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A practice in the Bristol area

P-003463 · Statement · Decision date: 20 March 2025
Complaint (AI summary)
Mr G complained about a Practice's poor mental health support, including unreturned calls and lack of follow-up. He also raised an issue about a doctor's conduct in 2021.
Outcome (AI summary)
Case closed. The Practice had sufficiently addressed its mental health support failings. Other complaints were not robustly decidable due to insufficient evidence.

Full decision details

The Complaint

4. Mr G complains the Practice provided a poor standard of care to him after his GP referred him to its mental health support services on 10 October 2023. Specifically, that:

• the mental health practitioner failed to contact him or provide support after an initial meeting on 17 October 2023 • the care co-ordinator failed to return his telephone calls or provide support with a letter from the council, and he spent almost one-and-a-half hours on a call waiting to speak with them.

5. Mr G also complains that in March 2021 a doctor forcefully removed a needle from his arm and mocked his accent.

6. Mr G says he was left struggling to function with day to day life and his mental health deteriorated. Mr G told us he had to call the Samaritans regularly because of the lack of support.

7. Mr G says he has experienced trauma, and he needs support to manage anxiety and other mental health difficulties. He feels frustrated, dismissed and ignored by the Practice.

8. Mr G wants the Practice to acknowledge its mistakes and provide a financial remedy.

Background

9. On 10 October 2023, Mr G attended a GP consultation about anxiety and depression, after NHS talking therapies had declined to support him. The GP referred him to the Practice’s mental health practitioner and care co-ordinator, as he was struggling with social issues and wanted guidance on benefits.

Findings

Mental health practitioner

12. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event 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.

13. Mr G complains the mental health practitioner failed to provide any meaningful support or contact after their initial meeting. Information from the NHS says the role of a mental health practitioner is to support adults with mental illnesses to live well in their communities. They act as a bridge between primary care and specialist mental health services.

14. The records say the mental health practitioner had a face-to-face consultation with Mr G on 17 October 2023. They referred him to a social prescriber (who connects people to activities and groups in the community) and arranged to review Mr G in four weeks.

15. On 13 November 2023, the mental health practitioner had a telephone consultation with Mr G. They said they would look into alternatives to NHS talking therapies, and review Mr G on 12 December 2023. This review did not happen.

16. In its complaint response dated 25 March 2024, the Practice said its mental health practitioner had been long term leave due to unforeseen circumstances, and it did not have a date for their return. The Practice said it did not know at the time that Mr G needed support and offered to arrange this with another practitioner now that it was aware of his request. We cannot see that Mr G accepted this offer.

17. We have considered the impact this had on Mr G. We understand that Mr G was waiting for advice on alternatives to talking therapies and this was very important for him, as he felt he needed counselling to recover from trauma, but that did not happen. We accept this would have caused Mr G to feel dismissed and frustrated.

18. We can see there was a period of three months between the review that did not go ahead on 12 December, and the Practice offering support from another practitioner. That said, there are indications Mr G could have brough that to the Practice’s attention much sooner. The clinical records say Mr G had a GP consultation on 15 December 2023 for an unrelated illness, and a telephone consultation on 22 December 2023. At the time of these consultations, Mr G knew he had not received the expected contact from the mental health practitioner.

19. Mr G had an opportunity to speak with the Practice about the lack of support when he spoke with its staff on 15 and 22 December 2023. We think that by not doing this, he has contributed to the impact he experienced. We are very sorry if this causes Mr G any further upset.

20. For that reason, we consider there was a maximum period of three days where the Practice’s actions had an impact on Mr G’s health and wellbeing.

21. Our Principles of Remedy say to put things right, organisations should: ‘provide an apology, explanation, and an acknowledgement of responsibility, as well as remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures, policies or guidance to prevent the same thing happening again; training or supervising staff; or any combination of these.’

22. We think the Practice has acted in line with this. It has apologised to Mr G, provided an explanation on what went wrong, and offered remedial action to try and put things right.

23. Mr G told us he is looking for financial remedy as an outcome to his complaint. Our Principles of Remedy explain that organisations should compensate the affected person appropriately if they are not able to return them to the position they would have been in if the poor service had not occurred. When deciding the level of financial compensation, consideration should be given to the impact on the individual, in line with our severity of injustice scale.

24. We consider the impact Mr G experienced is within level one on our severity of injustice scale given the short duration of the frustration and distress the Practice caused. In these circumstances, a financial remedy is not appropriate. We consider an apology to be an appropriate remedy for these complaints.

25. We feel the actions the Practice has taken to remedy the complaint are in line with our Principles of Remedy and we would not expect the Practice to do any more to address Mr G’s complaint.

26. For those reasons, we have decided there are no indications of unremedied injustice, and we will not consider this complaint any further.

Care co-ordinator

27. Mr G complains the care co-ordinator at the Practice repeatedly failed to call him back or provide support in relation to a letter he had received from the council. Mr G also complains that when he tried to speak with the care co-ordinator by telephone, he was waiting for almost one-and-a-half hours.

28. In its complaint response the Practice explained the role of a care co-ordinator is administrative rather than clinical support, which covers a patient population of over 20,000 people.

29. The Practice has acknowledged that it should have provided Mr G with an accurate email address for its care co-ordinator and details for an alternative contact, in the event that they were unavailable. The Practice has apologised to Mr G for the mistake in the email address and for the anxiety that caused him. The Practice provided Mr G with the generic email address for its care co-ordinator team to ensure that an on-duty team member could provide support.

30. We need to balance the evidence we are provided with fairly and consider all information available to ensure our decisions are impartial and evidence based. The Practice has acknowledged its mistake in relation to email address information, but we have been provided with two different versions of events as to what happened next.

31. The Practice says the care co-ordinator provided Mr G with their correct email address by text message on 20 November 2023, and they also sent him an email. This is supported by the records. The Practice says its care co-ordinator did not receive a response from Mr G after this.

32. Mr G says he asked the care co-ordinator to contact him at the beginning of January 2024 if they had not received the council letter, but they failed to do so. At the time of the complaint, Mr G was still waiting for the care co-ordinator to contact him. We recognise this is very frustrating for Mr G.

33. Mr G also told us that when he did try to contact the care co-ordinator, he waited almost one-and-half-hours on the call. We have not seen any evidence of this in the records, but we do not dispute what Mr G has told us. We understand his experience has been very upsetting for him. We are very sorry for how it has affected him.

34. In this case we are unable to favour one account over the other. We were not present during the conversations with the care co-ordinator so we cannot determine, or judge the clarity or content of, what might have been said by whom, to whom, or in what context. In the absence of any other objective source of evidence, we would struggle to justify which account is the more accurate.

35. There is no other evidence we believe we can request that will help sway our decision one way or the other. As we are unable to reach a robust decision because of a lack of evidence, we have decided that we will not consider these complaints any further.

Complaints from March 2021

36. Mr G complains his doctor forcefully removed a needle from his arm and mocked his accent, which caused him significant distress. We are very sorry Mr G felt this way.

37. In its complaint response, the Practice said the doctor recalls discussing Mr G’s wish to visit or return to Sicily but did not mock his accent. They also denied forcefully removing an injection.

38. We need to balance the evidence we are provided with fairly and consider all information available to ensure our decisions are impartial and evidence based. We have been provided with two different versions of events about what happened at consultations four years ago. The only people who were present, and know what happened, are Mr G and his doctor.

39. We do not dispute what Mr G, or the Practice, has told us. But we are unable to favour one account over the other. There is no independent evidence we can obtain to help us determine which account is the more accurate.

40. As we are unable to reach a robust decision because of a lack of evidence, we will not consider these complaints any further.

41. We understand Mr G may be disappointed with our decision and we are sorry for any distress it causes. It is our duty to be impartial and transparent in explaining our decision. We thank Mr G for bringing his complaint to us.

Our Decision

1. We have carefully considered Mr G’s complaint about the Practice. We are sorry to learn about Mr G’s concerns about the care he received. We recognise he has been through a very difficult time, and life continues to be challenging for him.

2. After careful consideration, we have decided to take no further action on Mr G’s complaint. In relation to Mr G’s complaint about a lack of support from the Practice’s mental health practitioner, we think that where the Practice made a mistake, it has already done enough to put right the impact of that mistake.

3. We have decided we will not consider Mr G’s complaint about the Practice’s care co-ordinator, or the actions of his GP around March 2021, because of a lack of evidence. We think we are unable to reach a robust decision on these complaints.

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