A practice in the Teignbridge area

5. Miss F complains that in April 2025, the Practice sent her a warning letter regarding her behaviour. Specifically, she complains:

• the letter was inaccurate and unevidenced • the Practice sent this letter at a time Miss F was under huge stress, which staff were aware of - the Practice showed no consideration of the impact this would have on her mental and physical health • the Practice did not inform Miss F the warning would remain on her record for 12 months or it placed a behaviour flag on her electronic record.

6. Miss F also complains the Practice:

• marked her complaint as resolved without informing her - the Practice only sent her a final response after she chased it • incorrectly signposted her to escalate her complaint to NHS England in its complaint response.

7. Miss F says receiving the warning letter was very distressing. She said it was very stressful to have to chase up her complaint and she experienced additional stress having to escalate her complaint a second time due to the inaccurate signposting information provided in the Practice’s final response.

8. Miss F says she felt unable to see a GP after receiving the warning letter and while her complaint was ongoing. During this time her mental health was affected, her blood pressure was uncontrolled, and she experienced shortness of breath. She was very concerned she had developed fibrotic lungs because of her breast cancer radiotherapy treatment.

9. By bringing her complaint to us, Miss F would like the Practice to:

• retract the warning and flag on her notes • document her contestation of the warning • review its warnings process to ensure clear justification for a warning, and to consider how it impacts patients’ wellbeing • provide her with a full, formal apology in relation to its complaint handling errors • review its complaints process.

10. Miss F was diagnosed with breast cancer in summer 2024 and over the next nine months underwent surgery and radiotherapy. Following her cancer treatment, Miss F arranged a face-to-face appointment with the Practice on 3 April 2025 to discuss the possibility of continued oral treatment for breast cancer and its potential side effects.

11. Miss F said when she tried to arrange the appointment, she experienced three issues with the booking system. The third issue occurred on the day of the appointment.

12. The Practice operates two GP surgeries. On 3 April, Miss F arrived for her appointment according to the details in the text message confirmation she had received. She tried to check-in for her appointment on the self-service machine, but the machine told her she had no appointment. Miss F then spoke to the receptionist. She told us she was she was upset and distressed during the interaction, and she was anxious she would miss her appointment.

13. Miss F told us the receptionist was combative and did not try to deescalate the situation. She said the receptionist advised her appointment was at the other GP surgery and acknowledged the Practice had sent her to the wrong place for her appointment.

14. Miss F travelled to the second surgery and found a queue of people at reception when she arrived. Miss F told us she went to the front of the queue and interrupted the receptionist to make them aware she had arrived, considering she had been sent to the wrong place and was late. The receptionist told Miss F she had to wait her turn in the queue. Miss F says she did not behave in a way that could be considered rude, threatening or intimidating.

15. On 10 April, Miss F received a behaviour warning letter from the Surgery dated 7 April, relating to her interactions with the receptionists at both GP surgeries on 3 April. The letter stated Miss F had ‘engaged in inappropriate behaviour towards two members of staff’. Regarding Miss F’s interaction with the receptionist at the second GP surgery, the letter said she ‘exhibited intimidating and threatening behaviour towards her, which caused distress’.

16. Upon receipt of the letter on 10 April, Miss F emailed a complaint to the Practice. Miss F did not receive an acknowledgement of her complaint until she chased this on 16 April. Miss F did not receive a final response to her complaint until 11 June, after she had chased this.

17. The final response signposted Miss F to escalate her complaint to NHS England if she was unhappy with the response. It then said if Miss F was unhappy with the response from NHS England, to refer her complaint to us.

18. Miss F told us she followed this advice and escalated her complaint to NHS England. NHS England told her this was incorrect, and she instead needed to escalate her complaint directly with us.

Behaviour warning letter

21. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen.

22. We have done this and have not found any indications that something has gone wrong. We appreciate this decision will be upsetting for Miss F and understand the impact receiving the Practice’s behaviour warning letter had on her.

23. Miss F complains about the behaviour warning letter which the Practice sent her. The Practice said it sent the warning letter because Miss F had displayed behaviour which it considered inappropriate.

24. We cannot decide whether the Practice was correct in judging Miss F’s behaviour as inappropriate. This is subjective and we cannot determine how the person who experienced this behaviour felt.

25. In reaching a decision on this case, we have considered whether the Practice acted in line with its policy and national guidance when sending the letter. We would expect organisations to follow such guidelines if their staff considered a patient behaved in a way its guidelines describe as inappropriate.

26. The Practice’s policy outlines different steps it may take in response to inappropriate behaviour. It includes the practice manager writing to the patient to give details of their inappropriate behaviour and warning them about it.

27. The Practice did this in Miss F’s case. In the letter, the practice manager stated it was a first warning and explained why they sent her this letter.

28. Miss F said the warning letter she received from the Practice was inaccurate and unevidenced. There is no requirement in the Practice’s policy or in NHS England national guidance for a warning letter to provide evidence of inappropriate behaviour. However, we do note the Practice explained what had resulted in the warning, and when it considered she behaved inappropriately, in its letter.

29. Miss F also said the Practice sent her the letter at a time of huge stress. She said the Practice was aware of her circumstances and showed no consideration of the impact the letter would have on her mental and physical health.

30. The Practice’s Acceptable Behaviour statement on its website says, ‘we ask that you treat our staff with respect and courtesy at all times’.

31. In respect of inappropriate and unacceptable patient behaviour, NHS England’s national guidance further says for a patient who has not been aggressive, and/or is clearly under mental and physical distress, it is usually appropriate to follow a standard procedure for practice/patient relationship breakdown. The guidance notes this would usually involve sending a patient a warning letter.

32. We understand this was a very stressful time for Miss F. We also understand her frustrations at the Practice appointment booking errors and the anxiety she experienced when she thought she might miss her appointment.

33. We hope we have clearly explained why we cannot see the Practice acted wrongly by sending Miss F the warning letter. We hope the reasoning we have given assures Miss F we only reached our decision after carefully considering the relevant procedures.

34. Miss F also complained the Practice did not inform her the warning would remain on her record for 12 months or it placed a behaviour flag on her electronic record. While we understand why Miss F wanted to know this information, there is no local or national requirement in the guidelines we reviewed for the Practice to have shared this with Miss F.

35. Overall, we have seen the Practice followed its policy and national guidance when it sent Miss F her warning letter. We have not found any indication the Practice got things wrong in this case, and we will not be investigating this complaint further.

36. We hope we have clearly explained why the Practice acted in line with guidelines. We understand the distress Miss F experienced when she received the letter and are sorry this is not the outcome Miss F was hoping for.

Complaint Handling

37. We have carefully considered Miss F’s complaint about the way the Practice handled her complaint. We are very sorry to hear Miss F felt unable to visit the Practice while her complaint was ongoing and she ultimately lost confidence in the Practice.

38. The Practice acknowledged and apologised for some errors in the way it handled Miss F’s complaint. However, Miss F told us she still had outstanding concerns about this.

39. Following our request, the Practice has written a further letter of apology to Miss F, acknowledging Miss F’s remaining concerns (which we explained in paragraph six). It has also agreed to review and update the signposting to PHSO section of its complaints policy and complaints response template.

40. Miss F emailed her complaint to the Practice on 10 April 2025. As the Practice had not acknowledged her complaint, Miss F emailed again on 16 April to check her complaint had been received. In this email she also added some additional points.

41. Our NHS Good Complaint Handling Guides say when writing a final response, an organisation should make it clear it is their final response. The NHS Complaints Regulations say a final response from an organisation must include details of the complainant’s right to take their complaint to us.

42. The Practice responded to Miss F’s 16 April email the same day and addressed the points she had raised. The Practice also asked Miss F to re-send her original complaint. This email from the Practice did not state it was a final response. It also did not include any information on how Miss F could escalate her complaint if she was unhappy with the response.

43. Miss F re-sent her original complaint to the Practice, and the Practice then sent Miss F a formal complaint acknowledgement. The acknowledgement letter said the Practice would aim to respond to the complaint within 30 days, provide a detailed response and information on how to escalate the complaint if required.

44. The Practice told us the acknowledgement letter was sent in error. It explained it marked Miss F’s complaint as resolved, when it responded Miss F’s email on 16 April and addressed her points.

45. Based on the information the Practice gave her, we can understand why Miss F was unaware her complaint was resolved and expected to receive a further complaint response from the Practice.

46. Miss F chased the Practice on 6 June. The Practice replied to Miss F and said its previous email resolved Miss F’s complaint. However, it acknowledged it had missed additional complaint points from Miss F’s original complaint and responded to those in this email. This email included information on how Miss F could escalate her complaint if unhappy with the response.

47. Miss F told the Practice it had sent her a complaint acknowledgement in April, and she was therefore expecting a response. She also highlighted two points which had not been addressed and requested a response to her complaint letter. Miss F chased the Practice again on 10 June. On 11 June, the Practice sent Miss F a full, final complaint response.

48. In its response, the Practice gave Miss F information about escalating her complaint if she was unhappy with the complaint outcome. It said Miss F could contact NHS England and us.

49. Miss F contacted NHS England. Miss F said NHS England told her this was incorrect, and that she should contact us to escalate her complaint.

50. Our NHS Complaints Standards say when things go wrong, we expect an organisation to be open and honest and take responsibility for this. We expect an organisation to identify what learning can be taken from a complaint and to give a complainant a meaningful and sincere apology and explanation.

51. We asked the Practice if it would apologise to Miss F in relation to its complaint handling. The Practice then wrote to Miss F to apologise for sending a complaint acknowledgement after responding to her email and resolving her complaint on 16 April.

52. The Practice explained how this happened, acknowledged the confusion this caused and the impact to Miss F. The Practice also apologised for not including information on how to escalate a complaint to us in its email of 16 April. It identified learning to take and will also be updating its Complaints Policy and Complaints Response Template.

53. We consider the Practice’s letter of apology is in line with our NHS Complaint Standards. The Practice recognised elements of its complaint handling did not meet expected standards and apologised to Miss F. It also identified learning to be taken and has confirmed it will be updating its complaints policy. This is in line with the outcomes Miss F was seeking when she brought her complaint to us.

54. As the Practice’s actions are in line with our NHS Complaint Standards and match Miss F’s outcomes, we see no further action we would expect it to take. This means we consider this a satisfactory resolution, and we do not need to consider this part of her complaint further.

55. We hope the resolution we agreed with the Practice helps bring Miss F closure on what we recognise are difficult events for her. We also hope it assures her the Practice has learned lessons from what happened, so future patients have a better complaint handling experience.

1. We have carefully considered Miss F’s complaint about the behaviour warning letter the Practice sent her and the way the Practice handled her complaint.

2. We are very sorry to hear of the distress Miss F has experienced and to learn she ultimately lost trust in the Practice.

3. Considering the behaviour warning letter, we have seen staff acted in line with guidelines and have found no indication anything went wrong. We are sorry this is not the outcome Miss F was hoping for.

4. Considering the complaint handling, following our request, the Practice has written to Miss F to apologise and has advised it is updating its complaints policy. We are satisfied the apology and policy update from the Practice is sufficient to resolve this complaint. We explain this in more detail below.