PSOW Individual Decisions

Mrs D complained about the care and treatment she received from a GP Practice in the area of Betsi Cadwaladr University Health Board (“the Practice”) following the birth of her son. Mrs D complained that she had not received a response from the Practice to her complaint. The Practice said it responded to Mrs D on 12 September 2022. Mrs D did not receive the response. The Practice agreed to re-send its complaint response to Mrs D within 4 weeks. The Ombudsman considered that the agreed action resolved Mrs D’s complaint.

Mrs A complained that the Health Centre failed to verify and certify Mr A’s death within a reasonable time frame. The investigation acknowledged the waiting period was a distressing time for the family, but found that verification of a death is carried out as soon as reasonably practical for a busy GP. It would not have been appropriate for a GP to leave unwell patients to attend Mr A in those circumstances. The GP attended Mr A within 4 hours of becoming aware of his death. The Ombudsman did not uphold the complaint. As no failing was identified, the Ombudsman did not make any recommendation regarding this complaint.

Miss A complained that the GP Surgery failed to act on her late father’s (Mr A) repeated reports (over a period of approximately 5 years)of swallowing problems and monitor polyps that were present. The Ombudsman started an investigation, however, after a review of the records obtained from the GP Surgery, it was found that there were no documented reports of any problems relating to swallowing beyond a single consultation in July 2016 where Mr A had reported coughing on swallowing. On this occasion, Mr A was immediately referred to specialists in secondary care for investigation. The investigations carried out did not indicate that polyps had been found and Mr A was later discharged back to the care of the GP Surgery, following which no further reports of similar problems were recorded within the records. As a result, on the basis of this lack of documented evidence, the investigation was discontinued as there was little further that could be achieved by an ongoing enquiry into the matter.

Mrs X complained about the care and treatment she received from a GP Practice in the area of Betsi Cadwaladr University Health Board. Specifically, Mrs X complained that, between 19 January and 2 March 2022, the GP Practice failed to undertake appropriate investigations or make appropriate referrals in response to her presenting symptoms and patient history. Mrs X complained that this resulted in a delay in diagnosing her need for gynaecological surgery. The Ombudsman found that Mrs X’s symptoms were an unusual complication of a gynaecological condition. She concluded that the care and treatment provided to Mrs X was clinically appropriate, with suitable examinations and blood tests undertaken, and a referral made once her symptoms indicated that one was warranted. Mrs X’s complaint about the GP Practice was therefore not upheld.

Mrs X complained that the GP Practice did not recognise the severity of her mother Mrs Y’s presenting symptoms when she telephoned to request a GP appointment. She was offered a routine phone appointment two weeks later. No further enquiries or referrals were made by the GP Practice. Mrs X was hospitalised the following day and underwent emergency surgery for aortic dissection. The Ombudsman found that there was an inadequate GP triage of Mrs Y’s symptoms when she contacted the GP Practice. Whilst her symptoms were not typical of aortic dissection, she presented with symptoms which were potentially serious in nature and required further exploration by a clinician that day, either over the phone or face to face. Because of the atypical nature of her symptoms, further enquiries about the nature of Mrs Y’s symptoms may not have resulted in her being dia Mrs X complained that the GP Practice did not recognise the severity of her mother Mrs Y’s presenting symptoms when she telephoned to request a GP appointment. She was offered a routine phone appointment two weeks later. No further enquiries or referrals were made by the GP Practice. Mrs X was hospitalised the following day and underwent emergency surgery for aortic dissection. The Ombudsman found that there was an inadequate GP triage of Mrs Y’s symptoms when she contacted the GP Practice. Whilst her symptoms were not typical of aortic dissection, she presented with symptoms which were potentially serious in nature and required further exploration by a clinician that day, either over the phone or face to face. Because of the atypical nature of her symptoms, further enquiries about the nature of Mrs Y’s symptoms may not have resulted in her being diagnosed and admitted to hospital more quickly than actually occurred. However, an opportunity to properly consider her symptoms, and potentially have her condition identified at an earlier stage, was missed. The GP Practice also failed to give advice to Mrs Y as to what

Mrs X complained about the care provided to her later mother, Mrs Y, by the Health Board and the GP Practice following a fall, on 2 November 2018, at the care home where Mrs Y lived. The investigation considered whether the Trainee Advanced Nurse Practitioner (“TANP”) failed to appropriately examine Mrs Y on 5 November and therefore failed to identify that she had suffered a serious injury (diagnosed in hospital 4 days later as a left knee fracture). It also considered whether a GP at the GP Practice failed to send Mrs Y for an X-ray on the same date following a discussion with the TANP, and failed to visit Mrs Y to examine her. The Ombudsman found that the TANP failed to carry out an appropriate examination of Mrs Y and failed to keep appropriate records in relation to the examination and follow up with the GP. This complaint was upheld. The Ombudsman found that the GP’s approach to Mrs Y’s clinical situation was appropriate and that the decision not to send Mrs Y for an X-ray and to wait and see how she responded to an increase in pain relief was reasonable. In addition, as the TANP had examined Mrs Y and reported her findings to the GP, it was acceptable practice for the GP not to arrange a visit to examine Mrs Y. This complaint was not upheld. The Health Board accepted the Ombudsman’s recommendations to apologise to Mrs X for the identified failings and to remind the TANP of record keeping requirements in line with the standards of relevant clinical/nursing guidance.

Mr P complained that the Practice missed opportunities to diagnose his skin cancer at consultations in October and November 2019. The Ombudsman found that the Practice should have made an urgent specialist referral on 13 November 2019 and that this would have led to earlier diagnosis and treatment of Mr P’s skin cancer. It was not possible to say whether earlier detection would have avoided the need for Mr P to have neck surgery. However, he was denied this realistic opportunity, which was a significant injustice. Accordingly, the Ombudsman upheld the complaint. The Ombudsman recommended that the Practice should apologise to Mr P and make a redress payment of £500 in respect of the injustice caused to him. She also made recommendations to ensure that all GPs at the Practice are appropriately trained in assessing skin damage and providing appropriate follow up advice. The Ombudsman was pleased that the Practice agreed to accept these recommendations.

Miss A complained about the care provided by the Surgery for her late father, Mr B, during four telephone consultations between 17 and 29 July 2020 when he presented with symptoms of anxiety. Miss A said that, although Mr B’s symptoms worsened, the Surgery failed to offer a face-to-face appointment and prescribed medication without making appropriate physical health checks. In particular, the GP failed to consider that Mr B’s symptoms of shortness of breath and swollen ankles may be due to heart failure. Mr B was admitted to hospital on 2 August by the out-of-hours GP service and sadly died the next day due to worsening heart failure and pneumonia. The Ombudsman found that the latter two telephone consultations with the GP did not fall within the range of appropriate clinical practice as there were shortcomings in clinical assessment, prescribing and record keeping. Mr B should have been offered a face-to-face appointment in view of his symptoms and presentation and antibiotics should not have been prescribed. However, the Ombudsman could not say whether, but for the failings, Mr B would have been admitted to hospital or survived this episode of care. In response to Miss A’s complaint, the GP who provided Mr B’s care said that ongoing learning from the complaint was being already addressed through their annual medical appraisals (the process by which a doctor demonstrates that their knowledge is up to date, and they are fit to practise). The Surgery had also carried out a Significant Event Analysis (a method of reflective learning to analyse an episode of care for learning opportunities and to inform future practice). Although the Surgery had taken Miss A’s complaint seriously, the Ombudsman was concerned that it had not identified or acknowledged to Miss A that there were shortcomings in Mr B’s care. The Ombudsman’s provisional findings were shared with the Surgery, and it was asked to take some further action. The Surgery agreed to apologise to Miss A for the fail

Mr A complained about his late mother (Ms B)’s management and care and the GPs’ failure to see her face-to-face when she telephoned and raised concerns about weight loss and white patches over her gums and mouth. He was also dissatisfied with the robustness of the GP Practice’s complaint response. The Ombudsman was satisfied that the clinical failings by the GPs led to a delay in Ms B’s ongoing mouth symptoms being properly reviewed and assessed at a face-to-face consultation. The investigation found that the delays meant that a timely urgent suspected cancer (“USC”) referral to the Hospital’s Maxillofacial team had not been made by the GP Practice. This did not accord with clinical guidance. The Ombudsman also found shortcomings in the GP Practice’s record-keeping which meant that the USC referral did not provide a complete clinical picture in relation to the telephone calls that Ms B had made to the GP Practice regarding her symptoms. As it was not possible to say whether an earlier USC referral would have changed Ms B’s outcome or her treatment options this uncertainty was the injustice for Ms B, Mr A and the family. The Ombudsman also identified shortcomings in the GP Practice’s handling of Mr A’s complaint. Mr A’s complaint was upheld. The Ombudsman welcomed the steps taken by the GP Practice as part of learning from Mr A’s complaint to address the failings around clinical care and record-keeping. The GP Practice was asked to apologise to Mr A for the failings and to evidence the learning from Ms B’s case.

Ms X complained that she was dissatisfied with the response which the Practice had provided to her complaint. The Ombudsman noted that Ms X had asked the Practice to respond to several questions set out in her complaint letter. The Ombudsman was not satisfied that the Practice’s response had, in fact, adequately addressed all the issues raised. The Ombudsman considered it would be helpful for Ms X to receive a further written response. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to provide Ms X with a full written response within 30 working days.

Mr X complained about his experience with the Practice, who he considered to be transphobic. The Practice refused to prescribe hormones, requested by the local gender team, without seeking further clarification, but he had not received any update or response regarding this. Mr X was dissatisfied with the complaint response received, which did not include a salutation. Mr X wanted the Practice to refer to him by his legal name and title in correspondence. The Ombudsman found that although the Practice had provided a complaint response, this had raised further concerns and there were some elements which the Practice could respond to more fully. The outcome and reasons for the decisions in relation to prescribing testosterone had not been adequately communicated to Mr X. It seemed that the Practice could amend its systems to address Mr X by the name and salutation he requested. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to provide, within 20 working days, a further, more detailed complaint response addressing the concerns raised in the complaint to the Ombudsman, an update in relation to the Practice issuing the testosterone prescription and to review the Practice’s systems and processes to ensure that Mr X is addressed using the correct salutation and name, as requested, in all correspondence. The Ombudsman accepted this as a resolution to the complaint.

Ms X complained about the poor service she had received from a GP Practice in the area of Betsi Cadawaladr University Health Board. In making enquiries with the Practice, the Ombudsman was concerned that it had not formally responded to Ms X’s complaint despite receiving a complaint in writing from her. The Ombudsman asked the Practice to undertake the following in settlement of the complaint by 22 August 2022: a) Apologise to Ms X for failing to respond formally to her complaint b) Provide Ms X with a formal complaint response addressing the issues raised by her.

Mrs X complained about the way the Surgery handled her complaint about the attitude of a nurse at her cervical smear appointment. The Ombudsman found that whilst the Surgery had provided a response to Mrs X’s initial complaint, it had failed to respond to Mrs X’s further letter dated 23 May 2022. The Surgery agreed to complete the following in settlement of Mrs X’s complaint by 19 July 2022, as an alternative to the Ombudsman investigating it: a) Provide a response to Mrs X’s letter dated 23 May 2022 b) Review its complaints handling process and use this as learning tool.

Mrs G complained that for 4 years, the Practice had prescribed the wrong steroid cream making her lichen sclerosis (“LS” – a chronic inflammatory skin disorder that affects the genital area) worse and causing her constant pain. Mrs G also complained that the Health Board’s complaint response repeated the Practice’s comments, and it did not carry out an investigation into her concerns. The Ombudsman’s investigation found that the Practice had confused the names of steroid creams and Mrs G had been prescribed, at times, a different, less potent cream to that which had been prescribed by her Dermatologist. This was a service failure. However, the Ombudsman also concluded that guidance at the time suggested LS should not be treated in perpetuity with the strongest steroid cream and that at times using a less potent steroid cream was reasonable. Therefore, whilst the Ombudsman could not be precise about the significance of the injustice to Mrs G, the changes in steroid cream were not at the behest of the Dermatologist, and so it was difficult to evaluate accurately the effectiveness of the creams on Mrs G’s LS. The Ombudsman upheld this part of the complaint. The Ombudsman was satisfied with the Health Board’s complaint response as the information contained with its letter, provided by the Practice, was correct at the time, and it had consulted its Head of Pharmacy before responding. It was not until the Ombudsman began their investigation that the Practice accepted that it had confused the steroid creams. The Ombudsman did not uphold this aspect of Mrs G’s complaint. The Ombudsman recommended that the Practice apologise to Mrs G and provide assurances that it was taking steps to ensure errors like this do not happen again. The Practice agreed to the recommendations.

Miss X complained that the Surgery had not responded to her complaint regarding her concerns to do with her complex autoimmune illness. The Ombudsman decided that the Surgery should provide Miss X with a written response (within 3 weeks), which should include an apology for the confusion in not identifying her email to be a complaint. The Ombudsman considered this to be an appropriate resolution to the complaint instead of conducting an investigation.

Mrs X complained that the Practice had not responded to a follow-up letter that she had sent in relation to her complaint in June 2021. The Practice accepted that there had been delay in responding due to the pressures on the service. It agreed to provide a formal written response within 3 weeks.

Mr A complained about a suggestion of a Surgery in the area of Betsi Cadwaladr University Health Board (“the Surgery”) that he should leave, when the doctor concerned, in her complaints responses, had admitted to breaches of confidentiality; had not explained the medicine to him in full; that she had not present herself during a telephone consultation and had admitted to having an inappropriate discussion with his wife over the telephone. The assessment found that the Practice had responded reasonably to the complaint about one of the breaches of confidentiality and the failure of the doctor concerned to present herself, by apologizing and taking appropriate steps to avoid such instances from happening again in the future. The complaint regarding the lack of explanation in regard to the medication was not justified, as it was the correct medicine and any associated injustice was very limited. Regarding the inappropriate conversation with Mr A’s wife (and the alleged second breach of confidentiality), to resolve the complaint, the doctor concerned agreed to apologize for the distress caused by the conversation. The Surgery agreed to confirm that Mr A can continue to be a patient of Surgery and that they were only suggesting in the writing response referring to registering with another local practice. The Surgery agreed to take the relevant action within 2 months.

Mrs A complained about poor communication and complaint handling by the GPs and a GP Practice in the area of Betsi Cadwaladr University Health Board (“the GP Practice”) and a failure to arrange an informal meeting for months despite her repeated requests. Although the Ombudsman’s investigation found there was a delay in the GP Practice responding to Mrs A’s concerns, this was due to the GP Practice needing to consider further correspondence sent by Mrs A and her husband. The Ombudsman was of the view that it would have been better for the GP Practice to have contacted Mrs A to advise her that its ability to respond within the timescale previously provided would not be met. That said the Ombudsman did not consider the delay caused Mrs A any significant injustice. The Ombudsman noted that the GP Practice Manager had requested certain information from Mrs A on receipt of which she would arrange a meeting. However, there was no record of the information having been received by the GP Practice. The Ombudsman did not uphold these parts of Mrs A’s complaint.