Cancelled Prescriptions
12. Mr O attended the Practice on Wednesday 14 February 2024, to request repeat prescriptions. He gave a list to the receptionist to place the order, who told him the items should be ready by Friday 16 February.
13. On 16 February, Mr O went to the chemist to collect his prescription but was told nothing had been sent across to them. Mr O says he was in shock and went back to the Practice to query this, but the Practice was closed for the weekend.
14. On Monday 19 February, he returned to the Practice and informed it what had happened. The receptionist explained from looking at the system every item had been cancelled with no explanation as to why or who did it. They put another request for all of the medication again and it was issued for the next day.
15. Mr O says on 20 February, he received a text to confirm his prescription was ready to collect. He went to pick the items up, but three items were missing and had to wait 20 minutes until a doctor could authorise the items.
16. During our telephone conversation, we asked when Mr O usually places his repeat prescription and how long it usually takes. Mr O says it usually takes one or two days, and he has help from his carers to do this. He noted he had enough medication left for 14 February.
17. Mr O explained his painkillers were important as he suffers from a back, arm, ankle, and wrist injury and is in pain without them. We asked Mr O about any other form of painkillers he had at home to help with the pain. Mr O says he took paracetamol, but they were not strong enough to help with the pain as the strength of his pain killers are extremely high.
18. Mr O also explained his inhalers had finished, and he had two asthma attacks over the weekend. He says he has had asthma attacks in the past where he has needed an ambulance, but luckily, he did not need one during this time.
19. Mr O says he was feeling suicidal, he suffers with severe depression and could not stop crying. I asked how this presented and Mr O says he was in that much pain and crying, he phoned a friend who came with a bottle of whisky and that eased a pain.
20. Mr O says he turned to alcohol to mask the pain, he noted he is a recovering alcoholic and felt like he had no choice but to turn to alcohol. We understand Mr O felt nothing was easing his pain.
21. We asked the Practice about its policy regarding prescriptions, and it explained that all prescriptions should be processed within 48 hours. The website says prescriptions should be ready to collect from chemist between three to five working days after order has been placed. The website also asks patients to, ‘Please put your requests in with plenty of time before you run out of them.’
22. The Practice says each day GPs are allocated a number of prescriptions and will work through them throughout the day. It says any medication that is rejected should be sent back to the reception team or the requesting member of staff with a reason for rejection.
23. In its complaint response, the Practice explained a locum GP cancelled the medication without making staff aware or giving any reasons as to why it was cancelled. It says when Mr O attended the Practice on 19 February, it put another request in, and the prescription was issued later that day.
24. The Practice says regarding the three items that were missing, they are on a variable repeat prescription so are not needed every month but apologised the items were not issued at the time. Mr O also confirmed during our telephone call on 11 June 2024 the three items were not major items that were required.
25. Our Principles of Good Administration say organisations should provide ‘effective services, using appropriately trained and competent staff.’ We think the locum GP did not follow the Practice’s protocols when dealing with Mr O’s repeat prescription, meaning it did not provide an effective service to Mr O. This is an indication of a failing.
26. Our Principles of Good Administration also say organisations should be customer focused by ‘Dealing with people helpfully, promptly, and sensitively, bearing in mind their individual circumstances’. We think the Practice should have checked the items on variable repeat with Mr O to find out if he needed more. Instead these were missed off the re-done prescription and Mr O had to chase the Practice for these. This is also an indication of a failing.
27. Where we find an organisation has not acted properly, we consider whether it has already taken appropriate action to resolve the complaint.
28. The Practice explained to Mr O in its response what went wrong and why. We think this response is in line with our Principles for Remedy, as the Practice has been ‘open and accountable’. Our Principles of Remedy includes a list of appropriate remedies, ‘an apology, explanation, and acknowledgement of responsibility’.
29. Our Principles of Remedy also list the following actions as appropriate when needed, ‘revising procedures to prevent the same thing happening again, training or supervising staff’.
30. The Practice says it advised the agency it would not be booking the locum GP again using Mr O’s complaint as an example. The issue here seems to be one of human error.
31. In our telephone call, Mr O told us he went without medication for five days. He placed the prescription request on 14 February 2024 and had enough medication left for that day. This did not leave him with enough medication for the required 48 hours for the prescription to be processed. The website says prescriptions will be ready to collect within three to five working days of the order being placed.
32. We recognise Mr O has endured pain and discomfort during this time, and to manage the pain he turned to alcohol. It is understandable why he would be distressed by this experience. We must acknowledge there is some personal responsibility on Mr O to ensure he had enough medication to last the duration of the required three to five days the Practice website says should be allowed for orders to reach and be processed by the chemist.
33. While Mr O told us he gave the same notice he normally would to the Practice for this particular repeat prescription, at any time there may be any potential issue with prescription, which should be kept in mind when placing the order for medication so vital to his wellbeing in everyday life.
34. We asked Mr O if he started to feel better once he had his tablets. He explained he took the tablets straight away in the chemist to get the medication into this blood stream. We consider once this medication had got into his system, his anxiety and distress would have started to subside, knowing he had enough medication to take for the rest of the month. We are pleased to hear Mr O was able to start his medication again straight away to relieve his symptoms.
35. We fully appreciate and understand the distress Mr O says he was in during this time; he suffered a period of pain and distress of a short duration (five days) which ended once he had his medication. As such we do not consider this injustice had a significant lasting impact on his ability to live a normal life.
36. Mr O wanted to meet with the locum GP. The Practice has explained it will not be using the locum GP again and so a meeting would not be practical. The Practice has also apologised to Mr O for the errors and delay. Mr O also wants to achieve a financial remedy to his complaint.
37. Mr O has not told us this is a reoccurring issue with the Practice and seems to be a oneoff incident due to human error.
38. When considering what will put things right, it is for the Ombudsman to decide what we think is appropriate to remedy the injustice.
39. Where it did get something wrong, the Practice has apologised, informed Mr O what happened and why, and has explained it would not be using this locum GP again because of this incident. This is what we would have expected the Practice to do. It also noted in its complaint response, it would ‘not be using locum GP’s as often and we will have salaried GPs to maintain continuity.’
40. We think the Practice has done enough to put things right, in line with our Principles for Remedy. We do not think Practice needs to do anything further.
41. In making our decision, we do not wish to diminish what Mr O told us about his experience. We recognise Mr O has endured pain and discomfort, and it is understandable why he would be distressed by this experience.
42. Having considered all the information we have seen we think the Practice has identified where things went wrong and taken action to put it right. We consider the Practice’s actions to be sufficient to remedy Mr O’s injustice.
43. We are satisfied there is no unremedied injustice and on this basis we decline to take this case further.
44. We appreciate the time Mr O has taken to bring his complaint to us. We hope this statement clearly explains our decision.