PSOW Individual Decisions

Mr C complained on behalf of his late mother, Mrs A, about the care and treatment she received from her GP Practice. The investigation considered whether the management of Mrs A’s back pain from February to July 2023 was clinically appropriate. Mr C also complained about the care and treatment Mrs A received from the Health Board. However, the Health Board chose not to investigate this complaint. The Ombudsman used her discretion to investigate the matter without the Health Board having provided a response. The investigation considered whether Mrs A’s care and treatment during her first admission on 31 March 2023 was clinically appropriate and whether there should have been a follow-up. The investigation also considered whether the management of referrals from Mrs A’s GP by the Health Board was appropriate between February 2023 and her second admission on 17 July 2023. The investigation found that the management of Mrs A’s back pain by the Practice did not reach an appropriate standard, as red flags that might have indicated Mrs A’s cancer were not identified. The Ombudsman upheld this complaint point. It also found that the care and treatment provided to Mrs A during her admission on 31 March was not clinically appropriate because she was not examined by the correct specialism and clinicians failed to consider an alternative diagnosis for her pain. The Ombudsman also upheld this complaint point. Finally, the investigation found that the Health Board’s management of referrals from Mrs A’s GP was appropriate and so this point was not upheld. The Practice accepted the Ombudsman’s recommendations and agreed to apologise to Mr C and his family, and provide a copy of the Red Flags Guidance to all its clinicians. The Health Board accepted the Ombudsman’s recommendations and agreed to apologise to Mr C and his family, to review the case for points of learning, to remind relevant clinical staff of guidance around intimate examinations, and to make improvements to its record

Ms X complained that the Practice refused her request for a home visit to carry out a blood test. She stated that the Practice, failed to take into account how her mental health limited her ability to leave her home and, as a result, did not make reasonable adjustments for her needs. The Ombudsman found that Ms X’s blood test was routine and that she could reasonably attend at a later date. The Ombudsman was concerned to note that after Ms X disclosed her mental health difficulties and inability to leave her home, the Practice did not consider whether she would be placed at a substantial disadvantage or explore whether any reasonable adjustments were required. Additionally, the Practice’s claim that community nurses only visit patients who are ‘housebound’ was inconsistent with information published on its website. The Ombudsman decided to settle the complaint without carrying out a formal investigation. The Ombudsman sought and obtained the Practice agreement to, within 4 weeks: (1) remind staff that patients may be referred to a community nurse if they are unable to leave their home; and (2) review Ms X’s concerns to determine whether she would be placed at a substantial disadvantage and to explore whether any reasonable adjustments are required to reduce any barriers to her access to services.

We investigated Mr A’s complaint against a GP Practice in the area of Aneurin Bevan University Health Board (“the Practice”) that 2 safeguarding referrals made by the Practice to Social Services were not appropriate. The investigation found that both referrals were appropriate and the complaint was not upheld. The decision to make the first referral was appropriate. Even though there was no substantial new accusation contained in the second referral, safeguarding guidance is clear that this should not deter a professional from making a further referral if concerns continue.

Mr A complained that the GP Practice failed to recognise or respond appropriately to his needs, leading to him being removed from the patient list. The Ombudsman decided that the Practice had not communicated effectively with Mr A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to, within one month, consider how reasonable adjustments might be made to its appointment booking system, ensure that changes to prescribing practice are appropriately communicated and ensure all staff are aware of the process for booking interpreters.

Mrs X complained that the Practice failed to respond to her complaint that she submitted to it in November 2024. The Ombudsman found that the Practice had failed to respond to Mrs X’s complaint, and it had also failed to regularly update her. She said this caused uncertainty and frustration for Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to, within 4 weeks, apologise to Mrs X for the delay and for the lack of regular updates, to issue its complaint response and offer her £100 redress payment for the delay, lack of regular updates and for the time and trouble in making a complaint to the Ombudsman.

Mrs X complained about the care provided to her late mother by a GP practice in the Aneurin Bevan University Health Board area. The Ombudsman found that the GP Practice held a meeting with Mrs X to discuss her concerns; however, it had failed to provide a complaint response in line with the ‘Putting Things Right’ procedure. She said this had caused uncertainty for Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the GP Practice’s agreement to apologise to Mrs X for failing to provide a complaint response, and to issue its response within 2 weeks.

Miss T complained that the Surgery had failed to respond to the complaint she submitted in May 2024. The Ombudsman decided that there had been a significant delay by the Surgery to provide Miss T with a response. She said this had caused frustration and uncertainty for Miss T. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Surgery to provide Miss T with a written apology and explanation for the delays, £150 redress in recognition of the delays and to issue a complaint response within 2 weeks.

Mrs T complained that although her GP Practice (“the Practice”) accepted it did not make a referral to a Breast Clinic following her appointment on 9 September 2021, it had not considered the impact its error had caused on her treatment and prognosis when in May 2023 she was diagnosed with terminal Stage 4 breast cancer. We also considered what actions the Practice had taken in response to Mrs T’s complaint and whether these were sufficient to mitigate the chances of a similar incident happening in the future. The investigation found that a GP at the Practice failed to refer Mrs T twice to the Breast Clinic and these were significant service failures. The impact of these failures were that Mrs T’s diagnosis and treatment were delayed and it was more likely than not that an earlier diagnosis would have resulted in a better prognosis and a higher chance of a cure. The investigation also found that whilst the Practice had taken strong, robust action in response to Mrs T’s complaint, there were some further actions it could take to mitigate the chances of such an instance happening again. Mrs T’s complaint was upheld. The Ombudsman recommended that the Practice within 1 month: • Apologise to Mrs T. • Make a financial redress payment of £2,500 to reflect the significant services failures. • Ensure the case is discussed with the GP in question at their next appraisal. • Share guidance on safety netting with all its clinical staff. The Practice agreed to the Ombudsman’s recommendations.

Ms D complained about the care and treatment provided to her grandmother, Mrs F. Specifically, the investigation considered whether, between June 2021 and June 2022, Mrs F’s GP Practice failed to take appropriate action which would have resulted in an earlier diagnosis of her bladder cancer. My investigation found that Mrs F had ongoing urinary symptoms and a presence of blood in her urine without infection, which should have resulted in an urgent suspected cancer referral in July 2021. There were a number of missed opportunities to make this referral, and it was not made until May 2022. This was a significant service failing. I am saddened to conclude that had an urgent referral been made for Mrs F at an earlier stage, on balance, it is likely that the bladder cancer would have been diagnosed and treated sooner. Whilst I cannot be certain that this would have prevented Mrs F’s death, on balance, it is likely she would have survived longer. This is a grave injustice, not just to Mrs F, but as an enduring source of distress for Ms D and her family. I recommend that the Practice, within 1 month of this report: a) Provides Ms D with a fulsome apology for the failings identified in this report. The apology should make reference to the clinical failings, the impact of these on Mrs F’s outcome and the impact on Ms D and her family. b) Provides my office with confirmation that the new alert system for follow-up of patients with persistent blood in their urine is in use. I recommend that the Practice, within 2 months of this report: c) Reviews this case, along with its original significant event analysis, and the opportunity for earlier suspected cancer referral in line with NICE guidelines, to identify any points of learning which can be applied in future care and when dealing with complaints. d) Provides relevant clinicians with training on NICE guidelines for urinary tract infections in adults and bladder cancer diagnosis and management.

Mr A complained about the GP Practice’s complaint response about his mother’s management and care in February 2024. Mr A also complained about a later period of care (in April ) that the GP Practice had not had an opportunity to consider. The Ombudsman exercised her discretion and decided to look into this aspect of Mr A’s complaint. As part of the settlement the GP Practice were asked to provide a written response to address the specific concerns that Mr A had raised about his mother’s management in the February; apologise to Mr A and his mother for the shortcomings in complaint handling and the distress that shortcomings in the second episode of care had caused them. Additionally, the Medical Practice was to reinforce at an appropriate forum to non-clinical staff appropriate clinical/non-clinical boundaries during patient interactions which would include situations where clinical input is required as well as review the April episode of care and identify areas for learning. Finally, if this is not already in place, the GP Practice should ensure that patient contact with non-clinical staff was appropriately recorded in the patient’s clinical records.

Miss A complained about the care and treatment provided to her late brother, Mr B, by a GP Practice in the area of Aneurin Bevan University Health Board (“the Practice”). Miss A complained specifically that between 26 January and 13 March 2023 the Practice failed to provide appropriate care and treatment to Mr B and undertake appropriate investigations into his reported breathlessness. The investigation found that the care and treatment provided to Mr B by the Practice fell below expected standards. This is because, although an appropriate history was taken, the examination recorded on 26 January 2023 was inadequate and the follow-up or safety-netting plan was absent. The Practice failed to take appropriate action to investigate Mr B’s breathlessness as it did not make a follow-up plan to review, investigate or refer Mr B. The Ombudsman therefore upheld the complaints. The Ombudsman recommended that the Practice should apologise to Miss A for the failings identified and provide evidence that it has reflected on the care provided and undertaken relevant learning.

Mrs N complained that Aneurin Bevan University Health Board (“the Health Board”) failed to provide her with appropriate care while she received blood transfusions and discharged her inappropriately after the transfusions were complete. Mrs N also complained that the GP Practice failed to appropriately assess and treat Mrs N’s symptoms in her left foot and leg when she was seen 4 days after her discharge. The Ombudsman found that Mrs N was appropriately monitored during the blood transfusions and that it was appropriate not to prescribe treatment to prevent blood clots. She was appropriately monitored during the transfusions and her discharge and the plan for follow-up care were clinically appropriate. There was no clinical reason for Mrs N to stay in hospital once her blood transfusions were complete. These elements of the complaint were not upheld, although the Ombudsman invited the Health Board to consider how it could ensure that patients are informed of appropriate self-care following blood transfusions, and the warning signs of a negative reaction. The Ombudsman found that the documented assessment of Mrs N’s foot and leg when she was seen at the GP Practice was inadequate. Relevant clinical findings were omitted and indications of the severity of her reduced blood flow were misinterpreted. Mrs N should have been referred urgently to the Vascular Team but, as a result of these failures, her referral and assessment by that team was delayed by at least 24 hours. This delay did not materially impact the clinical treatment Mrs N received, which ultimately required her leg to be amputated. However, if the GP had considered all the relevant factors and appropriately referred Mrs N for an immediate review by the Vascular Team, this could have reassured her that her concerns were taken seriously and that everything possible was done, even if this would not have saved her leg. This element of the complaint was therefore upheld. The GP Practice agreed to apologise to Mrs

Ms A complained that she was unhappy with the Practice’s response to her complaint about accessing appointments over the past 12 months. The Ombudsman decided that the Practice’s response did not explain what it found as a result of its investigation into Ms A’s concerns. It did not confirm if any learning was identified or if any changes could be made. No information was provided about how to escalate the complaint to the Ombudsman. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to reconsider Ms A’s complaint, explain what it found in its investigation and any learning points identified. The Practice also agreed to review the information it provides to complainants about their rights to escalate their complaints.

Mrs D complained about the care and treatment provided to her husband, Mr D, by Aneurin Bevan University Health Board (“the Health Board”) and his GP Practice. Mrs D’s complaint that the GP Practice missed opportunities to carry out assessments, investigations and/or referrals that would have led to the earlier identification of Mr D’s cancer was partially upheld. The investigation found that the clinical treatment provided to Mr D by the Practice prior to 21 December was appropriate. However, it found that there was a failure to send a stool sample for analysis which meant that GPs assessing Mr D’s symptoms were deprived of potentially significant clinical information. The investigation found that there was a failure to make an urgent suspected cancer referral on 21 December which placed Mr D at avoidable risk of harm. The Ombudsman also upheld Mrs D’s complaints that the Health Board failed to investigate and treat Mr D’s cancer in a timely and appropriate manner and failed to keep Mr D appropriately informed about and involved with decisions about his care. The investigation found that there was an unreasonable delay by the Health Board in the investigation of Mr D’s symptoms following a GP referral on 11 August 2021. Although it was not possible to say whether his cancer would have been diagnosed earlier, this missed opportunity was an injustice to Mr D. The investigation also found that there was a failure by the Health Board to provide appropriate communication and support for Mr D following his cancer diagnosis, causing him avoidable distress. The Practice agreed to the Ombudsman’s recommendations to apologise and make a financial redress payment to Mrs D of £250, and to share the report and learning points with relevant clinicians. The Health Board agreed to the Ombudsman’s recommendations to apologise and make a financial redress payment to Mrs D of £750, to share the report and learning points with relevant clinicians, and to review its process for listing

Mrs X complained about the standard of care and treatment provided to her late husband, Mr X, after he tested positive for COVID-19. Specifically, she complained that opportunities to treat him, as a vulnerable patient, with antiviral medication were missed. Mrs X was concerned that he should not have been initially discharged from the Grange University Hospital and that additional treatment should have been given to him for COVID-19. She complained that he was prescribed antibiotics by the GP following a telephone consultation as opposed being seen by the GP. When Mr X was later admitted to the University Hospital of Wales with COVID-19 symptoms, Mrs X felt that the provision of antiviral treatment was delayed. The Ombudsman found that the decision to discharge Mr X from the Grange University Hospital was reasonable as Mr X had not required any specific hospital treatment for COVID-19 at that point. His condition had not met the national criteria for prescribing antiviral medication. On admission to the University Hospital of Wales, Mr X’s condition had deteriorated, and he was assessed as needing the antiviral treatment. This was prescribed within an appropriate timescale. The prescribing of antibiotics by the GP was appropriate as it was based on a detailed history and telephone assessment of Mr X’s presenting symptoms. The Ombudsman found no failings in the care provided and did not uphold the complaints.

Ms B complained about the care and treatment provided by a GP Practice in the area of Aneurin Bevan University Health Board. She complained that when she presented at the Practice on 11 June 2020 with a lump in her left breast, she was reassured that it was a benign cyst that required only monitoring. When she re-presented on 22 September, concerned that the lump had grown, she was examined by a different GP who, without any obvious means of comparison, assured her that the lump had decreased in size. When she informed the Practice on 14 December that the lump had increased in size and that she had detected a second lump in her left armpit, it was 3 February 2021 before she was seen by a breast specialist. Ms B complained that contrary to established guidance, GPs failed to make this referral under the appropriate urgent suspected cancer (“USC”) pathway. The Ombudsman found that the care provided at the consultation of 11 June was below an adequate standard as a referral should have been made at this point, under the USC pathway. This caused a significant injustice to Ms B as, had her cancer been diagnosed at this time, she could have been counselled against becoming pregnant and avoided being in the difficult and avoidable position whether to delay cancer treatment to complete her pregnancy or to have a termination. Similarly, had referral and diagnosis been made sooner, she may have elected to accept a short delay in treatment to pursue the option of harvesting her eggs with a view to using them in the future for IVF. This aspect of the complaint was therefore upheld. The investigation found that the care provided at the consultation of 22 September was below an adequate standard as there was a failure to properly record the size of the lump identified and because there should have been an USC referral this aspect of the complaint was upheld. The Ombudsman found that the USC referral made on 14 December was appropriate and in accordance with the USC pathway and th

Ms C complained about the care and management she received from her GP Practice (“the Practice”) between 23 October 2020 and December 2021. She complained that a GP (“the First GP”) failed to recognise abnormal cholesterol result, to provide support and assessment when she requested a nutrition supplement. She complained that at another consultation another GP (“the Second GP”) and the Asthma Nurse had not listened/understood her condition, and that the Advance Nurse Practitioner told her to leave the premises following her attendance at the Practice. Ms C also complained about the cardiology care and treatment she received from the Health Board in2020, in that it failed to identify that her Emergency Department attendances in October/November 2020 were related to her heart condition. Ms C complained that she was not referred toa cardiologist, which led to a deterioration in her health and delay in receiving treatment. Finally, she complained that the Health Board’s complaint response was not robust. The Ombudsman found that the care and management Ms C received from the Practice and from the Health Board’s Cardiology Department was appropriate. The Ombudsman was also satisfied that the Health Board’s complaint handling accurately reflected the care provided to Ms C. Ms C’s complaints were not upheld.

Mrs Y complained about the treatment given to her husband, Mr Y, by a GP Practice (“the Practice”) in the area of Aneurin Bevan University Health Board (“the Health Board”) between September 2019 and May 2021. Specifically, Mrs Y complained about the Practice’s management of Mr Y’s open sores, referrals for specialist input (including both Dermatology and Cardiology), medication reviews and complaints handling. The Ombudsman found the Practice’s management of Mr Y’s open sores, the referral to Dermatology, liaising with Cardiology, and the monitoring and review of Mr Y’s medication, were appropriate in the circumstances. Accordingly, these aspects of Mrs Y’s complaint were not upheld. However, the Ombudsman found that the content of the Practice’s complaint responses was not sufficient to address Mrs Y’s concern and were not in line with the PTR Regulations. The failure of the Practice to adequately address Mrs Y’s concerns amounted to an injustice and accordingly, this aspect of Mrs Y’s complaint was upheld. The Ombudsman recommended that the Practice arrange for complaint handling training to be provided to its staff by the Health Board.

Ms A complained that a GP Practice in the area of Aneurin Bevan University Health Board failed to deal with her complaint appropriately. The Ombudsman found that the Practice had provided Ms A with a response, but the response was not in keeping with the Putting Things Right Regulations and that parts of the response were inappropriate in tone or content. This resulted in Ms A feeling that her complaint was not dealt with appropriately and, she said, inflamed her concerns. The Ombudsman contacted the Practice and in resolution of Ms A’s complaint it agreed that within 20 working days, to provide a written apology, acknowledging that parts of the complaint were not investigated or responded to appropriately and that staff would re-familiarise themselves on how to manage complaints under the Regulations. The Ombudsman considered this to be an appropriate resolution and did not investigate.

Mr A complained about the standard of care provided to his wife, Mrs A, by a GP Practice in the area of Aneurin Bevan University Health Board. Specifically, Mr A said that his wife should have been offered a face-to-face appointment or examination, rather than a telephone consultation. The Ombudsman found that, although Mrs A was not offered a face-to-face appointment, the action taken by the GP in arranging follow-up investigations for her was appropriate. She also found that although Mrs A was not provided during this appointment, with safety netting advice about how to seek support, she had done so previously and therefore had a good understanding of how to access assistance. The Ombudsman considered that this might not have been the case for other patients, and so took the opportunity to ask the Surgery to consider this as a learning point. The Ombudsman contacted the Practice, and in resolution of Mr A’s complaint, it agreed to, within 20 days, provide Mr and Mrs A with a written apology for the fact that they were unhappy with the care provided to Mrs A and to provide a reminder to all clinical staff to ensure that appropriate safety netting advice is provided to patients during all consultations, whether conducted in person, via telephone or via video call.

Mrs X complained that there was no proper examination or assessment of her late husband, Mr X’s condition during a GP consultation in August 2021. As a result, no appropriate treatment or referral for further investigation was made. Whilst the ultimate diagnosis would not have been altered, the Ombudsman found no evidence to indicate that an appropriate assessment of Mr X’s presenting symptoms, or proper examination, took place during the consultation. The response to the complaint by the GP Practice was also inadequate resulting in Mrs X having to pursue her complaint to the Ombudsman. The Ombudsman upheld the complaint and the following recommendations were agreed: • The GP Practice should review and discuss the complaint at a Significant Event Analysis (SEA) meeting. • The GP Practice should provide a further written apology to Mrs X reflecting the Ombudsman’s findings, and explain the outcome of the SEA meeting. • The GP should discuss the complaint, and his learning from it, at his next annual appraisal. 18 April 2023

Ms B complained that for an 8-month period, a GP Practice in the area of Aneurin Bevan University Health Board (“the Practice”) failed to offer her an in-person consultation and appropriate care and treatment for nasal and breathing problems. She since had received a cancer diagnosis. Sadly, Ms B died before the conclusion of the investigation. The Ombudsman found that although Ms B should have been offered an in-person GP consultation during the 8-month period, it was not likely that it would have necessitated a referral or alternative care and treatment at that time. Therefore, the level of injustice was limited. There was no evidence that Ms B reported symptoms to the Practice that should have resulted in an urgent chest X-ray referral. There was no evidence to suggest that the Practice should have suspected that Ms B had lung cancer, or to have initiated investigations that may have detected it – even with the benefit of hindsight. Although a review identified shortcomings in the Practice’s standard of record keeping, which the Practice was asked to reflect upon, this did not clinically impact the outcome for Ms B. The Ombudsman did not uphold the complaint.

The investigation considered Ms A’s complaint about her treatment by a GP Practice (“the Practice”), in the area of Aneurin Bevan University Health Board (“the Health Board”). Ms A said she reported to the Practice’s Advanced Mental Health Nurse Practitioner (“AMHNP”), on 15 October 2020, that she was experiencing an adverse reaction to sertraline (a type of antidepressant). However, the AMHNP failed to advise her to discontinue the medication or act upon the deterioration in Ms A’s mental health. Ms A said that the AMHNP failed to schedule a follow-up appointment and arrange blood tests to investigate her symptoms. Ms A said that the AMHNP did, in due course, advise her to discontinue sertraline, but this was done rapidly and she developed symptoms as a result of the discontinuation. Ms A said that the AMHNP failed to acknowledge and respond to her mental health crisis and reacted to her having an aggressive outburst by calling the Police and escorting her from the Practice. Ms A said she was removed from the Practice with immediate effect and considered this response to be inappropriate and unwarranted as her outburst was a manifestation of her illness. The investigation found that Ms A was exhibiting symptoms of depression on 15 October and it was therefore appropriate not to discontinue sertraline. It was also reasonable for a definitive follow-up date not to be booked following the 15 October appointment. The AMHNP was not directed to arrange blood tests by the GP and therefore she could not be criticised for not doing so. The Practice was however, invited to remind the GPs of the obligations placed upon them by the General Medical Council’s ethical guidance for doctors. The clinical decision to cease the prescription of sertraline by gradual reduction on 1 December was appropriate. Whilst the speed of reduction was not in line with the prescribing guidance the impact of the side effects from continuation over a longer period was likely to have been clinically

Mr X complained that he had not received a complaint response following his complaint to the Surgery in July 2022 about his difficulty in getting an appointment with a doctor. The Ombudsman found that the Surgery had not issued a complaint response and had failed to provide regular and meaningful updates to Mr X. The Surgery agreed to write to Mr X with an apology and explanation for the lack of regular and meaningful updates and issue its complaint response within 4 weeks, as an alternative to the Ombudsman investigating it.

Ms A complained about her diagnosis and treatment by the GP Practice while she was going through a mental health crisis. The investigation considered whether the appointments provided to her were suitable, whether the Practice’s communication with Ms A regarding her requests for appointments was appropriate, whether the medications prescribed to Ms A were appropriate, and whether she was given timely support from the Practice in relation to her withdrawal plan from diazepam (a medication used to treat anxiety and agitation). The investigation found that Ms A was given appointments in line with the Practice’s policies, and that the communication with Ms A about her appointments was appropriate. It found the reduction of Ms A’s citalopram (a medication used to treat depression) was in line with relevant guidelines. Whilst the diazepam was prescribed for a longer period than recommended, this was justified given Ms A’s distress while waiting to be seen by support services, and that sufficient information regarding the potential of addiction to diazepam was provided to her. The investigation found that Ms A’s withdrawal of diazepam was also managed appropriately, and her complaints were therefore not upheld.