The Practice
Sharing medical records 17. Miss V says the Practice did not provide the information the NHSappointed imaging provider needed to carry out the MRI scan her father had been referred for, which meant the scan could not go ahead.
18. The Practice referred Mr F for an urgent MRI scan on 12 July 2022. In August, the imaging provider requested details of Mr F’s 2011 brain surgery. The Practice did not hold this older hospital correspondence and was therefore unable to supply it.
19. Our GP adviser explained it is not standard practice for GP practices to hold or send full historical hospital records when making referrals. A referral letter containing the relevant clinical information is usually sufficient, and GP practices do not routinely retain specialist notes from many years earlier.
20. GMC confidentiality guidance says doctors should share the information relevant to a person’s care, but they are not required to provide a patient’s full medical record unless it is necessary. Referral standards also require GPs to include the key clinical details needed for the receiving service to assess the patient, not full historical documentation.
21. The referral included the relevant clinical information, and it was reasonable the Practice did not have access to the 2011 surgical records the provider requested. The subsequent delay was outside the Practice’s control. We have not seen indications of failings in this part of the complaint.
22. We recognise this delay was frustrating for Miss V and her family at an already worrying time. We understand why Miss V expected the Practice to be able to obtain these older records. National guidance does not require GP practices to retrieve or store historic specialist documentation.
Emergency department referral 23. Miss V says the Practice did not do enough to ensure its referral to the Trust’s ED led to timely investigation. She says her father was told the scan would be done immediately, but when he arrived, he faced a long wait and became distressed. She feels the Practice should have anticipated this, given his fear of hospitals.
24. On 24 August 2022, a GP examined Mr F because of concerns about confusion and a possible head injury. They carried out checks on his brain and heart. Our GP adviser said these were appropriate and showed no immediate signs of a heart problem.
25. The GP also considered other possible causes of confusion, such as problems with blood sugar or salt levels (known as metabolic causes). Mr F had no chest pain, and because he had a recent injury and was confused, the most urgent concern was to rule out a possible brain injury.
26. After discussing the case with the on‑call elderly care doctor at the Trust, the GP advised Mr F to attend ED for an urgent scan. Before this, the Practice had supported Mr F in pursuing a scan through an NHS‑appointed imaging provider because of his reluctance to attend hospital. When this could not proceed, as discussed above, ED became the appropriate route for urgent assessment.
27. Records show Mr F attended the Trust but left before being assessed due to the waiting time. The Practice followed up by telephone on 31 August. The GP noted Mr F declined further investigations, ended the call, and did not answer when she rang back. She then contacted a family member and arranged a review appointment and blood tests, but this was later cancelled at Mr F’s request. Our GP adviser confirmed he had capacity to make these decisions, even when they increased risk.
28. GMC guidance says GPs must identify urgent concerns and escalate them appropriately. The Practice acted promptly, sought specialist advice, and escalated Mr F’s care in line with expected practice. Once a patient arrives at ED, responsibility for timely assessment rests with the hospital, and the Practice cannot influence waiting times or a patient’s decision to leave.
29. We have not seen indications of failings in this part of the complaint. We recognise how distressing it was for Miss V and her family when Mr F left the hospital without being assessed.
30. We understand Miss V’s concern that her father later died of a heart attack. The records show the GP carried out cardiovascular assessments when clinically appropriate, including checking heart rate, blood pressure and listening to the heart. There were no symptoms at the time that would have required referral for cardiac investigation.
Explaining medications and results 31. Miss V says the Practice did not clearly explain prescribed medications or what her father’s blood test results meant.
32. On 4 January 2023, Mr F agreed to blood tests. These showed a raised HbA1c, which is a test that reflects average blood sugar levels over the previous two to three months. This confirmed a new diagnosis of type 2 diabetes, a condition where the body has difficulty managing blood sugar.
33. Mr F was seen by his GP on 11 January. Records show the GP explained the diagnosis, the risks of untreated diabetes, and the recommended treatment. Mr F was advised to stop smoking, make dietary changes, and start metformin to control blood sugar and atorvastatin to reduce his risk of cardiovascular disease.
34. To support him in taking medication regularly, the GP contacted Mr F’s pharmacy to arrange a dosette box (a weekly pill organiser to help people take medicines correctly).
35. On 18 January, the practice nurse telephoned Mr F. During this call Mr F stated he did not accept the diagnosis. On 31 January, a family member emailed on his behalf to confirm he wished to decline medication and try lifestyle changes instead.
36. The doctor documented concerns that lifestyle changes alone might not be sufficient and advised repeat blood tests in two months.
37. Miss V questions how the Practice could describe her father as confused while stating he had capacity, and felt this meant the Practice should have involved her more closely in decisions about his care.
38. We therefore considered whether Mr F’s confusion affected his capacity to make decisions, and whether the Practice balanced his autonomy with appropriate family involvement.
39. Under NHS Mental Capacity Act guidance, a person has capacity if they can understand, retain, use or weigh relevant information, and communicate their decision. While Mr F was occasionally described as confused, the records show he consistently met these criteria when making decisions about his care.
40. The Practice documented his ability to recall previous consultations, understand the implications of his choices, and express clear preferences. The Practice therefore had a duty to respect his decisions unless there was evidence he lacked capacity.
41. The records also show the Practice involved family members where appropriate, including arranging joint discussions and responding to emails from relatives, in line with NHS consent guidance.
42. NICE guidance on type 2 diabetes recommends offering statin therapy to reduce cardiovascular risk, even when a person does not have established heart disease. Atorvastatin is the standard first‑line option. The GP’s recommendation was therefore consistent with national guidance and reflected Mr F’s increased cardiovascular risk due to diabetes.
43. Our GP adviser confirmed Mr F consistently demonstrated capacity to make decisions about his care, including refusing blood tests and declining medication. The Practice respected his autonomy while continuing to offer appropriate monitoring and support.
44. We note the Practice followed NICE diabetes guidance by making appropriate referrals, discussing results with Mr F, and raising concerns with adult social care when needed.
45. Taking all of this into account, we are satisfied the Practice explained the diagnosis and treatment options appropriately and acted in line with relevant guidance. We have not identified failings in this part of the complaint. We know from what Miss V has told us, how uncertainty added to a difficult time, and we hope our explanation provides some reassurance.
The Trust Timeliness of neurology appointments
46. Miss V says the Trust did not arrange neurology appointments in a timely way following her father’s CT scan. She says the family waited a long time for an appointment and that dates were repeatedly changed, which added to their worry during a period when his health was deteriorating.
47. The GP sent the neurology referral on 22 December 2022. The Trust’s records show it was logged on 1 February 2023. There is no information to explain the gap between these dates, but we have not seen evidence this affected the overall waiting time for a neurology appointment.
48. The Trust initially booked an appointment for 14 June 2023. This was later brought forward to 7 March 2023. The clinic on that date was cancelled at short notice because an outpatient room was unavailable, and the consultant’s administrator contacted patients to explain the reason.
49. The appointment was then rescheduled to 10 July 2023, before being brought forward again to 6 April 2023. Mr F died on 2 April 2023, before the appointment took place.
50. Neurology is a high‑demand specialty and waiting times of several months are common. The Trust brought the appointment forward twice when capacity allowed. We have not seen evidence the Trust failed to arrange neurology appointments within a reasonable timeframe.
51. Our Neurology adviser explained the CT scan did not show any acute findings requiring urgent neurological intervention (we explain this in detail at paragraph 61 below) and the timing of the appointment did not affect Mr F’s clinical outcome.
Communication and disputed cancellation
52. Miss V also raises concerns about how the Trust communicated with the family about appointments. She disputes the Trust’s record that her father cancelled an appointment, as she says he was unable to make outgoing calls at the time. She says the family were not informed about changes to appointments and only learned of the cancellation when they received the confirmation letter.
53. The Trust’s records show an appointment for 12 October 2022 was cancelled on 6 October, with the radiology system recording the reason as ‘patient choice to cancel’.
54. As part of its complaint investigation, the Trust reviewed staff rotas, call logs, and radiology system entries. The investigation found that a temporary staff member, who no longer works at the Trust, took a call on the day the cancellation was recorded. The Trust said it could not confirm who made the call
55. The Trust concluded it was most likely the temporary staff member misunderstood the call and believed a cancellation was being requested. They cancelled both the referral and the appointment in error. A second, more experienced staff member later entered the cancellation reason based on information given to them by the temporary staff member.
56. The Trust acknowledged this was an administrative error and apologised. It explained that due to system limitations and the temporary staff member no longer being employed, it could not retrieve the call recording or confirm exactly what was said. The Trust also outlined steps taken since then to improve staffing stability and strengthen booking processes to prevent similar errors happening again.
57. This response aligns with the NHS Complaint Standards, which expect organisations to identify what went wrong, apologise, and explain how they will prevent recurrence.
58. We recognise how frustrating and distressing this was for Miss V and her family. The Trust’s investigation identified an administrative failing in how the appointment was handled. Under the NHS Complaint Standards, organisations are expected to maintain accurate records and communicate clearly with patients.
59. The administrative error did not lead to a missed opportunity for treatment. As noted below, the CT scan did not show any acute findings requiring urgent intervention, and there was no clinical disadvantage caused by the delay. In light of this and given the steps the Trust has taken to prevent similar errors, we are satisfied the Trust has taken appropriate action to address the issue.
Follow‑up of the November 2022 CT scan
60. Miss V says the Trust did not follow up appropriately on the CT scan and believes the findings should have prompted urgent action because her father later died of a heart attack.
61. The CT scan showed three things:
• changes in the small blood vessels in the brain which are common in older adults and in people with risk factors such as diabetes or smoking - they share the same underlying risk factors as heart disease, but they do not show that someone has heart disease or predict a heart attack • old scarring on the right side of the brain from surgery in 2011 -this was longstanding and not causing new problems • a small area on the left side of the brain that may have been an old stroke, although this was not identified as a stroke by the radiologist at the time.
62. Our neurology adviser explained smallvessel changes in the brain and heart can occur for similar reasons, such as age, diabetes, high blood pressure, or raised cholesterol. This means they share risk factors, not that one causes the other or that the brain scan showed heart disease.
63. Because the radiologist did not report a stroke, there was no reason at the time for the Trust to start strokerelated investigations. Even if the possible old stroke had been identified, the usual followup tests (such as heartrhythm monitoring or an ultrasound of the heart) are routine and would not normally lead to tests for blocked heart arteries in someone with no heartrelated symptoms.
64. We note Miss V’s recollection that her father described rib‑area pain. This was not documented in the clinical records during the period under review, and there were no recorded symptoms suggestive of heart disease at the time.
65. A heart attack is caused by a sudden blockage in the arteries supplying the heart. These blockages cannot be seen on a CT scan of the brain, and Mr F was not experiencing any heartrelated symptoms. There was therefore no clinical reason to investigate his heart further at that time.
66. We also considered the Trust neurologist’s later explanation to Miss V that the smallvessel changes in the brain were caused by the same underlying risk factors that can also affect the heart.
67. Our neurology adviser said this does not mean the CT scan showed heart disease, or that the brain findings could have predicted the later heart attack. A CT brain scan cannot show the coronary arteries or detect the type of blockage that causes a sudden heart attack.
68. Our neurology adviser concluded it is unlikely earlier neurological followup would have led to tests that would have identified Mr F’s heart disease, or that the outcome would have been different.
69. Taking all the clinical evidence into account, we are satisfied the Trust acted appropriately in response to the CT findings, and that the delay in the scan did not have a clinical impact on Mr F’s care. We hope these explanations provide some reassurance to Miss V.