17. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so. We have discussed this with Mr P to understand the reasons why he could not do so. We have also considered the time the organisation has taken to respond to Mr P.
Fibro scan
18. A fibroscan is a non-invasive ultrasound-based test that assesses liver stiffness and fat content, helping to diagnose and monitor liver conditions. Mr P explained he sourced an independent fibroscan from Liver Wellness in August 2021.
19. Mr P says Liver Wellness recommended a follow up within a year. He complains the Practice failed to arrange this and instead it arranged an ultrasound.
20. Mr P will have been aware his concern around August 2022 when the Practice did not arrange a follow up fibroscan. This means he had until August 2023 to bring this part of the complaint to us.
21. Mr P bought the complaint to us in July 2025 approximately one year and ten months outside of our time limit.
Endocrinologist
22. Mr P says the Practice repeatedly refused to refer him to an endocrinologist for further investigation regarding his diabetes. He says the Practice said it could deal with the issue inhouse.
23. We asked Mr P to provide further information about when this happened. He said he did not have the dates but it was around the time the Practice offered him metformin. Metformin is an oral medication primarily used to manage type 2 diabetes by lowering blood sugar and improving insulin sensitivity.
24. Mr P explained he was concerned because his diabetes was high for years. He also thought his weight gain was associated with metformin.
25. Mr P’s medical records show he started metformin in January 2022.
26. Mr P says the Practice did not control his diabetes ‘for years’.
27. Mr P’s medical records show in November 2023 Mr P asked to see an endocrinologist and the GP did not think that was warranted. It says, ‘patient not accepting of this’.
28. As there is specific mention of this concern in Mr P’s records we consider this was his date of knowledge. This means he had until November 2024 to bring the complaint within our time limits.
29. Mr P came to us around seven months outside of our time limit.
Varicose veins
30. Mr P says he asked the Practice to refer him for specialist care for varicose veins in 2021 and 2022. He says the doctor dismissed his concerns saying, ‘it looks fine’.
31. Mr P had until 2023 to bring this part of the complaint. He has bought this part approximately two years outside of our time limit.
Diabetes and hypertension medication
32. Mr P complains in October 2023 the Practice incorrectly denied him access to diabetes and hypertension medication.
33. We consider he was aware of the concern at the time it happened therefore Mr P had until October 2024 to bring this part of his complaint within our time limit.
34. Mr P bought this part his complaint approximately nine months outside of our time limit.
Indapamide
35. Indapamide is medication primarily used to treat high blood pressure. Mr P complains the Practice overprescribed indapamide.
36. Mr P says he was not aware the Practice were over prescribing until he changed blood pressure medication in December 2024. He says when he stopped indapamide, the symptoms he had been suffering in his hands and feet stopped.
37. The records show Mr P originally started indapamide in February 2022.
38. In March 2023 Mr P reported indapamide caused hypersensitivity, vomiting and pains.
39. In September 2023 Mr P had reduced his dose to half as he was getting twitching muscles from indapamide.
40. Mr P stopped taking indapamide in October 2023 as he was unable to tolerate arm numbness and twitching. He started it again in February 2024.
41. In October 2024 he reported red and hot hands as well as itchy hands and feet. Mr P stopped the medication himself in November 2024 as he developed redness and itchiness on his arms. The GP advised him to take his prescribed medications.
42. In a medication review in December 2024 Mr P said his symptoms worsened when he restarted indapamide. He advised he wanted to reduce the dose as he felt it was causing numbness, pain and itchiness in his hands. The GP reduced the dose.
43. A GP agreed to stop the medication on Mr P’s request in January 2025.
44. From what we have seen Mr P had concerns about symptoms he felt were related to indapamide before December 2024. He had already stopped taking the medication previously in October 2023 due to side effects.
45. Mr P said he noticed his symptoms worsened when he re-started the medication in February 2024. We consider this was his date knowledge. At that time, he had already been on the medication previously and had to stop due to the side effects. Mr P had until February 2025 to bring this part of his complaint within our time limit. He came to us five months outside of the time limit.
Reasons for delay
46. We can set the time limit aside but only in exceptional circumstances where we can see it was not possible for a complainant to come to us any sooner. We asked Mr P to explain his reasons for the delay in coming to us to see if we could set the time limit aside.
47. Mr P said he had raised numerous complaints to the Practice over the years in different situations but did not get responses. He says this led him to lose faith.
48. Mr P also said he had contacted the general medical council (but could not remember when) who refused to investigate his concerns.
49. Mr P explained he experienced considerable emotional distress related to his medical condition. He said managing his health caused significant stress and he tried to remain calm to avoid complications.
50. We appreciate Mr P has numerous chronic (long term) conditions which must be difficult to live with. We also must consider Mr P was able to bring his complaint whilst he had those conditions. Further, he was able to bring numerous complaints over the years.
51. We are sorry to hear Mr P lost faith in the Practice and felt ignored. We do not consider this was a significant barrier which prevented him from complaining sooner than he did.
52. We also looked to see whether the time the Practice and ICB took to respond to Mr P’s complaint may have caused a delay in him being able to come to us. We did not find it did as at the time Mr P raised his complaint in January 2025, he was already outside of our time limit.
53. We have not seen sufficient reason to put the time limit aside. We cannot consider the above parts of the complaint any further.
Weight loss injections
54. 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. We have done this and have not found any indications that something has gone wrong.
55. Mr P complains in November 2024 the Practice refused to refer him for Mounjaro (weight loss injections) to manage his insulin resistance.
56. The Practice complaint response said ‘there has been no service for us to refer you to, just for injections and we are unable to initiate them in primary care for this indication. We therefore cannot take responsibility for not referring you appropriately as, in any case, there was nowhere for us to refer you to.’
57. Mr P explained he went on to start Mounjaro at his current Practice shortly after he joined.
58. In follow up communications with us, the Practice explained Mounjaro was still very new at the time Mr P requested it. It said guidance did not come out until March 2025.
59. NHS England explains ‘From 23 March 2025, you may be prescribed tirzepatide (Mounjaro) to manage your weight only if it is prescribed by a specialist weight management service, where a healthcare professional feels it is the right treatment for you.’
60. The ICB did not issue a statement on what to do for new patients eligible for Mounjaro in primary care until June 2025.
61. The records show in November 2024 Mr P and the GP discussed how he was having trouble losing weight. The GP noted Mr P’s BMI was high and he would benefit from losing weight. The plan was for the GP to liaise with a colleague about Mr P’s diabetes and starting Mounjaro.
62. Around three weeks later the GP messaged Mr P advising they had looked into different options and found he was eligible for a programme called ‘NHS Type 2 Diabetes Pathway to Remission programme’ with Oviva which is a weight loss service.
63. GMC guidance for good medical practice says in providing clinical care doctors must adequately assess a patient’s condition(s), taking account of their history, including:
• symptoms • relevant psychological, spiritual, social, economic, and cultural factors • the patient’s views, needs, and values.
64. It also says promptly provide (or arrange) suitable advice, investigation or treatment where necessary.
65. We consider the GP acted in line with this. The GP took account of Mr P’s concerns about his weight and diabetes control then found a service which was fitting to address them.
66. We appreciate it must have been frustrating for Mr P being unable to access Mounjaro when he first requested it. At that time guidance was not in place and the medication was highly restricted.
67. We have not seen indications of a failing.
68. We thank Mr P for bringing his complaint and sharing his experiences.