19. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events 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.
20. Our investigation first looked at what happened in this case and compared it to what should have happened according to accepted practice and national guidance.
21. Both Mrs P and the Practice agree the Practice was asked to refer WP to Secondary Care in June 2022, and there appears to be a delay in July 2022 as the Practice had not received WP’s full medical record from her previous GP. Without WP full medical records the Practice could not confirm the WP’s ADHD diagnosis.
22. The Practice referred WP to Community Paediatrics (CP) in March 2023. The Practice says Mrs P informed it she was not in favour of medicating WP until a conversation in March 2023, and Mrs P denying this. As above, as we do not have evidence to challenge the clinical records we are obliged to accept the version of events contained within.
23. In July 2023, the Practice chased CP regarding the referral and were told by CP it had not received a referral from the Practice. CP had only received a statement from the Practice confirming what diagnosis WP had. The Practice informs us CP told it due to WP’s age a referral would have to go to Children and Adult Mental Health Services (CAMHS) instead of CP.
24. In July 2024, the Practice advised Mrs P that no referral had been made to CAMHS and apologised.
25. On 29 August 2024, the Practice made another referral to CAMHS which was accepted.
26. In our judgement there was a suggestion of failing by the Practice between July 2023 and July 2024, in that they delayed sending the referral to the correct body despite knowing what it should do. We cannot see why the Practice took no action on this matter.
27. To assess this matter further, we instructed an independent GP (our adviser) to consider this case and inform us of the clinical guidelines.
28. Our adviser informs us that ADHD is governed under the NHS by NICE NG87. This guidance is focused on the care and treatment of ADHD by public healthcare practitioners. However, our adviser also informed us that this guidance does not detail referral pathways. By this, we mean there is not a formal policy for how GPs should manage ADHD referrals, nationally.
29. There is also not an obligation for GPs and local Integrated Care Boards (ICBs) to have a referral pathway. There was no guidance, policy or accepted practice at this time.
30. Our adviser also informed they could not find the relevant ICB had a referral policy at the time. Furthermore, following consideration of the documents provided by the Practice, our adviser could not see the Practice had an ADHD specific referral policy at the time.
31. As such, we are unable to say the Practice acted incorrectly in how it made an ADHD referral, as at the time there was no guidance for how they should do so. We cannot say it was wrong to refer to CP rather than CAMHS, and we cannot say its management of this ADHD referral was wrong.
32. However, GPs have a broader responsibility in how it manages referrals, which our adviser informs us is governed by the GMC’s Good Medical Practice guidance. At the time of this incident, the guidance obliged GP Practices to refer promptly, manage effectively, and keep patients informed of the status of their referral. We cannot say that the Practice’s actions, particularly between July 2023 and July 2024 were in keeping with the GMC’s Good Medical Practice guidance.
33. From the records provided, we cannot see the Practice had a good reason for such a delay between referrals, especially with no attempt to inform the complainant of what was going on. We do see the Practice has offered some mitigation as at some point it was undergoing staff changes. However, the Practice do not deny it was fully aware of the advice given by CP, and the fact it had to make the referral, it just did not do it.
34. Therefore, we find indications of failing in how the Practice acted with regards to the acting on advice from CP.
35. Next, we must consider if the Practice attempted to resolve its failings, and if these resolutions are in line with the outcomes the complainant seeks. When considering resolutions, we look to the NHS Complaint Standards 2022 (the Standards), which detail how public health providers should respond to complaints.
36. Considering the scope agreed with the complainant, detailed at point 7 above, we see firstly the complainant has requested an apology from the Practice.
37. We have first considered the clinical records, which indicate a GP at the Practice apologised to Mrs P on 9 July 2024 for the lack of a referral. We have no evidence to suggest this did not happen.
38. We have then reviewed the Practice’s complaint response letter of 18 October 2024. In this, the Practice fully acknowledges its failings in relation to the delay in the second referral. It apologised without reservation.
39. The Standards state that apologies should be meaningful and sincere and reflect how the issue may have affected the complainant. Whilst we cannot comment on the apology referred to in the clinical records, as all we have is a note the apology happened. It is our view the apology within the letter of 18 October 2024 abides by the guidance given in the Standards, and we would be unable to achieve a more comprehensive apology via further action.
40. We then consider Mrs P’s request for a systemic improvements in how the Practice acted to ensure this does not happen again.
41. As stated above, all parties agree that between July 2023 and July 2024, the referral was with the Practice but was unactioned.
42. In the 18 October 2024 response letter to the complainant, the Practice states that it will implement new processes to prevent what happened with WP’s referral happening again.
43. In the course of our investigation, we requested the Practice’s up to date policy on referrals, which was updated following the 18 October 2024 letter. This policy creates a tracking system for referrals as well as a system for taking follow up checks.
44. The Standards state that Practices should identify how it can put right what has been done wrong and provide guidance and resources to do so. We believe that the actions shown in the Practice’s updated referrals policy show this and appears to be an adequate solution for the problem raised.
45. We have carefully considered if we would be able to achieve a greater outcome and are satisfied the Practice has taken all reasonable measures and we would not be able to achieve anything further.
46. Finally, we have considered if a financial remedy would be reasonable. It is our decision that we are not able to make this determination.
47. In order to determine if a financial remedy is appropriate, we are obliged to consider the impact of the failing on the complainant.
48. As detailed above, it is our decision that whilst there has been an injustice done to WP in line with Mrs P’s complaint, the Practice has taken appropriate steps to remedy this.
49. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.
50. Our Principles for Remedy are reflected in the NHS Complaints Standards UK Central Government Complaint Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.
51. We have decided there is sufficient outcome for the complainant in the apology and the systemic improvements offered by the Practice. We feel these are fair remedies to address Mrs P complaint.
52. We would like to thank both Mrs P and WP and the Practice for bringing this matter to our attention, and for both parties’ engagement with the process. We hope that this investigation has gone some way to resolve the concerns raised by Mrs P and we hope that WP’s future care and treatment is less challenging.