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Dorset Healthcare University NHS Foundation Trust

P-004594 · Statement · Decision date: 9 January 2026 · View Dorset Healthcare University NHS Foundation Trust scorecard
Record keeping and management Drugs / medication Inaccurate and inaccessible patient records Complaint record keeping failures
Complaint (AI summary)
Mr U complained a practice wrongly stopped his aspirin, leading to a heart attack, and the Trust recorded inaccurate mental health information in his medical records.
Outcome (AI summary)
The ombudsman found the aspirin complaint was outside their time limit and saw no failings by the Trust regarding the inaccurate medical record entries.

Full decision details

The Complaint

3. Mr U complains the Practice incorrectly stopped his aspirin medication despite his history of cardiovascular issues. He complains the Trust recorded inaccurate information about his mental health in his medical records.

4. Mr U states he suffered a heart attack only four days after he stopped taking Aspirin leading to him being hospitalised.

5. Mr U says the inaccurate information in his medical records meant he has been unable to work.

6. In bringing the complaint to us, Mr U would like to be compensated an amount in line with level six of our Severity of Injustice scale, and for the information recorded on his medical history to be removed or amended.

Findings

Complaint about the Practice

9. The Law says a person must bring their complaint to us within one year of becoming aware of the issue. We cannot investigate complaints made outside of this time limit unless we consider there is a good reason to do so.

10. Mr U explains in March 2023 the Practice informed him he should stop taking Aspirin. The Practice confirmed this in their response to Mr U’s complaint. The Practice explained the appointment where the Aspirin was removed from Mr U’s treatment plan was on 13 February 2023. As the dispute over the appointment date is not critical to the timeline of this case, we have not further investigated the discrepancy between the accounts.

11. Mr U informed us he had a heart attack approximately four days after the appointment discussed above.

12. Using Mr U’s recollection of when the Aspirin was stopped and factoring in when the heart attack is likely to have taken place, we conclude he had his heart attack in early April 2023. He was therefore aware he had cause to complain at this point. This is supported by Mr U’s explanation that he complained to the Practice via telephone in approximately March or April 2023.

13. To be within our time limit, Mr U needed to bring his complaint to us by April 2024 at the latest. He brought his complaint to us on 24 July 2025, 15 months outside of our time limit.

14. Mr U complained to the Practice on 30 December 2024, approximately twenty months after he became aware of the need to complain. We asked Mr U about the reason for this delay. Mr U told us he had forgotten about this complaint as he was dealing with issues with other organisations.

15. We would expect complainants to progress their complaints in a timely manner to allow organisations the opportunity to learn from any issue raised and to make improvements where needed. We do not consider Mr U forgetting about his complaint to be sufficient reason to put this eight-month delay aside.

16. The Practice responded to Mr U’s complaint on 16 June 2025, around six months after he submitted his complaint. As the time the Practice took to respond to his complaint is outside of Mr U’s control, we will put this time aside.

17. Mr U brought his complaint to us on 24 July 2025, around one month after he received the Practice’s final complaint response. We have not considered this time when reaching our conclusions.

18. Mr U’s complaint falls outside of our time limit. Based on the information available, we do not consider Mr U has provided sufficient reason for us to put aside the twenty-month delay in him raising his complaint to the Practice which resulted in him being outside of our time limit. We will therefore not take any further action on this part of his complaint.

Records complaint

19. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs of service failings or maladministration which the organisation has not put right. Having done so, we have found it followed the NHS records guidance correctly. We have not seen any indications of failings.

20. Mr U complains the Trust recorded inaccurate information about his mental health in his medical records.

21. The response sent by the Trust states they do not believe the clinician’s clinical opinions contained within the records to be factually inaccurate. It confirmed as part of their review into this matter it sought a second opinion which agreed with the first clinician.

22. NHS records guidance says where there is a query from a patient about the accuracy of the recorded health information, the Trust should liaise with the health professional who entered the information to understand their views to determine if the information is accurate and can be justified.

23. Where the health professional states the record is correct, NHS organisations are not allowed to amend the record.

24. We can see the Trust acted in line with the NHS records guidance as it reviewed the information it held to check it was factually correct. We have not seen any indication of failing in their handling of Mr A’s request.

25. We note the Trust have provided Mr U with details on how to request a comment is placed on his records stating he does not agree the clinical opinion. We advise Mr A does so should he still disagree with the inclusion of the mental health diagnosis on his records.

Conclusion

26. For the reasons outlined above, we will not be taking any further action on Mr U’s complaint about the Practice or the Trust.

27. We understand this decision may be disappointing for Mr U, especially given the time and effort he has invested. We thank Mr U for bringing his complaint to us and appreciate the opportunity to consider it. We hope Mr U feels his voice has been heard even though we are unable to take further action.

Our Decision

1. We have carefully considered Mr U’s complaint about a GP Practice in the Dorset Council local authority area (the Practice) and Dorset Healthcare University NHS Foundations Trust (the Trust). We have considered the evidence regarding Mr U’s complaint and consider the complaint about the Practice is outside of our time limit and we have not seen sufficient reason to put the time aside for us to investigate. We have not seen any indications of failings in how the Trust have dealt with the issue raised.

2. We are sorry to hear about Mr U’s heart attack following him stopping aspirin and his distress at the entries in his medical records have caused him. We understand the difficulties that Mr U faced recovering from his heart attack and his efforts to have his medical records amended. We recognise how frightening and overwhelming this experience must have been, and we do not underestimate the impact it has had on Mr U’s wellbeing and daily life.

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