she felt she had no option but to seek care privately abroad.

41. We have seen Miss T’s previous medical records which staff at the Practice would have had access to, had the administrative failing not occurred.

42. The records show Miss T saw her GP regarding vaginal bleeding between periods on 17 August 2023. Her periods were also heavier than normal. Miss T’s previous GP took a detailed history, conducted a physical examination, reviewed previous blood tests, arranged a further blood test, arranged a pelvic ultrasound scan and referred Miss T to a gynaecologist. Our clinical adviser said this referral was a routine, non-urgent referral.

43. Miss T had a pelvic ultrasound scan on 20 September 2023 which showed a small, benign (non-cancerous) fibroid. Our clinical adviser said the scan did not show anything that required an urgent gynaecology referral. Our clinical adviser said Miss T’s blood test was normal and did not show a reason for an urgent gynaecology referral.

44. NICE guidance says if a woman has fibroids, doctors should arrange a referral to an appropriate specialist, the urgency depending on clinical judgement if the woman has severe heavy menstrual bleeding. Our clinical adviser said Miss T’s GP made a clinical judgement based on her symptom of bleeding between periods, to make a routine referral to a gynaecologist.

45. The records show separately, Miss T had a hip x-ray on 9 September 2023 because of hip pain, not due to her gynaecological symptoms. It was noted in this x-ray that one sterilisation clip was seen in the pelvic cavity. This was an incidental finding and there is no suggestion in the records that the clip was causing Miss T pain. Our clinical adviser said the only adverse effect from a sterilisation clip coming off, is a possible pregnancy.

46. Our clinical adviser said if Miss T’s GP had access to her ultrasound report from September 2023 showing a fibroid, they should have referred her to gynaecology when they saw her in June 2024. They said this should have been a routine referral.

47. We asked Miss T’s local NHS Trust about its waiting times in June 2024. The NHS Trust told us that the average wait time for routine outpatient referrals was around ten months. Miss T moved abroad in early 2025. Considering the average waiting times, had the Practice referred Miss T in June 2024, on the balance of probabilities, we do not think she would have had a gynaecology appointment before she moved abroad.

48. We cannot say definitively the Practice’s failings prolonged Miss T’s pain. The ten-month wait was for a first gynaecology appointment, and we do not know a gynaecologist would have taken action to resolve Miss T’s symptoms at this appointment. We also cannot say the Practice failing to refer Miss T to gynaecology caused her to move abroad.

49. We can see however the Practice’s failing resulted in a loss of opportunity for Miss T to have the reassurance she was on a pathway to be seen by a gynaecologist.

50. Miss T seeks financial remedy to resolve her complaint. When deciding on a level of financial compensation, we use our severity of injustice scale (our scale) to guide what we ask an organisation to provide. We would place Miss T’s injustice at level one on our scale. Level one injustices include losses of opportunity. We consider an apology is an appropriate remedy for an injustice of this nature.

51. In its complaint response, the Practice apologised to Miss T for its administrative failings regarding Miss T’s medical records. It also apologised to Miss T for the upset it caused her. It also told Miss T about the learning it had taken from her case and the service improvements it had made for future.

52. We can see the Practice has already apologised to Miss T and therefore do not consider the Practice needs to take any further action in respect of this part of Miss T’s complaint.

Investigations and actions on gynaecological symptoms

53. 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.

54. Miss T complains between March 2024 and January 2025, the Practice did not investigate or act on her gynaecological symptoms.

55. In its complaint response the Practice said Miss T had an appointment to discuss gynaecological issues on 12 June 2024. It said the doctor ordered blood tests for Miss T. It further said Miss T had an appointment with the Practice nurse on 20 June for a routine smear test.

56. Miss T’s medical records show she had a face-to-face appointment with a GP on 12 June as she had reported leaking urine, feeling thirsty and drinking too much, and changes to her periods. The GP documented they took the following actions:

• took a history of Miss T’s symptoms • examined Miss T’s abdomen • performed urinalysis (a urine test checking for blood cells, proteins and other substances) • ordered blood tests • ordered a urine microscopy, culture and sensitivity test (used to detect a urinary tract infection and what specific bacteria or yeast is causing the infection) • booked a smear test for Miss T, which was overdue.

57. Our clinical adviser said Miss T’s GP had a lot to consider at this appointment. They said based on the symptoms Miss T presented with they might have been thinking about urinary incontinence, diabetes and whether Miss T could be reaching menopause.

58. Our clinical adviser said the GP took a relevant history from Miss T and found she had experienced erratic periods over a year varying from regular to bleeding between periods. They found Miss T did not experience bleeding after sex and occasionally experienced pain during sex.

59. Our clinical adviser said the investigations and actions the GP took were in line with guidance.

60. Good Medical Practice says doctors must provide a good standard of practice and care and if assessing, diagnosing or treating patients, must work in partnership with them to assess their needs and priorities. It says the investigation or treatment a doctor proposes, provides or arrange must be based on this assessment, and on their clinical judgement about the likely effectiveness of treatment options.

61. It also says doctors must adequately assess a patient’s condition(s), taking account of their history, including symptoms. Doctors must also carry out a physical examination and promptly provide (or arrange) suitable advice, investigation or treatment where necessary.

62. BMJ Best Practice guidance says in investigating abnormal uterine bleeding, the first investigations to order are a pregnancy test and a full blood count (FBC). An FBC is a common blood test that measures red blood cells, white blood cells and platelets and help assess your overall health.

63. Miss T had sterilisation surgery in 2002 so did not require a pregnancy test. Miss T’s GP did order blood tests, including an FBC. The guidance says further investigations to consider include an ultrasound scan.

64. Our clinical adviser said they would have ordered an ultrasound scan if seeing a patient for the first time who reported irregular periods. They said however the GP made a clinical judgement at the time not to do this and could have been expecting to receive the patient’s previous clinical records and ultrasound.

65. We can see Miss T’s GP acted in line with guidance when taking actions and ordering the investigations they did. They also acted in line with Good Medical Practice guidance when they made a clinical judgement about which investigations to arrange.

66. On 20 June 2024, Miss T attended the Practice for a routine smear test with the Practice Nurse. Our clinical adviser noted the nurse performed the smear test and made sure everything was ok.

67. On 24 June, Miss T submitted an online consultation form about her ongoing gynaecology symptoms, possibly related to menopause. It is shown in Miss T’s clinical records, the Practice sent her a text message asking her to book a routine phone appointment. Our clinical adviser said the expectation here was for the patient to access this request. We have found no evidence that Miss T booked this appointment.

68. We have found staff at the Practice investigated Miss T’s gynaecological symptoms in line with guidance and have not seen they got things wrong. We hope we have clearly explained our decision on this matter.

69. We understand it has been very distressing for Miss T to experience ongoing gynaecological symptoms and to feel these were not being acted on. We understand this is not the outcome Miss T is hoping for and in no way mean to diminish her distress.

1. We have carefully considered Miss T’s complaint about a medical centre in the Stratford-on-Avon area (the Practice). We are very sorry to hear of her concerns about the care the Practice provided her and of her ongoing pain and symptoms.

2. Regarding the gynaecology referral, we have decided the Practice has already done enough to put right the impact of these events on Miss T.

3. Regarding the investigations and actions taken by the Practice for Miss T’s gynaecological symptoms, we have not seen indications the Practice got things wrong.