PSOW Individual Decisions

Professor X complained that she had not been able to book an appointment at the Surgery for her partner, and had not received a response to her complaint. The Ombudsman was concerned about delays Professor X had experienced, that she had not received a response to her complaint, and had therefore been inconvenienced by the Surgery’s actions. She decided to settle the complain without an investigation. The Ombudsman sought and gained the Surgery’s agreement to: • Provide Professor X with an apology for the delay in responding to her complaint • Provide Professor X with an explanation for the delay • Provide Professor X with a complaint response by 13 May 2022 4 May 2022

Mr X’s complaint related to the care and treatment that his late son, Mr Y, received from a GP Practice in the area of Swansea Bay University Health Board following his diagnosis of chronic pancreatitis in February 2017. Specifically, Mr X complained about the GP Practice’s management of his son’s condition, which included concerns surrounding the adequacy and monitoring of pain relief, the lack of action taken on receipt of 3 photographs and a “Do Not Resuscitate” letter on separate occasions, and whether appropriate referrals to hospital to investigate, by way of scans, the severity of his pain had been made. Mr X also raised concerns about 2consultations in particular that occurred a few days before Mr Y’s death. Lastly, Mr X complained that the GP Practice had discriminated against his son on the basis of him being a recovering alcoholic. The Ombudsman concluded that the GP Practice took reasonable and appropriate actions to try to manage Mr Y’s pain levels, and that his pain relief medication was appropriately monitored with reasonable explanations about its usage having been given to him. The Ombudsman also found no evidence to indicate that the GP Practice had failed to make appropriate referrals for the purpose of investigating the severity of Mr Y’s pain, particularly as he was already under the care of appropriate specialists in secondary care. Following on from this, the Ombudsman also concluded that the GP Practice had acted appropriately on receipt of Mr Y’s letter indicating that he did not want to be resuscitated. Although the Senior Partner had stated that he could not recall being shown the photographs of Mr Y by his mother, and that these photographs were not referenced within Mr Y’s medical records, the Ombudsman noted that there had nevertheless been no concerns with the management of Mr Y’s pain at any point during the period under review. As a result, the Ombudsman did not uphold these complaints. Given that there was no evidence that the GP Pr

Mr D complained about the care and treatment provided by the GP Practice to his late sister, Ms E, in the weeks leading up to her death in February 2020, and about the difficulties he had experienced in making appointments for Ms E. Ms E had undergone surgery and chemo-radiotherapy for advanced stomach cancer in 2017; although the chance of relapse was quite high, she had no gastrointestinal symptoms when she was last reviewed by a consultant surgeon in April 2019. The Ombudsman could not reach a conclusion regarding what Mr D said about making appointments for Ms E, as the Practice could not provide any records or information about this. The Ombudsman found that the GP should have considered that Ms E’s abdominal symptoms might have been related to her previous stomach cancer when he saw her on 29 January, rather than diagnosing and treating her for viral gastroenteritis. Had he done so, or given Ms E appropriate “safety netting” advice (to be alert to symptoms which would indicate her condition was worsening and what to do in those circumstances), it was possible that Ms E would have been referred to Gastroenterology or admitted to hospital before her death. However, it was unlikely that Ms E would have lived significantly longer, and thus Ms E had not sustained any injustice as a result of the failings. Therefore, the Ombudsman did not uphold the complaint.

Mrs A complained about the care and treatment that Mrs X received at the Care Home between February and March 2017. Mrs X was unable to make decisions about her treatment and care arrangements. Mrs A complained that the Care Home failed to treat Mrs X’s chest and urine infections, failed to notify the immediate family she was seriously ill until it considered she was going to die, misdiagnosed her, withheld treatment, food and fluid, actively encouraged the family to let her die and failed to notify social services of the aforementioned. The investigation found that it was appropriate for the Care Home to rely on the diagnosis and treatment plan formulated by the GP. Appropriate attempts were made by the nursing staff to administer treatment in accordance with the instruction of the GP and any omissions were a consequence of safety concerns. Timely contact was made with the immediate family, appropriate updates were given and their concerns were relayed to the GP. The Care Home did not withhold food and fluid however due to the lack of documentary evidence, the investigation could not determine whether the amounts offered were appropriate to meet her dietary needs and so this aspect of the complaint was partially upheld. There was no evidence to suggest that the Care Home staff “actively encouraged” the immediate family to let Mrs X die; rather an accurate and frank description of the clinical situation and advice was given. There was no contractual obligation for the Care Home to keep social services updated unless there were safeguarding concerns. The Care Home agreed to provide Mrs A with an apology for the failings identified. It also agreed to undertake an audit and any action necessary in response to the audit findings to ensure compliance with the completion of approved electronic fluid and food charts. Mrs A complained about the primary care service provided to Mrs X by the GP Practice. In particular, the appropriateness of the assessments and investigations

Mrs A complained that despite sending three reminder letters, the Practice had failed to respond to her complaint made in September 2020. The Ombudsman was concerned that Mrs A had not received a complaint response. He decided to settle with complaint without an investigation. The Ombudsman sought the Practice’s agreement to, by the end of the week, provide an apology, complaints response and Practice Manager’s direct contact number, to avoid future communication difficulties.

Mr Y complained that a GP Practice in the area of Swansea Bay University Health Board (“the Practice”) incorrectly removed him for its patient list at the end of 2020. He said the Practice failed to give him a written warning, failed to give him a reason for the decision to remove him from the patient list and failed to arrange an informal meeting with him to discuss the Practice’s decision. The National Health Service (General Medical Contracts) (Wales) Regulations 2004 (“the Regulations”) outline the circumstances when a patient can be removed from a GP practice list. The Ombudsman found that the decision to remove Mr Y from the Practice list was in accordance with the Regulations as was the decision not to give him a reason for the decision to remove him. However, the Practice should have documented a statement of reasons for Mr Y’s removal, the grounds why it felt it was not appropriate for a specific reason to be given to Mr Y, notified him that he was being removed from the patient list and explained to him that it was not required to give specific reasons for the decision. This was maladministration which caused Mr Y an injustice as the Practice failed to notify him of the decision to remove him from its patient list. The Practice was not required under the Regulations to arrange an informal meeting with Mr Y. The Ombudsman upheld the complaint to the extent that the Practice should have written to Mr Y to confirm that he was being removed from its patient list. The Practice agreed to apologise to Mr Y for not notifying him of the decision to remove him from its patient list, review the application of the Regulations in relation to patient removal and review its removal policy.

Mr X complained about the poor care and treatment he had received from a GP practice in the area of Swansea Bay University Health Board (“the Practice”). He was unhappy that he had not received a response to his complaint. In making enquiries with the Practice, the Ombudsman was advised that a response was in the process of being prepared. The Ombudsman decided to settle the matter without an investigation. In settlement of the complaint the Practice agreed to, By 30 November 2021 a) Provide Mr X with an apology for the delay in responding to his complaint b) Provide Mr X with a detailed complaint response

Mrs X complained that a GP Practice in the area of Swansea Bay University Health Board (“the Practice”) had failed to provide a written response to her formal complaint in accordance with the Putting Things Right Regulations 2011. Following discussions with the Ombudsman, the Practice agreed to meet with Mrs X and her advocate to fully explain the reasons why it had not formally responded and to discuss her concerns. Following this, it agreed to provide a formal written response in accordance with Putting Things Right.

Ms X complaint that about a GP Surgery’s, in the area of Swansea Bay University Health Board, handling of her complaint. In particular, Ms X complained that the GP Surgery’s complaint response contained derogatory comments about Ms X. The GP Surgery agreed to provide Ms X with a fulsome written apology for the delay in its complaint handling errors and comments. The GP Surgery agreed to offer Ms X the opportunity of a complaint meeting to discuss any outstanding concerns relating to her complaint. Finally, the GP Surgery agreed to update its complaint policy to include a responsible officer for dealing with complaints and set out, in its complaint policy, an alternative member of staff (appropriately senior) to handle any complaints directed at the responsible officer. The Ombudsman considered this to be an appropriate settlement.