18. 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.
19. We have done this. After reviewing all the evidence available to us, we have not found any indications that something has gone wrong.
Decision against providing LLLT and ritlecitinib
20. Mr A says the Trust did not provide T with LLLT treatment nor with the ritlecitinib medication they requested, despite staff seeing T’s alopecia areata worsening.
21. We first considered the Ritlecitinib Guidance. This says ritlecitinib is prescribed for SALT scores over 50, but patients with:
‘moderate Alopecia areata (SALT score 21-49) may have their severity rating increased by one level to severe if there is…negative impact on psychological functioning resulting from Alopecia areata … inadequate response after at least 6 months of treatment (treatments include topical or intralesional steroids or oral steroids)’
22. We know T’s condition was deteriorating even with the interventions put in place by his doctor, which must have been very distressing for him. We can also see the doctor prescribed medication only when there was definite evidence to say T had a SALT score over 20. This happened in June 2025, after Mr A brought his complaint to us.
23. We consider this shows the specialist was working within clinical guidelines. They raised T’s severity rating only when his SALT score increased and the guidance indicated they could, taking into consideration the impact the condition was having on T’s wellbeing.
24. We reviewed advice from our clinical advisor. Our advisor reviewed T’s records and advised only once his SALT score was above 20, he was put on ritlecitinib, which means T was put on the right medications at the right time. They said the treatment given was appropriate for T’s diagnosis.
25. Our adviser told us T was first given topical steroids and safer, simpler treatments and then medications like oral minoxidil and oral prednisolone when he showed signs of his condition deteriorating. They said that, because T had a SALT score of 13 in January 2025 and a SALT score of 36 in June 2025, T was only eligible for ritlecitinib in June 2025.
26. We then considered the LLLT treatment which Mr A and T requested from the Trust. We cannot find any clinical guidance which would indicate LLLT therapy is advised for alopecia areata. It is not funded or prescribed by the NHS for the condition.
27. Our advisor indicated LLLT is not recommended or useful for alopecia areata. They advised LED lights, lasers or any other light or electromagnetic treatment (including LLLT) is not recommended in the treatment of alopecia areata. This is because there is no evidence it treats the condition or acts as a supporting treatment alongside other treatments. It is not routinely provided by the NHS for hair loss, even in exceptional cases. They advised LLLT is only used in cosmetic practices, with questionable benefits for alopecia.
28. After reviewing the evidence, advice and guidelines, we cannot see the LLLT treatment Mr A sought is a treatment the Trust should have provided. As it is not something recommended by the NHS, we cannot recommend the Trust reimburse Mr A for the cost of it. We also conclude the Trust gave T ritlecitinib at the right time. If the Trust had prescribed the treatment before May 2025, this would not have been supported by the guidelines we considered.
The length of time the Trust took to provide treatment
29. Mr A also complained to us that the Trust was not proactive and took too long to provide the correct treatment for T’s alopecia areata.
30. In considering this part of Mr A’s complaint, we looked at the Alopecia Pathway. This guidance tells clinicians to undertake a full history and clinical assessment by judging the impact the condition has on the patient, assessing their SALT score, performing biopsies and blood tests, and providing a patient information leaflet.
31. We have reviewed T’s medical records and can confirm staff followed this guidance. We can see blood tests, referral and summary notes from the doctors making note of SALT scores, advising on the impact the condition has on T and changing his medication to fit the progress of the condition and the side effects T was experiencing. We consider this shows staff at the Trust were proactive.
32. The Alopecia Pathway also advises that, depending on how severe the alopecia areata is, clinicians should offer medication like prednisolone when the condition becomes more serious and does not respond to simpler treatments like topical creams. Our clinical advisor said staff treating T had worked in line with this guidance. We can see the Trust prescribed oral prednisolone to T. They also considered the effect medication was having on T, adjusting where needed when he suffered with palpitations.
33. We also considered the Alopecia Information Leaflet. We can see in T’s records this guidance was recommended to Mr A and T on 5 March 2025. It states minoxidil and ritlecitinib is approved for those with severe alopecia. We know clinicians told T that ritlecitinib could only prescribed with a SALT score over 20, and we now also know that T was recommended to go on this medication as of 9 June 2025 when there was evidence his SALT score was above 20.
34. We then asked our clinical advisor to review Mr A’s complaint that T’s treatment took too long and treatments were not proactive. Our clinical advisor said T was seen quicker than the expected NHS waiting times for specialist dermatology treatment. Our advisor also told us oral prednisolone was the correct treatment for T. They said that, until there was evidence the condition had worsened beyond a SALT score of 20, the NHS would not have been allowed to prescribe ritlecitinib. Our clinician’s view was that T needed to give the medications (oral minoxidil and oral prednisolone) time to work before staff at the Trust could reasonably offer changes to his treatment. There was only six months between T’s first official diagnosis of alopecia areata in December 2024 and Mr A’s complaint reaching our organisation.
35. We understand Mr A and T felt frustrated at seeing T’s condition deteriorate, and we are sorry to hear of the distress this caused. We cannot reasonably conclude the Trust took too long to provide treatment to T. The evidence and advice we have reviewed tells us the treatment pathway T was on was recommended by guidelines, more timely than normal NHS expectations for treatment, and he was given the correct treatment at the right times.
The Trust’s communication and how long T waited for appointments
36. Mr A complained he faces a lack of communication from staff and delays in getting appointments to treat T’s alopecia areata at the Trust. He told us he was frustrated that T was turned away from seeing a specialist in February 2025. He was also concerned that when he requested information from the Trust regarding reviews of T’s condition, it took a long time to hear back from staff.
37. We considered the Trust’s complaint response to Mr A regarding this issue. The Trust noted T had visited the dermatology department in February (two days after he had seen a specialist about his condition) without a prearranged appointment, requesting to be seen so he could get an alternative medication for his condition. The Trust said in their complaint response their policy is not to see any patients out of appointment time.
38. We discussed this policy with the Trust. Staff confirmed they have this local policy in place for all their patients. They said patients must have a pre-booked appointment, and walk-ins cannot be accepted, because the hospital can get very busy and this policy ensures all patients have a fair chance of being seen by clinicians. The Trust added that even though they cannot accept walk-ins, they do provide a phone number to patients so they can ask for advice or book an appointment easily.
39. We consider the Trust’s policy regarding appointments to be in line with our Principles of Good Administration. Part one of this guidance says public bodies should follow their own policy and procedural guidance, whether published or internal. In this case we can see the Trust did follow its own internal guidelines regarding walk-in appointments and applied this policy to Mr A and T when they were turned away from seeing a specialist in February 2025.
40. Our Principles of Good Administration also say organisations should act fairly and proportionately. It says public bodies should:
‘treat people equally and impartially…and ensure equal access to services and treatment regardless of background or circumstance’.
In this instance we consider the Trust’s decision to insist on pre-booked appointments, even in Mr A and T’s case, allows fairer access for all patients to see the staff they need.
41. We appreciate not being able to see the specialist doctor on this day was distressing as T felt his medication was causing him side effects and he was worried about his condition further deteriorating. Our clinical advisor told us even if T had been seen in February 2025 when he wanted, it is still likely the treatment prescribed would have been the same. There is no indication that being seen two days after his appointment would have led to a different diagnosis or prescription, as he was already on the correct medication.
42. We considered the range of face-to-face appointments, telephone consultations and testing T had at the Trust from December 2023 until May 2025. We can see as soon as there was evidence of T’s condition deteriorating, the specialist clinic referral and treatment for his alopecia areata was completed within a short period of time, with relatively frequent appointments with specialists.
43. This means taking all clinical guidelines, specialist advice and records into account, we consider T was given the correct treatments by the Trust within a short timeline.
44. We understand Mr A and T will be disappointed with this decision. We hope our reasoning reassures them we investigated their complaint thoroughly. We cannot find any evidence which says the Trust could have done more to stop T’s alopecia areata from progressing.
45. We are aware that as of June 2025 T has been prescribed ritlicitinib by the Trust. We appreciate it is frustrating for Mr A and T that this could not happen earlier. We sincerely hope the continued treatment with the Trust works well for T and wish them both the best for the future.