Decision report 201103542

Summary
Mr C made a complaint alleging that a GP refused to issue a long-term medical certificate; failed to examine and assess his condition and made an inappropriate note in Mr C's medical records. He complained that none of the GPs at the practice have fully examined him or assessed his condition including his level of pain and ability to sit, stand or walk for any length of time.

Mr C has been unwell for some time, firstly with low mood and latterly with back and leg pain. The Department for Work and Pensions (DWP) assessed him as being fit for work as far as his low mood was concerned. Two months later Mr C asked a GP to issue him with a sickness certificate covering a period of four months. The GP declined but did continue to issue certificates for shorter periods.

After taking advice from one of our medical advisers, we did not uphold any of Mr C's complaints. On the issue of the certificate, we found the GP had considered that Mr C's condition would be better managed with regular reviews and so his clinical opinion was that it would be inappropriate to issue a long-term certificate. We found that this complied with guidance from the DWP which says that in the first six months of an illness, certificates can only be issued for a maximum period of three months at any one time (and that this should be the exception rather than the rule). Our adviser agreed with the GP that it was clinically appropriate to monitor Mr C's condition regularly.

Examination of Mr C's clinical records confirmed that Mr C had attended the practice on a regular basis and the records contained evidence of examinations, investigations, referrals to specialists, reviews of medication and trials of therapy.  Our medical adviser confirmed that the records indicated that the GPs had taken appropriate action to review, treat and monitor Mr C's condition.

One of the GPs had put a temporary 'pop-up' note on the practice's computerised records to remind staff that if a telephone request was made for an extension to Mr C's medical certificate for low mood, it was not to be issued. The note was not part of Mr C's actual medical records. Mr C claimed that the note prevented any of the GPs from issuing him with a medical certificate. When we examined Mr C's electronic medical records, we found that the note did not form a part of these, and we found it reasonable that the note was made. Our adviser commented that such notes are normal and considered to be good practice. We found no evidence that this prevented the GPs from issuing medical certificates to Mr C.