PSOW Individual Decisions

Mrs A complained about Welsh Ambulance Services NHS Trust (“WAST”) and Swansea Bay University Health Board (“the Health Board”). The investigation considered Mrs A’s complaint about the care her late husband, Mr B, received from WAST. Mrs A complained about the delay in an ambulance arriving following her 999 calls and questioned whether the 999 calls were correctly categorised. She also complained that a further delay in transporting Mr B to the Emergency Department (“ED”) at Morriston hospital (“the Hospital”) affected his prognosis. In relation to the Health Board, the investigation considered whether the care provided to Mr B was timely and appropriate and a failure to communicate her husband’s deteriorating condition meant that she was unable to be with him during his final hours. The investigation found that the 999 calls to WAST were correctly categorised and appropriately prioritised and that the delay in an ambulance reaching Mr B was outside of WAST’s control due to the pressure on its services. The Ombudsman did not uphold this part of Mrs A’s complaint. The investigation found a missed opportunity to recognise Mr B’s heart failure and change the treatment regime and consider further treatment intervention. That said the Ombudsman was satisfied that it was extremely unlikely that, had Mr B been taken to hospital earlier and heart failure treatment had started sooner, the outcome would have changed. The investigation concluded that the lack of a documented reason for the paramedic delay and the lack of timeliness in transporting Mr B to the Hospital was not reasonable or appropriate and, to that extent, represented a service failure which caused distress and upset to Mrs A, and her complaint was upheld to a limited extent. In relation to Mrs A’s complaint about the Health Board and the care Mr B had received in Hospital, the investigation concluded that the care provided to Mr B was timely and appropriate and therefore the Ombudsman did not uphold the comp

Mrs Z complained about the care and treatment that she had received from Swansea Bay University Health Board. The investigation considered whether there was a failure to assess Mrs Z’s injury properly when she attended hospital, which led to a failure to diagnose a hamstring tear, and if this led to Mrs Z not being referred for more timely management and treatment of her injury. The investigation also considered whether Mrs Z’s complaint to the Health Board was handled appropriately. The investigation found that the assessment Mrs Z underwent when she attended hospital was appropriate and that a diagnosis was made in line with relevant guidelines. This aspect of Mrs Z’s complaint was not upheld. Mrs Z was not referred for timely management and treatment of her injury, but this was due to an insufficiently detailed discharge summary, not a failure to diagnose her injury appropriately. This part of Mrs Z’s complaint was partially upheld. Mrs Z received a response to her complaint in line with the relevant regulations. This part of Mrs Z’s complaint was not upheld. The Ombudsman recommended that the Health Board apologise to Mrs Z for the failure to complete a sufficiently detailed discharge summary, and to offer her a payment of £125 in recognition of the delay this has caused in her receiving appropriate treatment for her injury. The Ombudsman also recommended that the Health Board remind the doctor that treated Mrs Z of the importance of completing sufficiently detailed discharge summaries.

Mr A complained about the care and treatment provided by Swansea Bay University Health Board (“the Health Board”) after he accidentally cut his left index finger with a utility knife. In particular, he said that the Health Board failed to prescribe appropriate antibiotics to prevent an infection at the time of surgery to repair the cut. Mr A said that this resulted in his wound becoming infected and the eventual loss of his finger. The investigation concluded that the decision not to prescribe Mr A antibiotics at the time of surgery was correct, as the wound did not appear to be infected at that time. Missed opportunities were identified to prevent an infection occurring and to recognise that Mr A’s wound may have become infected. As such Mr A’s complaint was partially upheld. As a result of these failings the Health Board agreed to apologise to Mr A and offer him a payment of £750. The Health Board also agreed to refer Mr A for consideration of a prosthetic to replace his amputated finger, remind staff involved in Mr A’s care of the importance of keeping accurate records and ensure that clinicians responsible for would assessment and management are appropriately trained.

Mrs B complained to Swansea Bay University Health Board (“the Health Board”) about the care and treatment provided to her late mother. Following receipt of the Health Board’s complaint response, Mrs B remained dissatisfied, as not all issues she had raised had been addressed. The Ombudsman found that the Health Board had not provided a response to Mrs B about her concerns that her mother’s hospital call bell had not been responded to by nursing staff. The Ombudsman sought and gained the Health Board’s agreement to provide a further complaint response to Mrs B, specifically addressing this issue, within 20 working days.

We investigated complaints made by Mr A about his treatment by his Dental Practice. These consisted of whether the decision to remove a tooth was appropriate given the information known at the time, if Mr A should have been referred to a consultant earlier, and if the decision made not to treat Mr A owing to him being a high-risk patient, was appropriate and in line with relevant guidance. After the investigation had started, Mr A contacted the Ombudsman to state that he had since gone back to the Practice to ask for treatment but was refused because he had made a complaint. The Ombudsman therefore used her own initiative powers to expand the investigation and include 2 further heads of complaint. These considered whether it was reasonable for the Practice to refuse Mr A treatment because of the complaint he had referred to the Ombudsman, and, whether, in determining that future treatment be refused to Mr A, the Practice had failed to inform him appropriately of its decision. The investigation found that although some communication around Mr A’s treatment and changes to dental contracts could perhaps, have been explained better, ultimately Mr A’s dental treatment was appropriate for his presenting symptoms and in-line with relevant guidance. Therefore, these elements of his complaint were not upheld. However, the investigation found that the subsequent decision to refuse to see Mr A as a patient after he had made a complaint, and the way this was communicated to him was not in-line with relevant complaint handling standards, which was an injustice to him. These aspects of the complaint were therefore upheld. The Ombudsman therefore recommended that the Practice should apologise to Mr A for the failings identified and offer him £500 in recognition of the injustice caused to him. She also recommended that it should review its complaint handling practices to ensure that they are in-line with relevant Regulations and “Putting Things Right”, and invite the Health Board t

We investigated complaints made by Mr A about his treatment by his Dental Practice. These consisted of whether the decision to remove a tooth was appropriate given the information known at the time, if Mr A should have been referred to a consultant earlier, and if the decision made not to treat Mr A owing to him being a high-risk patient, was appropriate and in line with relevant guidance. After the investigation had started, Mr A contacted the Ombudsman to state that he had since gone back to the Practice to ask for treatment but was refused because he had made a complaint. The Ombudsman therefore used her own initiative powers to expand the investigation and include 2 further heads of complaint. These considered whether it was reasonable for the Practice to refuse Mr A treatment because of the complaint he had referred to the Ombudsman, and, whether, in determining that future treatment be refused to Mr A, the Practice had failed to inform him appropriately of its decision. The investigation found that although some communication around Mr A’s treatment and changes to dental contracts could perhaps, have been explained better, ultimately Mr A’s dental treatment was appropriate for his presenting symptoms and in-line with relevant guidance. Therefore, these elements of his complaint were not upheld. However, the investigation found that the subsequent decision to refuse to see Mr A as a patient after he had made a complaint, and the way this was communicated to him was not in-line with relevant complaint handling standards, which was an injustice to him. These aspects of the complaint were therefore upheld. The Ombudsman therefore recommended that the Practice should apologise to Mr A for the failings identified and offer him £500 in recognition of the injustice caused to him. She also recommended that it should review its complaint handling practices to ensure that they are in-line with relevant Regulations and “Putting Things Right”, and invite the Health Board t

Miss X complained that a Dental Practice in the area of Swansea Bay University Health Board had failed to respond to her complaint about being deregistered from the Practice. Miss X had made her complaint in September 2023. The Ombudsman found that the Practice had failed to respond to Miss X’s complaint and had not properly updated her during the delay. The Ombudsman said this caused frustration for Miss X and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to apologise and explain the reasons for the delay to Miss X, to offer her £50 in recognition of the complaint handling delay and failure to update Miss X, and to issue its complaint response within 4 weeks.

Mrs C complained on behalf of her husband Mr C, that he had waited a long time for orthopaedic surgery and that their understanding of how he would be treated was not managed well regarding the pre-operative assessments. The waiting time for orthopaedic surgery at the Health Board is more than 4 years. The Health Board had issues including not enough staff, not enough suitable places to operate, unclear management arrangements, and unclear processes for these operations. The Ombudsman identified that in this and 2 other cases, in addition to the long delays experienced by all patients awaiting orthopaedic surgery, the complainants had been treated unfairly because of errors in the way the waiting lists were managed. These issues raised the Ombudsman’s concerns about how the waiting list has been managed. Mr C, who had been assessed as needing surgery within a month, waited 43 months (3 years 7 months) for surgery in severe pain. During that time his position on the waiting list was reset in error and he was also removed from the list in error. Mr C was also put through the stress and pain of pre-operative assessments when the Health Board would have been aware that it was unable to provide surgery before the pre-operative assessment expired, but it failed to take this into account or tell Mr C. The Ombudsman noted that the Health Board has taken action to address the length of its waiting lists so made no recommendations about that. However, because of the issues identified she has asked the Health Board to review the decisions it made in respect of Mr C. The Health Board was also asked to audit the whole of its waiting list to establish whether errors had been made on the waiting list times or improper removal from the list for other patients and if so, it should apologise to those patients and correct the errors.

Mrs B said that she had waited a long time for orthopaedic surgery and that her understanding of how she would be treated was not managed well regarding the pre-operative assessments. The waiting time for orthopaedic surgery at the Health Board is more than 4 years. The Health Board had issues including not enough staff, not enough suitable places to operate, unclear management arrangements, and unclear processes for these operations. The Ombudsman identified that in this and 2 other cases, in addition to the long delays experienced by all patients awaiting orthopaedic surgery, the complainants had been treated unfairly because of errors in the way the waiting lists were managed. These issues raised the Ombudsman’s concerns about how the waiting list has been managed. Mrs B was referred in 2018 for right hip pain and again in 2021 for left hip pain. The referral for her left hip was closed in error, but in 2023 her left hip was treated (instead of her right hip as it was clinically worse) and she was removed from the waiting list for her right hip, even though this still required treatment. She continues to experience severe pain in her right hip 5 years after initial referral and is still waiting for it to be operated on. Mrs B was also put through the stress and pain of a pre-operative assessment, which raised her hopes that surgery would happen soon. This was due to an administrative error. The Ombudsman noted that the Health Board has taken action to address the length of its waiting lists so made no recommendations about that. However, because of the waiting time issues identified, she has asked the Health Board to review the decisions it made in respect of Mrs B and her position on the waiting list. The Health Board was also asked to audit the whole of its waiting list to establish whether errors had been made on the waiting list times or improper removal from the list for other patients and if so, it should apologise to those patients and correct the errors.

Mr D complained that he had waited a long time for orthopaedic surgery and that his understanding of how he would be treated was not managed well regarding the pre-operative assessments. The waiting time for orthopaedic surgery at the Health Board is more than 4 years. The Health Board had issues including not enough staff, not enough suitable places to operate, unclear management arrangements, and unclear processes for these operations. The Ombudsman identified that in this and 2 other cases, in addition to the long delays experienced by all patients awaiting orthopaedic surgery, the complainants had been treated unfairly because of errors in the way the waiting lists were managed. These issues raised the Ombudsman’s concerns about how the waiting list has been managed. Mr D was removed from the waiting list when he missed surgical appointments because he was in hospital for another illness. Despite provision in the guidance for this type of situation, Mr D was removed from the list and is waiting to be “treated in turn” which appears to be outside of the process. 65 months (5 and a half years) after being added to the list for surgery, he is still waiting for treatment. He is in a lot of pain, and this has affected his wellbeing significantly. Mr D was also put through the stress and pain of pre-operative assessments, which had raised his hopes that surgery would happen soon when the Health Board would have been aware that it was unable to provide surgery before the pre-operative assessment expired. It failed to take this into account or tell the patients. The Ombudsman noted that the Health Board has taken action to address the length of its waiting lists so made no recommendations about that. However, because of the issues identified she has asked the Health Board to review the decisions it made in respect of Mr D. The Health Board was also asked to audit the whole of its waiting list to establish whether errors had been made on the waiting list times or imprope

Mr A complained about the Health Board’s response to his complaint about his hip pain. He said that following the complaint response, he had not received clarity about the timescales for his hip surgery. The Ombudsman found that the Health Board had not formally responded to Mr A with confirmation of the current waiting time for surgery, together with Mr A’s current position on the waiting list. The Ombudsman sought and gained the Health Board’s agreement to provide Mr A with an update the current waiting time for surgery, together with his current position on the waiting list, within 10 working days.

Mrs B complained that Swansea Bay University Health Board had failed to provide a response to the complaint she had made to it in February2023. The Ombudsman found that the Health Board had failed to provide a complaint response or meaningful updates to Mrs B. The Ombudsman said this caused frustration for Mrs B. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise for the delay, explain the reasons for the delay, offer a payment of £100 to Mrs B and to issue the complaint response within 6 weeks.

Ms K complained about the treatment her late mother, Mrs L, received from Swansea Bay University Health Board (“the First Health Board”) and Hywel Dda University Health Board (“the Second Health Board”). In particular, she said that: The First Health Board • Failed to diagnose and treat Mrs L’s cancer in a timely manner and that the failure to operate sooner resulted in her premature death. • Failed to provide Mrs L and her family with an adequate level of information regarding her test results and treatment options. The Second Health Board • Failed to keep Mrs L informed as to the extent of her cancer and its clinical progression and provided conflicting information regarding surgery and treatment options. • Failed to provide Mrs L with appropriate medication and nutrition prior to her death. The Ombudsman’s investigation found the following: The First Health Board • Although the Welsh Government’s Suspected Cancer Pathway timeframe was missed, the First Health Board failed to take proactive action when a procedure could not take place due to a lack of anaesthetists. This delay meant there was a significant impact for Mrs L in that there was poor local tumour control which was the predominant cause of her cancer related symptoms. • There was a delay in Mrs L being given information about liver metastases as there were opportunities missed to communicate this information at an earlier stage. Both of these parts of the complaint were upheld. The Second Health Board • Although Mrs L received appropriate treatment and interventions, communication was poor with her family, national guidelines were not followed and there was confusion as to why certain decisions were made. In addition, a drug error was not reported to the family until after Mrs L’s death. This part of the complaint was upheld. • Mrs L was provided with appropriate medication and nutrition prior to her death. This part of the complaint was not upheld. The Ombudsman recommended that both health boards apol

Ms K complained about the treatment her late mother, Mrs L, received from Swansea Bay University Health Board (“the First Health Board”) and Hywel Dda University Health Board (“the Second Health Board”). In particular, she said that: The First Health Board • Failed to diagnose and treat Mrs L’s cancer in a timely manner and that the failure to operate sooner resulted in her premature death. • Failed to provide Mrs L and her family with an adequate level of information regarding her test results and treatment options. The Second Health Board • Failed to keep Mrs L informed as to the extent of her cancer and its clinical progression and provided conflicting information regarding surgery and treatment options. • Failed to provide Mrs L with appropriate medication and nutrition prior to her death. The Ombudsman’s investigation found the following: The First Health Board • Although the Welsh Government’s Suspected Cancer Pathway timeframe was missed, the First Health Board failed to take proactive action when a procedure could not take place due to a lack of anaesthetists. This delay meant there was a significant impact for Mrs L in that there was poor local tumour control which was the predominant cause of her cancer related symptoms. • There was a delay in Mrs L being given information about liver metastases as there were opportunities missed to communicate this information at an earlier stage. Both of these parts of the complaint were upheld. The Second Health Board • Although Mrs L received appropriate treatment and interventions, communication was poor with her family, national guidelines were not followed and there was confusion as to why certain decisions were made. In addition, a drug error was not reported to the family until after Mrs L’s death. This part of the complaint was upheld. • Mrs L was provided with appropriate medication and nutrition prior to her death. This part of the complaint was not upheld. The Ombudsman recommended that both health boards apol

Mrs A complained that her late father-in-law’s, Mr B, multiple discharges from the Assessment Units of both Singleton and Morriston Hospitals between 14 August and 31 August 2020 were not appropriate. She also complained that as part of discharge planning, communication with both the family and the residential Care Home was inadequate. The investigation found that the level of care that Mr B received in relation to his blood sodium level (salt levels in the blood) at each of his 3 admissions fell below the standard expected. The reasons for this included insufficient monitoring and investigation of Mr B’s low sodium levels. In addition, looking at each discharge in isolation, more could have been done to address the deterioration in Mr B’s walking ability. The investigation also identified that communication could have been better and more effective than it was, including around documentation and the discharge process. The investigation found that the clinical failings identified amounted to service failings and the administrative failings around documentation was maladministrative. Whilst Mr B’s final outcome might not necessarily have changed, Mrs A and the family would have to live with the fact that aspects of Mr B’s care were not reasonable or appropriate, as well as the ensuing distress that his multiple discharges had caused them. This was the injustice to Mrs A and the family. Mrs A’s complaints were upheld. The recommendations made included the Health Board apologising in writing to Mrs A for the failings identified, especially around Mr B’s low sodium levels during his 3 admissions. The Health Board was also asked to remind staff about the need to complete the discharge checklist.

Mrs S complained that despite raising her concerns with Swansea Bay University Health Board in May 2023, she had not received a complaint response. The Ombudsman found that the Health Board had not acted in line with its statutory complaint’s procedure, and failed to provide meaningful updates to Mrs S. She said this caused frustration and uncertainty to Mrs S. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Mrs S with an apology and explanation for the delay and issue a formal complaint response within 6 weeks.

Mr A complained about whether the Health Board appropriately considered his mother’s case as part of its nosocomial review process (a process set up by Welsh Government for Health Boards to review cases where a patient may have contracted Covid-19 in hospital) and in line with the National Framework and any other relevant policies/procedures. The investigation found that, although the review carried out by the Health Board into the care supplied to the complainant’s mother concluded it was reasonable, the explanation about how that decision had been reached was insufficiently detailed. The decision that there was no breach of duty and no qualifying liability was also not explained. The Health Board had reached a decision to revise the content of decision letters to improve the way it communicated key issues, in light of issues raised by the Ombudsman. However, given the timing of the complaint, this improvement did not impact the complainant’s case. The Ombudsman therefore reached an agreement with the Health Board for it to carry out afresh, thorough, nosocomial review, to include consideration of nosocomial, duty of care and qualifying liability issues. When that had been concluded, the Health Board agreed to write to the complainant to provide a fulsome explanation of the reasons for its decision within 6 weeks of the closure of the complaint.

Ms A complained about how the Practice had off listed her and handled her complaint about that matter. The Ombudsman had previously addressed the Practice’s failure to respond to Ms A’s complaint through an early resolution decision. However, the Ombudsman was concerned that the Practice had failed to demonstrate that it had provided Ms A with the necessary warning within 1 year before her off listing. This amounted to maladministration on the part of the Practice which caused Ms A an injustice. Instead of investigating the complaint, the Ombudsman obtained the Practice’s agreement to provide Ms A with a meaningful apology for failing to warn her that she may be removed from the Practice’s patient list and to undertake a lesson learning exercise so that the off listing procedure would be correctly followed in future. The Practice agreed to do this within 1 month.

Mrs A complained to the Health Board about the delay on the part of its Mental Health Service in getting her mother the correct urgent medical attention and required nursing care, whilst she was resident in a care home. In her complaint submission to the Ombudsman, Mrs A said that she disagreed that the Health Board had followed The National Health Services (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 (“the Regulations”) in its investigation of her complaint. The Ombudsman found that the complaint response from the Health Board did not comply with the Regulations. It failed to specifically address Mrs A’s complaint about delays on the part of the Health Board in getting her mother medical/nursing care, and it appeared to be a chronology of events only. Further, it did not comment on whether the Health Board considered that there were missed opportunities to intervene in her mother’s care, or if the deterioration in her mother’s physical condition were noted at the time of the visits from the Health Board staff. Additionally, it made no comment on whether there was any qualifying liability on the part of the Health Board, which the Regulations stipulate that the response should include. The Ombudsman sought and gained the Health Board’s agreement to provide Mrs A with a response to her complaint, in accordance with the Regulations, within 20 working days.

Ms A complained about the care and treatment provided to her father whilst in hospital. She felt that her father was discharged too soon and the family were not aware of the full extent of his condition. Although the Health Board responded to her complaint, following receipt of her father’s medical records, she said it caused more questions to be raised concerning his general decline, diet, diagnosis, discharge and the Health Board’s record keeping. The Ombudsman was concerned to note Ms A’s further concerns and considered it would be helpful for her to receive a response. As an alternative to investigating the complaint, the Ombudsman made a recommendation which the Health Board agreed to implement. The Health Board agreed to review the medical records and provide a response to Ms A’s additional concerns within 20 working days.

Ms C complained about her father, Mr A’s care and treatment when he was taken to Morriston Hospital’s (“the Hospital”) emergency department (“the ED”) in September 2020. She was concerned that the correct stroke pathway had not been followed and a CT scan was not carried out. She was also dissatisfied that the Hospital had not responded to her concerns about her father’s deteriorating level of consciousness and his need for an urgent assessment. Finally, she was unhappy with the Health Board’s handling of her complaint. The Ombudsman’s investigation concluded that it was not unreasonable to have diagnosed Mr A with a possible UTI on admission. While Ms C’s concerns about her father’s deteriorating consciousness the following day should have been escalated by the nurse for medical review at the time, and could have led to Mr A being reviewed sooner, the investigation concluded that the additional time delay had no impact on Mr A’s prognosis. These parts of Ms C’s complaint were not upheld. The investigation did find that a CT head scan should have been carried out on admission as there was evidence to suspect a stroke. This resulted in uncertainty for the family as to whether an earlier CT scan might have revealed an intra-cerebral bleed and therefore Mr A’s prognosis might have been different. The investigation also found shortcomings around complaint handling, and the robustness of the complaint response, had caused Ms C an injustice as she had to complain further in order to get answers. This had added to her distress. The Ombudsman therefore upheld these aspects of the complaint. As well as apologising to Mr A and Ms C for the failings identified, the Health Board was asked to facilitate learning from Ms C’s complaint, which included discussing Mr A’s case in an anonymised form at an appropriate clinical forum.

Mrs A complained about the care she received from the Health Board, in particular that she had to wait an unacceptably long time for orthopaedic surgery when taking account of her clinical need, and the impact her condition was having on her daily life. She also complained that a review of her condition should have occurred sooner, so any deterioration could have been taken into account in determining her priority for surgery. The investigation found significant deficiencies in the Health Board’s delivery of orthopaedic services, which caused Mrs A an injustice, due to the time she waited for her treatment and the pain and inconvenience she experienced. This aspect of the complaint was therefore upheld. However, the investigation also found that although the X-rays arranged to re-assess Mrs A’s categorisation for surgery took place outside the target period of 8 weeks, this was not unreasonable, given that the time period spanned the Christmas break and COVID-19 restrictions contributed to the delay. The second aspect was not upheld. The Health Board agreed to the Ombudsman’s recommendations to apologise to Mrs A for the service failure identified in this report. It also agreed to pay Mrs A £500 in recognition of the injustice and distress caused to her by its failure to explore solutions to its known waiting list position sooner, and for her time and trouble in pursuing this complaint.

Mrs E complained that Swansea Bay University Health Board failed to provide a response to her concerns about the care and treatment provided following her smear test which showed high grade changes. The Ombudsman found that the Health Board failed to provide regular and meaningful updates to Mrs E. She said that this caused frustration and uncertainty to Mrs E. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Boards agreement to write to Mrs E with an apology and explanation for the failure and to issue a complaint response within 5 weeks.

Mr P complained that Swansea Bay University Health Board failed to provide a response to his complaint. The Ombudsman found that whilst the Health Board had responded to Mr P’s initial enquiry it had not provided a response to his second email. She said that this caused frustration and uncertainty to Mr P. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide an apology and explanation to Mr P for this oversight and issue a response within 1 week.

Mr A’s complained about care and treatment that his late wife received from a GP Practice in the area of Swansea Bay University Health Board (“the Practice”) in October 2021. Specifically, Mr A complained that his wife should have been admitted to hospital following consultations with a GP between 25 October 2021 and 29 October 2021, and whether the GP may have missed the symptoms of sepsis which might have given his wife a better chance of survival. The Ombudsman found that the care and treatment provided by the Practice was clinically appropriate at each of the consultations during the period, with suitable examinations undertaken. She noted that the timing of the consultations and the changes in the provision of healthcare as a result of the global blood collection tube shortage at the end of 2021 was likely to have been an important factor in the GP’s decision making, which was considered to be within the range of appropriate clinical practice. Mr A’s complaint about the GP Practice was therefore not upheld.