A medical practice in the Torbay area

3. Mrs E complains about the care and treatment provided by the Practice on 29 September 2020. She says she has anxiety, and the Practice refused her entry for blood tests as she was not wearing a face covering. She also complains the Practice removed her from its patient list.

4. Mrs E tells us she is exempt from wearing a face covering and was distressed to be turned away at the Practice. She also says she was inconvenienced in trying to find an alternative GP.

5. As an outcome, Mrs E wants an explanation of why she was discharged and seeks service improvements.

6. Mrs E was a patient on the Practice’s register. This Practice has two clinics at different locations. Mrs E says she was suffering with a painful right knee for a long time, and in August 2020, it became very hot and swollen and it was difficult for her to walk.

7. Mrs E says when she contacted the Practice about her knee, she was given telephone consultations. Mrs E says she told the reception staff she could not tolerate wearing a mask due to her anxiety.

8. Mrs E spoke at length on the telephone to different doctors at the Practice on 15 September and again on 24 September about her knee problem and was advised of the referral process for treatment with the orthopaedics team. The local agreement was for primary care to refer patients to physiotherapy who would assess and, if necessary, refer the patient on to the surgical orthopaedic team.

9. Mrs E says she was due to have some blood tests at the Practice on the 29 September, so she went, without an appointment, and was denied access by a receptionist as she was not wearing a mask. Mrs E left without being seen.

10. On 30 September Mrs E contacted the Practice asking for a doctor to call her regarding her knee, which was still painful and swollen. An hour later she called the Practice again asking to speak to the Practice Manager, and for the guidelines saying she must wear a mask. It is documented in the medical notes as a 20-minute call with Mrs E shouting and saying the Practice is discriminating against disabled people. She said she had put photographs of her knee on social media and threatened to say that all the GPs at the Practice do private work instead of their actual job.

11. The notes say Mrs E was warned the call would be terminated if she did not stop shouting. Mrs E calmed down and was told a double appointment for 30 minutes was arranged for that afternoon, and she could discuss her knee with the doctor at her appointment.

12. Later that morning, Mrs E called the Practice again regarding her appointment and said that she would not wear a mask. It was explained to Mrs E in that case she would need to go to a designated consulting room at the Practice, designed to isolate that person from others. She was told to telephone the reception desk on arrival and wait in the car park until a doctor came out and escorted her into the building and she would be seen in this clinic room.

13. Mrs E attended her appointment, as arranged, she was examined, had blood tests taken, prescribed medication and referred to the physiotherapy knee clinic for onward referral for surgery.

14. On 1 October the Practice contacted the police to report Mrs E’s behaviour from the 29 September, saying she had been filming a member of staff without their permission and had been verbally abusive, and threatening to put the footage on social media. On the same day, the Practice contacted Primary Care Support England (PCSE) and requested the immediate removal of Mrs E from the Practice list.

15. PCSE contacted the Practice the following day to confirm whether the incident was accompanied by any other genuinely threatening behaviour that would reasonably lead to staff fearing for their safety. If so, it would action an immediate removal. If not, then it advised it may be more appropriate to request an eight-day removal under a breakdown in doctor/patient relationship.

16. On 2 October Mrs E rang the Practice asking for the results of her blood tests. She was told the reception staff did not have access to them, so she requested a doctor ring her back that day. Mrs E then asked about her referral for knee surgery. She was told by the receptionist, there was a referral to physiotherapy about her knee and Mrs E then said, ‘so [GP 1]’s [the doctor Mrs E had seen on 30 September] another liar then’ and kept asking if there was a referral or mention of a diagnosis. Mrs E then asked the receptionist to give her the readings of the blood test. The receptionist replied unfortunately they could not, and Mrs E went on to say, ‘well you can’t help me with a lot can you? I am strong don’t worry about it’ and then terminated the call.

17. Later that day, the Practice telephoned Mrs E about her vitamin B12 injection. An appointment was booked at the same clinic as before, so she could attend without wearing a mask. The appointment was arranged for 9 October and Mrs E was again advised of the process to telephone reception and wait in the car park until a nurse came out and escorted her into the building for her treatment. A few hours later Mrs E’s blood test results were updated by a doctor onto her record to say there were all normal.

18. On 5 October Mrs E called the Practice asking for the results of her blood tests. She was advised they were all normal and satisfactory. She then asked for all the readings and details of her referral to the knee clinic. She said she would like a doctor to call her. The doctor updated the record to say they would call her on Wednesday about the results. A text message was then sent to Mrs E to advise her the doctor would ring her on Wednesday.

19. On 7 October Mrs E rang the Practice to cancel her appointment for her B12 injection. She also requested a repeat prescription and asked if she could be contacted if her blood tests showed any sign of arthritis, and if normal then no need to ring. Later the same day, the doctor sent a text message to Mrs E to advise there were no signs of rheumatoid arthritis or infection in her recent blood tests.

20. The Practice resubmitted the removal request to PCSE on 7 October. This asked for removal within eight days due to doctor/patient relationship breakdown. On 8 October, PCSE confirmed Mrs E would be removed from the list on 16 October and it would write to inform her of this.

21. On 14 October Mrs E contacted the Practice to say she had received a letter about her removal from the list and asked why. The Practice informed Mrs E of the reasons for the request.

22. On 5 November the Practice received an email from PCSE to ask it to write to Mrs E detailing the exact reason for her removal. The Practice sent a letter, dated 9 November, to Mrs E confirming her removal from the patient register and the reasons why.

The Practice told Mrs E it would not take blood tests as she refused to wear a mask

25. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has gotten something wrong. We do this by comparing what should have happened with what did happen. We have done this, and we have not found any indications that something has gone wrong here.

26. In response to the COVID-19 pandemic the Government introduced The Health Protection (Coronavirus, Wearing of Face Coverings in a Relevant Place) (England) Regulations 2020. These regulations do not cover areas where NHS care is administered, such as a GP Practice. As such, these regulations, and their exemptions, do not apply to the Practice. It is therefore entitled to form its own policy to minimise the spread of infection and protect staff and patients. This policy would be to regulate who could and could not enter without a face covering, provided this is not clearly unreasonable.

27. Mrs E says she suffers from anxiety and for this reason she cannot wear a face mask when attending the Practice. She tells us she visited the Practice on 29 September to have blood tests taken and she was not allowed access as she refused to wear a mask.

28. She says she was greeted at the entrance of the Practice by a member of staff wearing full Personal Protective Equipment (PPE), with a temperature gun. She was told she could not enter the Practice without a mask, and Mrs E says she explained she was exempt because of her anxiety.

29. Mrs E says the staff member repeatedly told her she could not go in, and then went off to check with the doctor if she could be seen without a mask. When they returned, she was denied access if she did not agree to wear a mask. Mrs E said she had heard that people were not being allowed into the clinic unless they wore a mask, and she video recorded her discussion with the staff member on her mobile phone.

30. The Practice says its policy is, all patients attending the Practice must wear a face mask to protect its staff and other patients. This was a process adopted by all practices throughout the pandemic to minimise infection risk to patients and staff, and to maintain a level of service during unprecedented times and significant demand.

31. It says the Practice doctors, nurses, and reception staff must all adhere to the policy. The Practice says it recognises there will be exceptions for extremely vulnerable patients, such as those with dementia or learning difficulties. For those patients it set up a separate clinic where they could be seen in isolation, without the need to wear a face mask.

32. The Mask and Appointments policy is accessible on the Practice website. It says face masks are still required to enable it to continue to safeguard vulnerable patients and staff alike. All patients will continue to require an appointment before entering the surgery to maintain social distancing and safety. It asks patients to telephone or email with enquiries and says it will aim to deal with all urgent medical concerns the same day, whether on the phone, email, face to face, or at the patient’s home.

33. The Practice says Mrs E first told it, on 4 May 2020, that she would not wear a face mask as she did not believe there was any risk. The Practice says it then reviewed Mrs E’s medical record and decided she was not deemed vulnerable and exempt from wearing a face mask.

34. We recognise Mrs E has her reasons for not wanting to wear a face mask due to having anxiety. We can also see the Practice acted in accordance with its own policy of seeing her without a mask at its other clinic. We can further see, on the day of the visit, the staff member sought further consideration from a GP on Mrs E’s arrival and went to make enquiries regarding her claim of exemption, based on her anxiety.

35. Based on this, we do not consider there were any indications of failings in the care and treatment the Practice provided, or in the action it took, so we have decided not to take any further action on this aspect of the complaint.

The Practice removed Mrs E from its patient list in October 2020

36. When deciding if we should investigate a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. We have done this and identified an indication of a failing against the guidelines and, after consideration, we have found the Practice has already done enough to put right the impact of this event.

37. The relevant guidance for removal of a patient can be found in the British Medical Association (BMA) Removing patients from your practice list, September 2020. This says:

‘Practices have the right to ask for a patient to be removed from their list. In cases other than violence and abuse, the decision to remove a patient should only be made after careful consideration. Many patients who are misusing services can change their behaviour if it is brought to their attention. If all else fails, however, it is not in the best interests of either the patient or doctor for an unsatisfactory relationship to continue.

• Where practices intend to remove a patient because of the breakdown of the doctor-patient relationship, it should first consider discussing the problem with an independent party, e.g., Local Medical Committee (LMC) secretary.

• Issue a warning to the patient, preferably in writing, giving the reasons for the possibility of removal. Warnings are valid for 12 months and a written record must be retained.

• Send a written notice to Primary Care Support England (PCSE), giving the patient’s name, address, date of birth, and NHS number.

• The removal will take effect on the eighth day after the request is received.

• The only exception is on the grounds of violence, e.g., when police are involved, in which case the patient will be removed immediately.

• If the removal is on the grounds of violence or threatened violence, the police must have been informed’.

38. Further to this, the NHS sets out its zero-tolerance approach in its Stronger protection from violence for NHS staff policy:

• ‘The zero-tolerance approach aims to protect the NHS workforce against deliberate violence and aggression from patients, their families and the public, and to ensure offenders are punished quickly and effectively.’

39. In her complaint to us, Mrs E says the Practice have discriminated against her because of her disability and failed in its duty of care to her. She tells us she distrusts the Practice so when she went for blood tests, she had her telephone recording and filmed the member of staff who denied her access to the clinic.

40. The Practice tells us it contacted the police (on 1 October 2020) about Mrs E’s behaviour, saying she had been filming a member of staff without their permission, had been verbally abusive, and threatening to put the footage on social media.

41. On the same day the Practice contacted PCSE and requested the immediate removal of Mrs E from the patient list. From the evidence we can see PCSE contacted the Practice on 2 October to confirm whether the incident was of a violent nature and advised if not, it would be more appropriate to request an eight-day removal under a breakdown in doctor/patient relationship.

42. The Practice says, following advice from PCSE, it felt that although the staff were upset and disappointed, they did not feel threatened by any acts of violence. As such, it changed the request from immediate to an eight-day removal. The Practice resubmitted this request on 6 October. On 8 October, PCSE confirmed Mrs E would be removed from the patient list on 16 October and it would write to inform her of this.

43. The Practice says Mrs E telephoned on 14 October to say she had received a letter advising of her removal from its patient list. Mrs E asked for an explanation of why she was being removed as she was unclear as to the reason/s. The Practice tells us there was a 30-minute telephone conversation with Mrs E which outlined the reasons why she had been removed, however, she was not sent a letter confirming this conversation.

44. We can see from the evidence the Practice received an email on 5 November from PCSE to ask it to write to Mrs E detailing the exact reason for her removal. The Practice sent a letter, dated 9 November, to Mrs E confirming her removal from the patient register and the reasons why. It said this was due to several occasions where she had chosen not to comply with the Practice polices and processes, and current government guidelines.

45. The letter also said communication had been extremely difficult, and attitudes and behaviour towards staff, both on the telephone and face to face, was very challenging. It said the recent episode where she had filmed a staff member at the Practice without consent was inappropriate and unacceptable. The letter confirmed the Practice had prescribed Mrs E with four weeks of medication, and she had been advised to seek an alternative GP.

46. We can see from the records Mrs E contacted the Practice several times from July through to October, both on the telephone and in person. It is recorded some of these conversations were very long and repetitive, with Mrs E not accepting what was being said to her. The records say Mrs E was rude and challenging on several calls with the reception staff and filmed a staff member on 29 September 2020 without their consent.

47. Mrs E tells us she did not trust the Practice and says it discriminated against her, and she is not getting the treatment she needs. We can see the Practice tried to assist Mrs E by advising her of the referral pathways to orthopaedics and arranging face to face appointments at its designated clinic. From the evidence we have found no indications of discrimination.

48. We have seen the Practice was acting in line with its own policies in managing the situation and have not seen indications that prejudice based on disability, race, sex, religion, or held beliefs has occurred. However, though we have not seen an indication of discrimination, if Mrs E considers the Equalities Act has been broken, it would be a matter of law and for the courts to provide that decision. This decision is not in our remit.

49. While we recognise it caused inconvenience for Mrs E to find a new GP, it is clear the doctor/patient relationship had broken down for both parties, and our view is it was appropriate for the Practice to remove Mrs E from its register. However, we cannot see the Practice had previously warned Mrs E about her behaviour, in line with the guidelines. Further to this, the Practice liaised with PCSE in changing Mrs E’s immediate removal from its list to an eight-day removal once it reassessed the nature of the encounter between Mrs E and its staff. In consideration of this change, it is our view there has been an indication of failings here.

50. We have been in touch with the Practice about this issue and it acknowledged there was confusion as the request had been changed, and a warning letter had not been sent to Mrs E.

51. On reflection, the Practice said it recognised that it would have been best practice to put this in writing to Mrs E. It said, as a learning point within the Practice, it will now always send written confirmation to request a patient modifies their behaviour, and an explanation of what the patient can do to restore doctor/patient relationship.

52. The Practice has shared a letter with us on 2 February. The Practice took this matter to a meeting to discuss significant concerns, and specifically spoke with staff involved at the time. It recognised the need to document verbal communication more accurately, and to ensure this is followed up in writing in seven days, to support the verbal conversations. This written communication will clearly outline why behaviour may be seen as unacceptable and consequences if behaviour is not modified.

53. As an outcome to her complaint Mrs E said she wants to see service improvements and an explanation. Mrs E does not wish to be restored on the Practice register as an outcome. In line with our Service Model Guidance, it is for us to decide whether an organisation’s actions have resolved a complaint and whether to conduct a full detailed investigation.

54. Our Principles of Remedy says good practice means putting things right and seeking continuous improvement. We can see Mrs E was provided with an explanation of the reasons she was removed from the patient list, in its 9 November letter. We have also seen the Practice has taken action to ensure there is no repeat of this service failure in the future.

55. Therefore, we have decided not to proceed any further with this complaint as we consider there to be no unremedied injustice.

1. We have carefully considered Mrs E’s complaint about a medical practice in the Torbay area (the Practice). We understand Mrs E is anxious about wearing a mask and was distressed when she was denied access to the Practice. We have found no indications of failings in the action taken by the Practice, and we can see it did provide alternative appointments for Mrs E in a consulting room, so she did not have to wear a mask.

2. Regarding Mrs E’s complaint about being deregistered from the Practice, we recognise the patient and GP relationship did break down and Mrs E then had to find an alternative practice. We did find an indication of a failing in how the Practice removed Mrs E from its patient list, as it did not correctly follow guidelines. However, we consider the Practice has done enough to remedy this and decided to take no further action on this complaint.