14. 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 Provider has already done enough to put right the impact of these events.
15. Our Principles of good administration, section 3 say an organisation should ‘be open an accountable…Keeping proper and appropriate records’. Section 5 says organisations should put things right ‘acknowledging mistakes and apologising…putting mistakes right quickly and effectively’.
16. Ms N says that following her appointment at the Provider in November 2024, the consultant added notes of the previous patient to her medical records in error. She says this resulted in her being booked in to have a YAG capsulotomy (a laser procedure to treat cloudy vision after a cataract procedure).
17. Ms N says she had not undergone a cataract procedure in the first instance, so this surgery was not necessary, nor was it discussed at her appointment. She said at her previous appointment the clinician had noticed the start of a cataract developing but the latest scan had not shown this to have developed further. The clinician had said they would continue to monitor this regularly along with her other eye conditions. Thus, Ms N says had been expecting her next scan appointment as the clinician had said she needed regular monitoring.
18. In its first response to Ms N’s concerns, the Provider says the notes were correct and that the clinician had asked she be booked in for a YAG capsulotomy procedure as noted in her records.
19. In its second response, the Provider confirmed the clinician had mistakenly added another patient’s appointment notes to her medical records. It apologised for this and, as Ms N had asked to transfer her care to another organisation, that it had contacted the other organisation with the corrected information.
20. From the information provided by the Provider, we can see the original note from the appointment in November 2024 refers to Ms N’s known degenerative eye conditions. In addition, it says she needs a YAG capsulotomy on the right eye as ‘patient sees a shadow moving in front of the eye causing intermittent vision’.
21. In accordance with the instruction of the clinician, staff booked Ms N an appointment for the procedure to take place in early February 2025. Ms N says she received the letter for this in January and that her partner contacted the Provider to question it.
22. Between the receipt of the appointment letter and the date the procedure was to take place, Ms N’s partner attempted to speak with the Provider leaving messages for contact. The medical notes show the Provider attempting to contact Ms N without success and that some correspondence had taken place using email. The last contact note made by the Provider says it was attempting to speak with Ms N to tell her it had cancelled the operation.
23. Ms N formally complained to the Provider at the end of February 2025 and emailed again over the following days to say she thought the appointment note from the end of November 2024 referred to another patient and not her. She suggested the Provider check her previous records as this would show the error. She also asked that it transfer her care to another hospital.
24. In early March 2025, the Provider responded to Ms N’s complaint and assured her that her records were correct. It confirmed it had transferred her care to the hospital she had requested.
25. When Ms N emailed CH the Provider EC to ask whether anyone had spoken directly to the clinician about this, it said it had and that the clinician had confirmed the notes to be accurate. As she remained dissatisfied, Ms N responded and escalated the complaint to the second stage of the Provider’s process.
26. The Provider responded at the second stage in April 2025. In the letter, it said that further investigation and conversation with the clinician had established the notes of her appointment in November 2024 did refer to a different patient.
27. It went on apologise for the error and explained that it had corrected the notes and had been in touch with Ms N’s new hospital with the correct information. It told Ms N what the outcome of the appointment had been (which was as she recalled) and apologised for the previous response. It explained the person who completed the first stage response been ‘influenced’ by the incorrect letter on her file.
28. Ms N says that receiving the appointment for surgery caused her mental health conditions to worsen, developing symptoms she finds hard to manage. She says this continued when she received the first response from the Provider which dismissed her concerns. She feels the Provider had not taken the opportunity to resolve her concerns in the first instance or taken these seriously.
29. In addition, she says regular scans did not take place between November 2024 and May 2025 when previously these had taken place every three months. This caused her further distress as she was concerned about her degenerative eye conditions deteriorating without being picked up at an early stage.
30. From the information above, there are indications of failings in the way the Provider managed Ms N’s medical records and in its first investigation into her concerns.
31. The response at the second stage recognised this, with the Provider apologising for the error in her medical records and its first response letter. It also explained what it had done to prevent this happening to other patients.
32. Our Principles of good administration say organisations are responsible for accurate record keeping and that where something goes wrong, it should acknowledge this and put things right ‘quickly and effectively’.
33. The Provider had not kept an accurate record of Ms N’s appointment in November 2024 and did not put this right when Ms N contacted to raise her concerns. Thus, the Provider missed an opportunity to put things right.
34. The Provider did correct this when Ms N escalated her concerns to the next stage of the complaints process. It apologised for not having done so in the first instance. It also explained that its regional clinical lead had been informed and had asked all clinicians the need to verify a patient's name and date of birth before adding to clinical records to prevent this happening again.
35. The issue with Ms N’s medical records became apparent to Ms N at the end of January 2025 when she received the letter advising of the surgery date. The Provider cancelled the surgery within six days of her making contact to say the surgery had not been agreed with her.
36. Ms N raised a formal complaint at the end of February 2025 and the first response to her complaint was issued within seven days of it being raised. Ms N raised further concerns after receiving this response and the Provider responded within six weeks of these being raised.
37. The second response said Ms N had been correct in saying the appointment notes were not in respect of her but were for another patient, explaining this had been corrected and her new hospital sent the correct information. It said this had been done earlier that month.
38. We consider the Provider acted promptly to put things right for Ms N as it cancelled the surgery quickly once aware Ms N did not want this to go ahead, meaning her concern about this ended within a short time.
39. Whilst its first response to Ms N’s complaint was incorrect, the Provider was quick to investigate this further when she escalated this through its complaint process. As a result, the Provider identified the error, put things right and instigated additional checks for clinicians when updating patient notes within a few weeks.
40. Whilst the whole situation will have caused distress and stress to Ms N, the impact of the immediate concern of having unnecessary surgery was removed within a few days of being raised with the Provider. This was not the case for her concern about the accuracy of her medical records which was resolved within two months of her having raised the original complaint.
41. We are satisfied that whilst adding another patient notes to Ms N’s medical records and not thoroughly investigating her complaint in the first instance are failings, the Provider acted quickly to put things right. It acted to prevent this happening again and has apologised for both the incorrect records and the first investigation not resulting in this being corrected. As such, we will not be taking this further as the Provider has already addressed this.
42. We realise this was a stressful and distressing time for Ms N.
43. In respect of the impact, Ms N says the issue with her records caused delays in regular scans with these not taking place every three months in line with her care plan.
44. We can see from the medical records the Provider booked an appointment for her regular scan. This was due to take place at the beginning of March 2025. The medical records show Ms N did not attend and the Provider contacted her two days later to rearrange but that she no longer wanted the appointment.
45. At this time, Ms N’s care was in the process of being transferred to another hospital at her request. An email asking her preferred hospital to take over her care is noted as sent the day after she raised her original complaint at the end of February.
46. Once accepted, the Provider sent her documents to the new hospital, but these contained the incorrect appointment note. The corrected version was sent over in early April 2025 after the second investigation found the notes were not in respect of Ms N. As such, the hospital that Ms N had been transferred to took over her care from mid-March. Up to this point, the Provider continued to book appointments for her care in line with her care plan with Ms N declining these.
47. We do not consider it is reasonable to hold the Provider responsible for the delay in Ms N’s regular scan. This is because the transfer was at her request and because the Provider did not stop her care until the transfer was confirmed, offering her an appointment in the interim. As such, we cannot say the delay in the new hospital arranging appointments was linked to the incorrect information.
48. We recognise the situation and concerns Ms N had about the Provider led to her request to transfer to another hospital and understand why she did this. We also acknowledge the impact her concerns were having on her mental health. We are pleased to hear that when she was scanned in May 2025, her condition had not changed, therefore there has been no impact to her health because of the delay.
49. When considering what will put things right, we use our severity of injustice scale (SoI). The scale contains six different levels of injustice that a complaint could fall into, which increase in severity. We categorise injustice types by four main categories. These are emotional, material, physiological, and bereavement.
50. Ms N has asked that she be provided a payment of £550, level two of our SoI. This is to recognise the impact of receiving an appointment for surgery that she did not need, the delay in this being put right, the delays in her being scanned and monitored and the way this affected her mental health.
51. Level two of the SoI refers to emotional impacts that affect day to day life for periods of more than six months, or where the impact will not diminish over time. It refers to delays in the complaint handling process of more than a few weeks.
52. We have acknowledged indications of failings on the part of the Provider and consider these have been addressed. We have not found links to all the impacts Ms N has referred to, with the delay in scans and monitoring of her eye condition lying outside of the control of the Provider.
53. We agree the situation will have impacted Ms N’s mental health but are unable to say this prevented her living a normal life for an extended period or that the impact of the issues raised will not diminish over time.
54. In respect of complaint handling, we have acknowledged that the Provider had opportunity to put things right on first contact. It did address this within an acceptable timescale with both stage one and two of the complaint process being completed in less than eight weeks.
55. Because of this, our decision is that the Provider has done enough to put things right and that we require if take no further action and that it should not be held responsible for delays in regular scans once care was transferred to another hospital.
56. We realise this is not the decision Ms N was looking for and it is not intended to diminish the impact this had on her at the time. We thank her for bringing her complaint.