A practice in the West Northamptonshire area

5. Miss R complains that between 8 July and 1 September 2024 the Practice did not: • give her clear and consistent advice on medication • check or chase her gynaecology referrals or promptly inform her about her referrals and booked procedures • give her empathy and support or respect and record her preference not to have a coil as her treatment • offer suitable treatment options for weight-management support or a clear diagnosis.

6. Miss R says the delays in her referrals and treatment meant she experienced heavy bleeding, severe pain, limited mobility and medication side effects (including increased blood pressure, migraines and additional weight gain) for longer than necessary. She says this affected her daily life and work and negatively impacted her ability to have a child.

7. Miss R says mixed medical advice and an inability to get a diagnosis, increased her anxiety, which harmed her mental health, personal relationships and social life. She also says lack of weight-management support has blocked her access to surgery and treatment. She told us she felt forced into seeking private care at her own personal cost because she was unable to get clear answers from the Practice.

8. Miss R is seeking an apology, service improvements and financial remedy.

9. Miss R, who is in her late thirties, has had significant period related problems for over 20 years. She had long-standing suspected endometriosis (where tissue similar to the lining of the womb grows outside it) and later possible adenomyosis (where similar tissue grows into the muscular wall of the womb).

10. On 8 July 2024, Miss R attended the Practice with prolonged heavy periods, large blood clots and severe pain. The Practice prescribed the mini-pill and norethisterone (both hormonal medicines), together with pain relief, tranexamic acid to help reduce bleeding, and omeprazole to reduce stomach acid.

11. The Practice referred Miss R to gynaecology on 9 July. Over the following weeks, there were further appointments about her ongoing symptoms, how to use norethisterone and the timing of her gynaecology review.

12. Miss R says she repeatedly told Practice staff she did not want an intrauterine device (coil, a form of contraception) because she wants a family. She also asked the Practice to prescribe her Mounjaro for weight loss, which she says the Practice declined without clear explanation.

16. 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. For some issues, we have done this and have not found any indications that something has gone wrong.

17. For Issues where there are signs the organisation has got something wrong, we look at whether there are signs the event(s) complained about had a negative effect which the organisation has not put right. Having done so we have found the Practice has already done enough to put right the impact of these events

Medication advice 18. Miss R says the Practice did not give her clear, consistent advice about how to use her prescribed medication.

19. The Practice prescribed Miss R norethisterone and the mini-pill to help control her heavy bleeding. Over the following weeks, different clinicians reviewed Miss R and made changes to her treatment.

20. Miss R says the Practice gave her conflicting instructions about whether she could take norethisterone and the mini-pill together, how long she could safely take norethisterone for and what to expect when she stopped it.

21. GMC prescribing guidance says doctors should: • give patients clear and consistent instructions about how to use medicines, including when to start, stop or change them • make sure patients understand why they are taking a medicine and how it fits into their overall plan • clearly explain any changes to treatment so patients know what to do.

22. Our adviser explained that, where norethisterone is used for short-term relief while a specialist appointment is awaited, good practice would be to record how long it should be used, what to do if symptoms returned or worsened, and when to contact the Practice again.

23. The Practice did not clearly document a plan for the length of treatment, what Miss R should do if symptoms returned or how it would manage changes to her medicines. In its complaint response, the Practice accepted it did not always clearly explain its advice about norethisterone and its communication could have been better. It apologised to Miss R for this and any confusion or distress it caused.

24. Based on the above, we consider the Practice’s advice about norethisterone was not always as clear or consistent as it should have been. This is not in line with the GMC guidelines above.

25. When we see an organisation might have got something wrong, we go on to consider what impact this might have had. Miss R told us the lack of clear and consistent advice caused her confusion, worry and inconvenience because she had to seek clarification. She says this increased her anxiety, which harmed her mental health, personal relationships and social life.

26. Our Principles for Remedy says where failings have had an impact, public bodies should try to offer an appropriate remedy such as an apology, explanation, and acknowledgement of responsibility.

27. The Practice has acknowledged its communication could have been clearer and has apologised specifically for this and the resulting distress and inconvenience. The Practice also indicated it will reflect on how it explains medicine plans in future. These actions are in line with our Principles for Remedy above and are part of the outcomes Miss R told us she wanted.

28. Miss R also told us she wanted financial compensation. Based on the evidence we have seen, and the worry caused by what went wrong, we are satisfied that this sits at level one of our Severity of Injustice scale. As such, we are satisfied the actions taken by the Practice are in line with our Principles for Remedy to address the worry and concern Miss R told us she experienced. We will therefore take no further action on this part of the complaint.

Referrals 29. Miss R says the Practice failed to appropriately check or chase her gynaecology referrals and did not keep her updated about referral progress and appointments. She believes this contributed to delays in her diagnosis and treatment.

30. GMC guidance on delegation and referral says that when a doctor refers a patient to another service, they are responsible for: • deciding whether a referral is needed and how urgent it should be • providing appropriate information in the referral • taking reasonable steps to make sure the patient’s safety is not put at risk while they are waiting.

31. The guidance also explains that once a doctor has made a referral appropriately, they are not responsible for the actions or delays of the service receiving the referral. Our adviser says doctors are not expected to routinely chase every referral, but should act if there is a clinical reason, such as a deterioration in the patient’s condition.

32. The records show the Practice referred Miss R to gynaecology in July 2024 when she reported heavy menstrual bleeding and it suspected endometriosis. Our adviser noted she had previously had gynaecology investigations which reported as normal.

33. The Practice used norethisterone as a bridging treatment to manage Miss R’s symptoms while she awaited her appointment. When it became clear that norethisterone only gave shortterm relief and her symptoms were continuing, the Practice sought advice from the gynaecology team and asked it to bring her appointment forward.

34. Our adviser told us the timing of this request, and the attempt to expedite the appointment, were in line with GMC guidance for Miss R’s clinical situation. They said earlier consultations, when norethisterone was still being trialled and giving some benefit, were reasonable steps to bridge the gap until the scheduled gynaecology review.

35. Based on the evidence we have seen, we are satisfied the Practice acted in line with the GMC guidance above, as it referred Miss R when it was concerned about her symptoms and possible endometriosis. It used interim treatment to manage symptoms while she waited and sought specialist advice and asked for the appointment to be expedited when her symptoms continued. Unfortunately, there was nothing further the Practice could do to expedite the appointment. We will take no further action on this issue.

36. We hope that the information we have provided above and our independent clinical advice has given Miss R reassurances she needs to show the Practice did not get this wrong.

Consultations 37. Miss R says the Practice did not provide empathetic consultations or respect her preferences, particularly about having a coil fitted. She says staff repeatedly suggested a coil despite her clearly saying she did not want one and that the Practice booked a coil appointment without telling her.

38. NICE guidance on heavy menstrual bleeding recommends a coil as a firstline treatment for women with heavy bleeding and no significant underlying pathology. When gynaecology saw Miss R, the specialist team advised that, if her scan was normal, a coil would be the most appropriate firstline treatment for her heavy bleeding. This is in line with the NICE guidance.

39. GMC guidance on decision making and consent says clinicians must involve patients in decisions about their care, explain the treatment options (including benefits and risks), respect the patient’s views and their right to accept or refuse treatment, not give treatment that conflicts with a competent patient’s clearly expressed wishes except where the law allows this, and make a clear and accurate record of the discussions, decisions and recommendations.

40. The Practice’s records from appointments during the time period complained about do not document anything regarding a coil or suggestion of Miss R having a coil fitted. There is also no record of any discussions about this or Miss R saying she preferred not to have this. Or that the Practice booked an appointment to have a coil fitted. Our adviser said it is possible that verbal discussions about a coil took place without the Practice writing them down.

41. Where there is uncertainty about what happened, we consider whether something is more likely or not to have happened, based on the simple balance of probability. To do this we must balance our decisions on the evidence available to us.

42. We consider that Miss R tells us she expressed a wish not to have a coil and that she felt dismissed in some consultations. We recognise how upsetting this was for her, especially given the long history of symptoms and her concerns about future fertility. The Practice has no record of this, and a coil was not fitted. But NICE gynaecology advice does recommend a coil as firstline treatment for heavy bleeding, so it is possible this could have been spoken about but not documented.

43. After reviewing all the evidence available to us, we are left with different accounts about what was said in consultations and how this was understood. Although we acknowledge that verbal conversations between Miss R and the Practice may have taken place, and that this may have given Miss R the view that the Practice made a coil appointment for her, from looking at the medical records it does not appear this was the case.

44. We have considered whether, on the balance of probabilities, we can say what is more likely than not to have happened based on the available evidence, including the clinical records and our adviser’s view. There is no further evidence for us to consider to resolve this matter.

45. When deciding whether we should investigate, we consider whether further work is likely to lead to a clear or useful outcome. In this situation, we do not think that further investigation would be likely to establish, on balance, exactly what was said between Miss R and the Practice, or how it was understood at the time, especially as there is no record of a coil appointment.

46. Based on this we will take no further action on this issue. We hope this information shows how we have carefully considered Miss R’s concerns about the Practice conducted its consultations and we are sorry for the distress this experience has caused her.

Treatment options, diagnosis and weight management support 47. Miss R says the Practice did not offer suitable treatment options or give her a clear diagnosis. She is concerned about how the Practice handled her suspected endometriosis and adenomyosis.

48. Our adviser explained that endometriosis is usually diagnosed in secondary care, often confirmed by laparoscopy. It is not a diagnosis GPs can usually make definitively in primary care. GMC guidance on providing good clinical care says in providing clinical care doctors must refer a patient to another suitably qualified practitioner when this serves their needs. Our adviser said when endometriosis is suspected, in line with these GMC guidelines the GP should: • recognise the possibility of endometriosis based on the symptoms • make a timely referral to gynaecology for investigation and diagnosis • offer appropriate symptom management while the patient is waiting.

49. In Miss R’s case, the records show the Practice referred her to gynaecology when there was concern about heavy menstrual bleeding and possible endometriosis. We consider this was the correct action and in line with GMC guidance.

50. Miss R also said the Practice did not prescribe her Mounjaro and did not give suitable alternative weightmanagement support.

51. Our adviser explained that, at the time of the events Miss R complains about, Mounjaro treatment for weight loss was not widely funded by the NHS in primary care and local criteria governed its use. Where patients might be eligible, GPs would usually refer them to specialist weightmanagement or endocrinology services rather than prescribe Mounjaro directly.

52. The Practice’s complaint response sets out the local criteria and explains that Miss R did not meet them. It also explains that where patients do not meet criteria for Mounjaro, they can still access lifestylebased weightmanagement support.

53. The Practice signposted Miss R to a health and wellbeing coach who could support lifestyle changes such as diet, activity, sleep and stress management, and invited her to contact the Practice if she wished to take this up. We have not seen any record that Miss R went on to have a specific consultation about accessing this support or about a referral to a specialist weightmanagement service.

54. GMC guidance for proposing, prescribing, providing and managing medicines and devices says that doctors must prescribe and recommend medicines in line with the best available evidence, relevant clinical guidelines and local policies, including commissioning and funding arrangements. It explains that doctors should only prescribe medicines when they are satisfied the treatment is needed, is safe and is appropriate for the patient, and that they must be open about any limits on what can be prescribed in the NHS locally.

55. We consider the Practice acted in line with GMC guidance by referring Miss R to gynaecology when it suspected endometriosis, using appropriate medicines for heavy menstrual bleeding, explaining the local criteria for Mounjaro and signposting her to lifestyle-based weight-management support.

56. We have seen no evidence to suggest the Practice failed to offer relevant NHSfunded treatment options that were clinically appropriate and available at the time. We have also seen no evidence that it withheld a diagnosis it was in a position to make. Therefore, we will take no further action on this complaint.

57. We thank Miss R for bringing this complaint to us. We recognise Miss R has lived with distressing symptoms for many years and that this has had a significant impact on her health, daily life and plans for the future. We also recognise the worry and frustration she has experienced in trying to obtain a clear diagnosis and effective treatment.

58. We hope our investigation can provide some closure to the difficult events Miss R experienced.