PSOW Individual Decisions

Mr X’s complaint concerned his medication for Diabetes. Although he had received a complaints response from the Surgery, he remained dissatisfied. The Ombudsman noted the Surgery had provided a reasonable explanation to several of the points raised by Mr X. However, it had not had the opportunity to respond to concerns about the frequency of blood screening, or medication which Mr X said affected his mood. The Ombudsman considered these issues were outstanding and it would be helpful for Mr X to receive a written response from the Surgery. The Ombudsman sought and gained the Surgery’s agreement to provide a response to the outstanding issues within 30 working days

Mr X complained that the Practice failed toappropriately change his pain relief medication as instructed by the hospitaland failed to issue a repeat prescription. The Ombudsman found that whilst the Practice responded to Mr X’s concerns, it had done so verbally. It had not offered its response in writing in line with policy. The Practice therefore agreed to issue a full written complaint response by no later than 14 July 2022.

Mrs A complained that the GP Practice (“the Practice”) failed to provide satisfactory care to her mother, Mrs B, and that this contributed to her rapid terminal decline in April 2020. Further, Mrs A said the Practice’s handling of her complaint was not adequate or robust. Mrs A also complained about the community nursing care provided the Health Board and about a telephone consultation with an Out of Hours GP (“the OOHGP”) on 15 April. Finally, Mrs A complained about the Oncologist at Velindre NHS Trust (“Trust”) and their communication with the family as well as the Trust’s complaints handling. The Ombudsman’s investigation found that, broadly, the consultations by the GPs were appropriate and that Mrs B’s rapid decline and death could not have been anticipated. However, given Mrs B’s sudden deterioration, a face-to-face consultation would have been helpful, especially as it later delayed the family getting a death certificate. Although this shortcoming did not contribute to Mrs B’s sudden deterioration, or alter the sad outcome, it added unnecessarily to the family’s distress at a difficult time. The complaint against the GP Practice was upheld to this limited extent. The Ombudsman also found shortcomings in the record keeping by the District Nurses’ that failed to provide adequate handover information for continuity of care. Records were also added retrospectively after Mrs A had complained. Although the investigation concluded that a home visit by the OOHGP was not necessary following the telephone consultation, given that there was every indication that Mrs B was likely to be close to death, this should have been discussed with Mrs A so that she was better prepared. The Ombudsman found that these communication failings caused an injustice to Mrs A and the family as it added to their distress at a very difficult time and this aspect of the complaint against the Health Board was upheld. Please Note: Summaries are prepared for all reports issued by the Ombudsman.

Ms A complained that a Surgery failed to correctly address her transgender son on its calling board, disclosing his identity to other patients. Ms A also said the Surgery informed her son that he needed a new NHS number to change his gender on the system, and she was concerned how this would impact him being called for routine ‘female’ screening. Ms A was unhappy with the Surgery’s complaint handling. She also said that it did not respond to her emails and she had to contact the Local Health Board. A resolution meeting proved unsuccessful and Ms A’s family was removed from the Surgery’s patient list, without explanation or warning. The Ombudsman decided that the Surgery had mishandled how it addressed Ms A’s son, and the family’s subsequent complaints. She decided to settle the complaint without investigation. The Ombudsman sought and gained the Surgery’s agreement to apologise to Ms A for the complaint handling, and to provide a complaint response and rationale for the decision to remove the family from its patient list. It also agreed to review its current system for dealing with patient emails within one month.

Miss X complained that the Surgery changed the frequency of her prescriptions from monthly to fortnightly without explanation. The Ombudsman decided that the Surgery should provide Miss X with a “Putting Things Right” (the formal NHS complaints process in Wales) compliant written response (within 3 weeks) which should explain the reasons why there was a change in the frequency of her medication. The Ombudsman considered this to be an appropriate resolution to the complaint instead of conducting an investigation.

Miss X complained about investigations and treatment carried out by her GP Practice and the Health Board into a cervical mass. She also complained about how both organisations dealt with her complaints. The Ombudsman found that the investigations and treatment of Miss X’s cervical mass were broadly reasonable, albeit there was a delay in the Practice making a referral on one occasion. In addition, the Health Board did not copy Miss X into a letter setting out the results of a biopsy and took her off the list for an appointment after the letter inviting her to the clinic was not sent to her. Although none of these failings ultimately affected Miss X’s treatment, they did cause her needless anxiety and time and trouble when attempting to resolve matters. To that extent the complaints were upheld. In relation to the handling of Miss X’s complaints, the Ombudsman found that when Miss X made a complaint about both organisations via the Health Board’s contact centre, the Health Board did not pass on the complaint about the Practice. As the Practice was unaware of it, it was unable to respond to Miss X’s complaint. For that reason the Ombudsman did not uphold the complaint about the Practice. He did uphold the complaint against the Health Board. In addition to the failure to pass on the relevant parts of the complaint to the Practice, the Health Board also wrongly treated the complaint about its own actions, as being resolved informally, when it should have sent a formal response. The Ombudsman recommended that the Health Board should apologise to Miss X and pay her £250 in recognition of the time and trouble she had been put to due to the shortcomings in how it handled her complaint. It also recommended that the Health Board should issue guidance to its Gynaecology Directorate about when complaints may be dealt informally and when a formal response is required.

Mr X complained that from January 2020 onwards, the Practice prescribed him bumetanide, gliclazide and omeprazole inappropriately. Mr X also complained about delays in treatment, diagnosis and poor communication. The Ombudsman found that the Practice prescribed the medications appropriately. These drugs were stopped when Mr X was admitted to hospital in April 2021, it was not a criticism of the Practice, it was because Mr X’s clinical condition changed at that time. The Ombudsman also found that the overall handling of Mr X’s appointments and referrals by the Practice and its communication with him was satisfactory. There was no evidence that Mr X was inappropriately referred by the Practice, or not referred when he should have been. Due to the COVID-19 pandemic, waiting times to see specialists became longer and the Practice managed Mr X’s complex clinical situation as best it could while awaiting guidance from specialists on an overall treatment plan. The Ombudsman did not uphold the complaint.

A complainant complained about the delay in an agreed complaint meeting taking place, and the fact that the Medical Centre did not retain telephone recordings, which the complainant considered would provide evidence in support of their complaint. The complainant also complained that the Medical Centre made reference to highly sensitive personal information being contained in a written reply to their complaint. The Ombudsman found that, while the delay in the complaint meeting taking place was reasonable, the Medical Centre should have preserved the telephone recordings because it knew there was a complaint on-going. The Ombudsman shared the complainant’s concern about the highly sensitive personal information contained in the complaint response letter, noting that the complainant had not referred to this in their complaint at all, and it would have been distressing for the complainant to read this as part of the response to their complaint. The Ombudsman also found that the Medical Centre did not mention the Ombudsman’s service, although there is a legal requirement for complaint response letters to signpost complainants to the Ombudsman. The Medical Centre agreed to apologise to the complainant and to offer them a payment of £100 for the time and trouble experienced in bringing their complaint to the Ombudsman, within 1 month. It also agreed to ensure that all template letters responding to complaints were compliant with the NHS Putting Things Right regulations within 3 months.

Mrs H complained that her GP Practice failed to manage her diabetes appropriately and that it removed her from its patient list after she submitted a formal complaint. The Ombudsman considered that there was insufficient evidence of harm to justify investigating Mrs H’s clinical complaint. However, having considered advice from one of his professional advisers, an experienced GP, he was concerned that the Practice had failed to follow due process when deciding to de-register Mrs H. The Ombudsman was also concerned that the decision was taken in close proximity to a related complaint and that the Practice had shown insufficient regard for Mrs H’s potential vulnerability, given her ongoing medical needs. In response to the Ombudsman’s concerns, the Practice agreed to formally acknowledge that it had failed to follow due process in reaching its decision and to apologise to Mrs H for the inconvenience and distress this caused her. It also agreed to convene a meeting of the partners to discuss the Ombudsman’s concerns and to provide evidence that it had put in place adequate procedures to ensure that future decisions to de-register patients will only take place in accordance with due process and relevant NHS regulations and professional guidance. The Ombudsman considered that these actions represented a reasonable settlement of the complaint.

Mr E complained that: a) The Practice provided a prescription for tamsulosin (medication used to treat symptoms of an enlarged prostate) when he had already been prescribed the medication, resulting in him potentially taking an overdose. b) The Practice removed him from their patient list alleging that he had threatened a member of staff during a telephone conversation. c) The Practice failed to comply with his request for a female doctor only to be involved in his care. The Ombudsman found that the Practice’s process for the issue of prescriptions, and record-keeping in respect of them, were appropriate; investigation by the Practice had failed to establish how an error had occurred, and further investigation was unlikely to resolve this. The unnecessary/duplicate prescription had been spotted by the Pharmacist, meaning Mr E had not taken an overdose. The Ombudsman concluded that Mr E had made implied threats to Practice staff, and that the Practice was justified in having him removed from their patient list. The Ombudsman found that the Practice had done what it could to comply with Mr E’s request for a female doctor, but that on one occasion an appointment had been transferred to a male doctor because of staff sickness; Mr E could have made another appointment with a female doctor if he wished. The Ombudsman did not uphold the complaints.

Mr H complained about the care provided to his late mother, Mrs T, by 2 GPs at her GP Practice. Mr H said that at a home visit, the First GP failed to arrange “just in case” medication or to ensure plans were in place for end of life care. Mr H also complained that when his father, Mr T, telephoned the Practice because Mrs T had deteriorated, the Second GP failed to ensure she received the care and medication she needed. Mr H said that the responses to the complaint were inadequate and failed to demonstrate that meaningful learning had taken place. The Ombudsman found that the First GP failed to prescribe “just in case” medication and that when Mrs T’s condition deteriorated, the Second GP should have returned Mr T’s telephone call, assessed the situation and arranged for medication to be urgently made available to Mrs T. The Ombudsman also found that the second GP and the Practice failed to communicate adequately with the District Nursing Service. He concluded that as a result of these failings, Mrs T did not receive medication to relieve her pain and agitation, causing her unnecessary suffering and distress and severe distress to her family, and he upheld the complaint on that basis. He did not find that the First GP failed to ensure that plans were in place for end of life care. The Ombudsman found that initial responses from the First and Second GP were inadequate and failed to demonstrate real learning from the complaint, causing additional upset to Mr H and Mr T. The Ombudsman upheld the complaint about the responses from the Practice. The Ombudsman noted that the Practice had reflected on these events and taken appropriate action to prevent a recurrence, including an audit of its end of life documentation. He recommended that within a month of the report, the GPs apologise to Mr H and Mr T. He also recommended that within 3months of the report, the Practice should provide evidence of its audit, including any action it planned to take. The Practice agreed to i

Miss A complained about the Practice’s management of her leg condition, issues with her prescriptions, and the way it dealt with her complaint about these matters. The Ombudsman found that the Practice had met with Miss A about her complaint, but it had not provided Miss A with a full and comprehensive written final complaint response in accordance with the National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations. Following contact from the Ombudsman, the Practice voluntarily held a further meeting with Miss A to discuss her complaint and it subsequently provided her with a written complaint response to the issues raised in her complaint. The Ombudsman considered the action taken by the Practice was reasonable and resolved the complaint.

Mrs A complained that the GP Practice had failed to provide a response to a complaint submitted on 25 October 2020 in respect of treatment provided to her late father. The Ombudsman found that the Practice had not responded to the complaint, despite a letter being sent to the Practice by his office on 17 December 2020, requesting it to do so. The Ombudsman contacted the Practice and it agreed to, within 10 working days: · Provide a comprehensive response to the complaint submitted by Mrs A on 25 October 2020, in respect of treatment provided to her late father, Mr B. The Ombudsman was satisfied that this would provide a resolution to the issues considered in this complaint.

Ms A complained about a GP Practice (“the Practice”) in the Aneurin Bevan University Health Board (“the Health Board”) area who provided care and treatment to her father, Mr B, while he was a resident at a care home (“the Care Home”). His residency at the Care Home was funded by Torfaen County Borough Council (“the Council”). Specifically, Ms A complained that: • The Practice failed to provide timely and appropriate care and treatment to Mr B between January and May 2019, when Mr B had a below the knee amputation. • The Care Home failed to provide timely care and treatment to Mr B in terms of pressure area management and wound management, failed to communicate with, and involve her, in decision making including failing to allow her to view Mr B’s foot, and failed to act upon concerns raised by Ms A. • The Council failed to review/monitor Mr B’s care while he was a resident at the Care Home. The investigation found that the care provided by the Practice was appropriate with timely and appropriate investigations conducted, that test results were reviewed in a timely manner and actioned appropriately, and it was appropriate not to refer Mr B to hospital before 13 May. As such, the complaint against the Practice was not upheld. The investigation found that the Care Home acted in a timely manner by seeking assistance from the District Nurse (“DN”) Team when Mr B’s heel wound was first noticed and acted promptly in seeking GP input when an infection was suspected. The investigation found that Mr B did not initially want his information shared with Ms A without his consent, and, therefore, it would not have been appropriate to share and involve Ms A in decision making regarding his health, care and treatment. The investigation found that the Care Home did not fail to act upon concerns raised by Ms A about Mr B’s foot. As such, these aspects of the complaint were not upheld. However, Mr B was not subject to a prompt and thorough skin assessment by Care Home staff when he wa

Inadequate treatment of symptoms and inadequate and inaccurate complaint response. ********************************************** Ms X complained about the complaint response she received from the GP Practice in respect of her concerns about treatment (or lack thereof) of her symptoms which she said had subsequently been found to result from Trans Ischaemic Attacks and a pinched nerve. She said that the treatment she received was inadequate and the complaint response was inaccurate and upsetting. The GP Practice agreed to hold a meeting with Ms X to discuss her clinical and complaints handling concerns and to provide her with a further written response following the meeting. The Ombudsman considered this to represent an appropriate resolution.

Mrs B complained about the care and treatment provided to her husband, Mr B, by a GP Practice in the area of the Aneurin Bevan University Health Board (the Practice). She complained that when her husband, Mr B, attended the Practice with symptoms and a family history of diabetes, the GP did not undertake any appropriate tests that day to check for diabetes. After the appointment, as Mr B was very unwell, Mrs B rang NHS Direct Wales and, on the advice provided, took Mr B to the Emergency Department, where he was admitted ,treated, and diagnosed with diabetes. Mrs B also complained about the Practice’s handling of her complaint. The Ombudsman found that the GP should have undertaken tests during the appointment, and that these would have revealed the severity of Mr B’s condition and shown the necessity of getting immediate treatment. He therefore upheld this element of the complaint. The Ombudsman found that the Practice had already made appropriate changes to its internal guidance and planned for future training to prevent a similar issue in the future. He found that although these responses to the incident were thorough and appropriate, they had not been fully communicated to Mr & Mrs B in the Practice’s complaint response, the content of which was unsatisfactory. He therefore also upheld this element of the complaint. The Practice agreed to apologise within 1 month to Mr and Mrs B for the failings identified and to provide them with a copy of the new Diabetes protocol and £250 payment for the injustice caused. It also agreed to share the Ombudsman’s report with relevant staff to facilitate learning.