A medical practice in the Torbay area

3. Ms U complains about the treatment she received from a medical practice in the Torbay area (the Practice) in January 2021. She complains that her liver function test results were incorrectly recorded, and she was not advised that her test results were abnormal.

4. Ms U says she has lost confidence in the Practice and felt she had to move to another practice, which was stressful and problematic.

5. Ms U would like us to investigate why NFA (Not for Action) was written next to her test results.

6. Ms U’s first abnormal liver function test was in April 2020, her second in September 2020. NFA was written next to both of these test results and no further action was taken.

7. Ms U was not made aware of the abnormal test results and continued to take her prescribed medications.

8. Another liver function test in January 2021 was also abnormal. The Practice contacted Ms U and an ultrasound was arranged. This showed Ms U had a fatty liver.

9. Ms U raised her complaint about the Practice with NHS England Southwest.

NFA was written next to the liver function test results and Ms U was not kept informed of the results

12. Before we decide if we should investigate a complaint, we look to see if there are signs these events had a negative effect which the organisation has not put right. We have done this and have found the Practice has already taken action to put right the impact of these events.

13. The Practice acknowledged it incorrectly marked the test results as NFA. The Practice also confirmed the first test result, from April 2020, should not have been marked as NFA.

14. The Practice explained it should have contacted Ms U to arrange a follow up test for three months later. A telephone call would have been arranged if the test results remained abnormal to discuss further actions, such as an ultrasound. This is per National Institute for Health and Care Excellence (NICE) CKS (Clinical Knowledge Summaries) guidance on Non-alcoholic fatty liver disease.

15. The Practice explained the abnormality was mild and did not indicate that she should change the dosage of her medications. Ms U could continue taking her medications as normal.

16. The letter from NHS England Southwest acknowledged there had been some errors and oversights. It advised that the following steps had been taken in response to the failing: • The complaint was upheld.

• The Practice had discussed the complaint at their governance meeting and as a result had made some changes to its processes to ensure the errors are not repeated.

17. NHS England Southwest advised that all GPs are required to undertake an annual appraisal during which they will discuss and reflect on any complaints or compliments which they may have received in the preceding twelve-month period.

18. This action to remedy the complaint is in line with our Principles for Remedy.

Our Principles for Remedy state, where there has been poor service or maladministration (fault) that has led to injustice or hardship, the organisation responsible should take steps to put things right.

19. Our Principles say that public organisations should look for continuous improvement and should use the lessons learned from complaints to make sure they do not repeat maladministration or poor service.

20. The Practice has taken responsibility for the error and apologised to Ms U. The Practice has also taken steps to make sure the error is not repeated.

21. We have considered the impact the mistake had on Ms U, and the action the Practice has taken. We are satisfied that the Practice has done enough to address the impact caused to Ms U. We have not identified any outstanding actions the Practice should take to address this complaint.

1. We have carefully considered Ms U’s complaint about a medical practice in the Torbay area (the Practice). We were sorry to hear about the experience she had, how this made her feel, and that she felt she had to move to another practice.

2. We have decided the Practice has done enough to put right the impact these events had on Ms U. To reach our decision, we reviewed the information provided by the Practice and Ms U (in writing and over the telephone). We have also considered the Parliamentary and Health Service Ombudsman’s Principles for Remedy.