PSOW Individual Decisions

Mr A complained that the GP Practice failed to provide appropriate care prior to his removal from its patient list. The Ombudsman found that, while the GP Practice had addressed Mr A’s concerns about being removed from the patient list, it had not provided a full written response regarding concerns he had raised about his care. This caused frustration and uncertainty for Mr A. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained agreement from the GP Practice to provide a comprehensive written response to Mr A’s concerns by 20 April 2026.

Mrs A complained that there was a failure by the GP Practice to refer her brother to secondary care in a timely manner between March and May 2024. As a result, there was a delay in identifying that his previously diagnosed bowel cancer had spread to his right parotid gland (a salivary gland just beneath and in front of the ear). The investigation found that the GP Practice’s management and care was reasonable and appropriate. Based on her brother’s presenting symptoms, there was no reason to suppose that they were anything other than an ear infection/congestion. Mrs A’s complaint was not upheld.

We investigated a complaint brought by M’s mother, Mrs P, which focused on whether M’s consultations with clinicians at a GP practice (“the GP Practice”) in relation to abdominal symptoms between 11 March 2024 and 8 June 2024 were appropriately managed and whether there were any missed opportunities to diagnose appendicitis. The investigation found that there were omissions in M’s consultations with the GP practice on 6 June and, in particular, the afternoon appointment on 6 June where there was no documented abdominal examination. The failure to document an abdominal examination when there was worsening abdominal pain meant there was uncertainty as to whether there was a missed opportunity for an earlier referral to secondary care. We partially upheld Mrs P’s complaint and recommended that the GP practice within 1 month of the date of the final report apologise for the service failure identified in the report and that the report is shared at a practice meeting to discuss the shortcomings identified.

Ms A complained about the care and treatment provided by Roseneath Medical Practice in relation to her mental health and about the action taken in relation to a private psychological assessment report. Ms A further complained about the handling of her complaint and said the Practice’s complaint response did not address her concerns. The Ombudsman found that there had been delay in the Practice responding to Ms A’s complaint and that she had not received an adequate complaint response. Ms A was inconvenienced by the Practice’s actions, which had caused her frustration. The Ombudsman decided to settle the complaint without investigation. The Practice agreed to, within 4 weeks, reconsider Ms A’s complaint, provide her with a further complaint response addressing the concerns raised with the Practice and the Ombudsman and also provide Ms A with a written apology for the failure to adequately address her concerns in its initial complaint response.

Mr C complained that a GP Practice refused to visit his partner, Ms A, at home for 6 months, despite her deteriorating health. He complained that when a home visit was undertaken, the assessment of his partner was inadequate and the referrals that were made were not appropriate. The Ombudsman found that the Practice did not take adequate steps to assess Ms A following concerning blood test results and failed to recognise that her health conditions prevented her from attending the surgery. This may have contributed to a delay in diagnosing cancer and providing treatment, albeit it was sadly unlikely that this would have changed the outcome. The Ombudsman found that the assessment carried out during a home visit that was undertaken, and the referrals that were made, were clinically appropriate. The Ombudsman upheld Mr C’s complaint that the assessment of Ms A’s need for a home visit was not clinically appropriate and did not uphold Mr A’s complaint about the care that was provided during the home visit. The Practice agreed to apologise to Mr C and provide feedback to the doctor involved within a month. The Practice also agreed to review its Home Visiting and Complaints Policy within 3 months.

Complaint about the care and treatment provided by the Practice and in its response to her complaint, it had not addressed her concerns. The Ombudsman decided that there had been a failure by the Practice to respond fully to the concerns raised by the complainant in its response to her complaint. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Practice to issue a further complaint response and to offer an in-person meeting. The Practice agreed to do this within 4 weeks of the Ombudsman’s decision.

Ms C complained that she was unable to make an appointment with a GP Practice in the area of Betsi Cadwaladr University Health Board, which resulted in delays in reviewing her medication and issuing prescriptions The Ombudsman decided that the Practice had failed to recognise that the patient had made considerable efforts to make an appointment using the appointment booking system. The Practice had missed opportunities to remedy the situation and offer an appointment, causing an injustice to Ms C. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms C within two weeks to apologise for the failings and confirm the arrangements for booking future appointments. The Health Board also agreed to consider, within 4 weeks, the Practice’s review of the booking system to ensure that patients were able to arrange appointments with their GP.

Miss D complained that her late aunt, Miss F’s, GP Practice incorrectly informed her that doctors did not do home visits when she rang with concerns about Miss F on 28 and 29 June 2023. The investigation found that, on the balance of probabilities, the appropriate policy was not followed by the GP Practice when Mrs D rang with concerns about Miss F on 28 and 29 June 2023. The GP Practice agreed to provide Mrs D with an apology for the failings identified and offer her a payment of £750 for the distress and uncertainty caused by these failings. It also agreed to undertake further training with its administrative staff to ensure full understanding of the Home Visit Policy and the need for a clinician to triage any requests for home visits. Finally, it agreed to review its complaint handling of this case to identify any lessons to be learned.

Ms X complained that the Surgery had failed to contact her to discuss her ongoing health checks and had not responded to the complaint she made in September 2023. The Ombudsman decided that there had been a failure by the Surgery to respond to the complaint and this had caused frustration and uncertainty for Ms X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Surgery to apologise to Ms X and provide her with a complaint response which addresses her original concerns within 4 weeks. The Surgery also agreed to pay Ms X financial redress of £75 in recognition of the delays.

Mr B’s family complained about the care provided to him by his GP practice and whether there was a failure to appropriately manage his Chronic Obstructive Pulmonary Disease (“COPD” – a long term lung condition) between March 2021 and August 2022. Specifically, whether Mr B’s medication was appropriately managed; whether referrals from other health professionals (including Pharmacists) were acted upon; whether appropriate reviews were undertaken; whether appropriate referrals were made, and; whether Mr B’s treatment plan was appropriate(including whether weight management should have formed part of the plan). The Ombudsman found that the care provided to Mr B by the Practice between March 2021 and August 2022 was acceptable and that his COPD was appropriately managed during this period. The Ombudsman did not uphold the first 4 complaints. The Ombudsman also found that Mr B’s treatment plan was acceptable overall. However, there was a missed opportunity for Mr B’s weight to be noted at the COPD therapy review on 23 June 2022 and, although there was no specific indication of detriment to Mr B or that the outcome would have been any different, this uncertainty was an injustice to Mr B. To that limited extent only, this element of the fifth complaint was upheld. The Ombudsman recommended that the Practice should write to Mr B’s family with an apology for the failing identified in the investigation. She also recommended that the Practice complete an audit of a random sample of COPD reviews conducted since 2023 to determine whether weight/BMI is being recorded and that appropriate dietician referrals or other action is taken, if indicated/required.

Mrs B complained about the care and treatment provided to her by a GP Practice (“the Practice”) in the area of Betsi Cadwaladr University Health Board. The investigation considered whether the Practice misdiagnosed Mrs B’s symptoms, which led to a delay in the diagnosis of laryngopharyngeal reflux/silent reflux (when stomach contents come back up into the oesophagus to the larynx) and gallbladder disease between October 2016 and November 2018. Specifically, it considered whether appropriate and timely referrals were made by the Practice and whether the Practice provided timely and appropriate responses to professionals who sought information on Mrs B’s condition. It also considered whether the Practice inappropriately cancelled appointments with Mrs B. Whether it should have taken action in response to adverse effects Mrs B suffered as a consequence of medication, including whether it declined to accept a list of medications that Mrs B wanted to provide. The Ombudsman found that the care and treatment provided to Mrs B by the Practice was clinically appropriate. Mrs B’s complaint was not upheld.

Mr A complained that the Surgery failed to respond to his complaint about the mismanagement of his referral. The Ombudsman decided that there had been a failure by the Surgery to respond to Mr A’s emails and said this caused frustration and inconvenience for Mr A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Surgery to provide Mr A with a written apology and a complaint response within 4 weeks.

Ms Y complained about the care a GP Practice in the area of Betsi Cadwaladr University Health Board, had provided to her. She specifically complained about comments made to her when she contacted the practice about her symptoms and said that the Practice did not provide appropriate support when she contacted it about pain management due to her diagnosis of endometriosis in December 2022 and February 2023. She complained that the Practice should have referred her to a specialist tertiary endometriosis centre, rather than referring her to gynaecology services to assess her. Finally, Ms Y complained that there were gaps in her records, as documents sent following an out of hours appointment and from a hospital outside of the Health Board were not present. She said the complaint response she had received did not address this concern and instead referred to historic documents. The assessment of Ms Y’s complaint identified that the care provided following her concerns about pain management was within the range of appropriate clinical practice. It also identified that the Health Board has a contract with the tertiary endometriosis centre for referrals to come from the gynaecology service and it was reasonable that the Practice did not refer her directly. The assessment also identified that the initial complaint response Ms Y received did not address her concern about why there were documents missing from her records. The Practice agreed to issue Ms Y with a further complaint response to apologise for not addressing her concern in its initial response and to address her concern about documents missing from her records. The Ombudsman considered this was a reasonable way to resolve Ms Y’s complaint and it was closed on this basis.

Mrs A complained about the care and treatment that her late mother, Mrs B, received during the final weeks of her life while she was a resident in a care home in the area of Betsi Cadwaladr University Health Board. Mrs A complained that the Care Home failed to appropriately manage her mother’s skin integrity, leading to the development of a grade 4 pressure sore, and failed to inform the family that Mrs B had developed this level of sore. Similarly, Mrs A raised concerns that the Care Home did not recognise that her mother was at the end of her life and provide appropriate nursing care, or provide clear communication with the family on this matter. Mrs A also complained that the Health Board, which had funded Mrs B’s stay at the Care Home, had failed to provide appropriate oversight of her mother’s condition while she was a resident. In addition, Mrs A raised concerns about the Health Board’s handling of her complaint. Lastly, the investigation considered Mrs A’s complaint that her mother’s GP Surgery failed to carry out appropriate consultations with Mrs B in July 2021 (which included the prescription of primidone) and so had been unaware of her deteriorating condition. The Ombudsman found that there was a lack of clear direction in managing Mrs B’s pressure areas at the Care Home and that it was not clear whether the referral to the Tissue Viability Team had been made in a timely way. Although the Ombudsman could not conclude that the later development of Mrs B’s grade 4 pressure sore was avoidable, there were lost opportunities to maximise the effectiveness of Mrs B’s pressure area care. Furthermore, the Ombudsman found that it did not appear that staff at the Care Home had recognised the grade of pressure sore, and so by extension did not fully inform Mrs B’s family of the severity of it. As a result, the Ombudsman upheld these aspects of Mrs A’s complaint. The Ombudsman also found that whilst staff recognised that Mrs B was possibly nearing the end of her life,

Mrs X complained that a GP Practice in the area of Betsi Cadwaladr University Health Board had failed to respond to the complaint she had made to it in July 2023. The Ombudsman found that the Practice had verbally updated Mrs X, but had not offered her a written apology, explanation or update regarding the delay. The Ombudsman said this caused frustration for Mrs X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to apologise to Mrs X, explain the reasons for the delay and provide an update to her within 2 weeks. The Practice also agreed to provide its response to the complaint within 13 weeks.

Miss R complained that the Surgery failed to provide a response to her complaint about the poor assessment of her foot injury which she said delayed her treatment and adversely affected her recovery. The Ombudsman found that whilst the Surgery had acknowledged the complaint it had failed to provide a complaint response. She said that this caused frustration and uncertainty to Miss R. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Surgery’s agreement to write to Miss R with an apology and explanation for the delay in responding to her complaint, offer to pay £75 redress and issue a complaint response within 2 weeks.

Mrs P complained on behalf of her late husband, Mr P, about Betsi Cadwaladr University Health Board (“the Health Board”) and a GP Practice (“the Practice”) in the same health board area. Mrs P complained about the Health Board’s handling of her complaint about the service provided by the Practice. Mrs P also complained about the treatment and care provided to Mr P by the Practice from February 2021 onwards. She said that the Practice failed to provide a consultation with a doctor when her husband presented with neurological symptoms on 17 February. Mrs P said that this caused a 7-week delay before her husband was referred for specialist review and his terminal cancer was diagnosed. The Ombudsman found that the Health Board handled Mrs P’s complaint appropriately and did not uphold this part of the complaint. The Ombudsman also found that Mr P should have had an urgent physical examination when his symptoms appeared to change. However, the Practice did not carry this out and this likely led to a delay in Mr P’s brain tumour being diagnosed. Despite this delay, Mr P’s prognosis would not have changed as the tumour was already large and had spread extensively. The Ombudsman upheld this part of the complaint. The Ombudsman recommended that the Health Board apologise to Mrs P and undertake a review of its policies to ensure instances such as this did not happen again.

Mrs A complained that the GP Practice’s management and care of her late father Mr B’s deteriorating kidney function in 2022 was not to an appropriate standard. The Ombudsman’s investigation found that most of the appointments and interactions relating to Mr B’s care, together with the medication management of his oedema, in the face of deteriorating kidney function, were reasonable and appropriate. However, there were instances identified when clinical decision-making ran counter to clinical and prescribing guidance, or expert advice received was not followed. This raised questions and concerns about the effectiveness of clinical oversight and monitoring at times in Mr B’s case. This was especially so given the absence of robust documentation to support some of the clinical decision-making. The investigation identified that where there are different clinicians involved in a patient’s care, a shared plan is important. Had such a plan been in place, it would have provided more clarity concerning Mr B’s management given his deteriorating kidney function. The investigation found that the injustice for Mrs A and her father was that the failings identified creates some uncertainty about the effectiveness of Mr B’s care and management, given his deteriorating renal function. To that extent service failings were found. Additionally, administrative failings around documentation were found to amount to maladministration. Mrs A’s complaint was upheld. The GP Practice agreed to implement the Ombudsman’s recommendations and apologise to Mrs A. It also agreed to carry out learning around prescribing to older people; undertake additional reflection in order to learn lessons and introduce process changes to improve clinical decision-making.

Mrs B complained about care and treatment provided to her late father, Mr D, by a GP Practice (“the Practice”) in the area of Betsi Cadwaladr University Health Board. The investigation considered whether the prescription in November 2021 of 2 mg of diazepam for Mr D was appropriate, especially given that the dosage was contrary to British National Formulary advice, that the medication increased the risk of respiratory depression and in light of his recent lower lobectomy (19 October 2021), which had resulted in a weakened respiratory system, and apparent breathlessness. It also considered whether the Practice failed to arrange a face-to-face appointment where appropriate examinations could have been carried out and whether the failure meant that an opportunity was missed by the Practice to have noticed the signs and symptoms of pneumonia which led to Mr D sadly dying 2 days after the telephone consultation. The Ombudsman found that whilst the care and treatment provided by the Practice to Mr D on 18 November 2021 fell below a clinically acceptable standard, it did not cause an injustice to Mr D in terms of contributing to the nature or timing of his death. Mrs B’s complaint was not upheld.

Mr A complained that he arranged to have travel vaccinations at a GP Practice in the area of Betsi Cadwaladr University Health Board (“the Surgery”), but that not all of them were available so he had to make a further appointment. When he tried to book another appointment, the Surgery said that he had already had the typhoid vaccine, which he disputed. The Ombudsman considered that Mr A had not had a full response to his complaint and contacted the Surgery, which agreed to undertake the following actions to resolve the complaint and as an alternative to a formal investigation: · To arrange a meeting between Mr A and one of the GPs to discuss his concerns before Mr A travels abroad unless this cannot be mutually agreed. · If the meeting does not resolve Mr A’s concerns, the Surgery will then provide a formal written response to Mr A’s complaint within the relevant timescales set out in the NHS complaints procedure.

Mrs D complained that there was a delay in the diagnosis and treatment of her late husband, Mr D, by Betsi Cadwaladr University Health Board and a GP Practice within the Health Board area. Mrs D complained that there were missed opportunities for the Health Board to diagnose Mr D with interstitial lung disease (“ILD” – an umbrella term which covers a number of different lung diseases) and idiopathic pulmonary fibrosis (“IPF” – a type of lung disease) between 2015 and 2021. Mrs D also complained that Mr D was referred to the Respiratory Clinic in January 2021 but was not seen until 28 May 2021. Mrs D complained that Mr D visited the Practice frequently in the years preceding his death and his ILD was not diagnosed on the occasions he presented with relevant symptoms. Mrs D also complained that the Practice should have taken action to expedite Mr D’s appointment with the Respiratory Clinic in 2021 when he presented with worsening symptoms. The Ombudsman found that there were missed opportunities for the Health Board to diagnose Mr D with ILD and this complaint was upheld. The investigation found that the time taken for Mr D to be seen in the Respiratory clinic in 2021 was reasonable and this complaint was not upheld. The investigation also found that the care and treatment provided by the Practice was reasonable and these complaints were not upheld. The Health Board agreed to apologise to Mrs D and make a payment to her of £2000 for the missed opportunities to diagnose Mr D, the uncertainty this caused him, and the ongoing uncertainty and distress this has caused Mrs D. The Health Board also agreed to share the report with relevant clinicians, ensure all relevant clinicians are reminded of their duty to take appropriate action when abnormalities are identified on images, and to provide an update on the actions identified in the Health Board’s own investigation to ensure incidental radiological abnormalities are dealt with and for Radiology Governance to consider addin

Ms C, Ms N, and Ms S complained that they had raised concerns with a GP Practice in the area of Betsi Cadwaladr University Health Board Practice informally in September 2022, and despite several attempts to receive answers to their concerns, without response, they submitted a formal complaint in February 2023. The family had still not received a response to their complaint. The Ombudsman was concerned that despite becoming aware of the family’s issues 5 moths prior to the formal complaint, the family had still not received a response, and they had been inconvenienced by the Practice’s actions. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to, within 4 weeks, provide Ms C, Ms N, and Ms S  with an apology for the delay in responding to their complaint, provide a full explanation for the delay and provide them with a complaint response addressing all their concerns.

Mr A complained about his care and treatment by the Practice in its prescribing of opioid medication to manage his pain after he had undergone weight loss (bariatric) surgery, and whether appropriate investigations were undertaken following his collapse. He also complained about the Practice’s handling and investigation of his complaint. The investigation found that the Practice had limited options available to it in order to manage Mr A’s pain, and that it was clinically appropriate to prescribe Mr A with opiates given there was no national guidance preventing that. Furthermore, it was found that appropriate investigations were undertaken when Mr A collapsed. Both these aspects of Mr A’s complaint were not upheld. In relation to the handling of Mr A’s complaint, the investigation found that the Practice’s complaint response was not in line with “Putting Things Right” (the formal process for handling complaints about the NHS in Wales), in that it lacked detail and was poorly drafted ,leaving Mr A feeling that his concerns had not been taken seriously. This was an injustice to him and might also have avoided a complaint to the Ombudsman if undertaken properly. This complaint was upheld. The Practice accepted the Ombudsman’s recommendations to apologise to Mr A for the complaint handling failings, and to liaise with the local Health Board to undergo complaint handling training.

Mrs A complained about the care and treatment provided to Mr B when he attended at a GP Practice in the area of Betsi Cadwaladr University Health Board. Specifically, the management of his groin wound and the decision not to immediately refer him to hospital for urgent treatment. Mrs A said that if this action had been taken, Mr B would not have had his left leg amputated. The Ombudsman found no shortcomings in the management of Mr B’s groin wound. She concluded that an immediate hospital referral was not clinically indicated and the overall outcome could not be attributed to the care received. Mrs A’s complaint was therefore not upheld.

Mrs Y’s complaints Advocate complained on her behalf about whether her mother, Mrs A’s, care by a GP Practice (“the Practice”) in the area of Betsi Cadwaladr University Health Board between 4 January and 28 June 2021 was appropriate. The Ombudsman found that the Practice’s care between 4 January and 28 June 2021 was reasonable. The Ombudsman found that although the Practice said that a GP tried to contact Mrs Y by telephone, this attempt should also have been included in her medical records. The Ombudsman invited the Practice to reflect that any such calls should be recorded in the patient’s medical records. The complaint was not upheld.