PSOW Individual Decisions

The investigation focused only on whether Mr A’s consultations with the GP Practice clinicians between July 2023 and February 2024 should reasonably have led to him being referred to secondary care for investigations. The investigation found that at each consultation up to and including 27 December 2023, the diagnoses, treatment and actions of the clinicians were within the range of acceptable practice. In addition, referrals made between August 2023 and January 2024 were clinically appropriate (spirometry test and 2 chest X-rays); there was no indication that further secondary care referrals were necessary before this time. Whilst the diagnosis and treatment at the 27 December 2023 consultation was clinically appropriate, Mr A should have been provided with safety-netting advice (advice to seek medical care if symptoms worsen or do not resolve) due to his condition. This was a shortcoming. In addition, we found that the actions in the consultations on 30 January and 6 February 2024 may or may not have been within the bounds of acceptable clinical practice in relation to reports of coughing up blood, either because this was not explored sufficiently, or at all. However, by 19 February there was an opportunity to refer Mr A to secondary care with suspected cancer and not doing so amounted to a service failure. That said, this would not have made a difference to his prognosis or planned treatment. On this basis, the complaint was not upheld.

Mrs A’s complaint centred on whether her gallstone management by the GP Practice had been appropriate, given her blood test results in 2021, 2023 and 2025. Mrs A was admitted to the local hospital with pancreatitis and gallstones via the Emergency Department on 26 January 2025. The Ombudsman’s investigation found no link between Mrs A’s previous blood test results in 2021 and 2023 and her subsequent gallstones. The Ombudsman found some shortcomings in Mrs A’s clinical management and documentation at a June 2023 GP consultation. However, on balance, it was concluded that even if the GPs had followed the relevant liver function pathway, Mrs A’s gallstones would not have been identified earlier. The GP Practice’s clinical management and care in relation to Mrs A’s 21 January 2025 blood test results was also found to be reasonable and appropriate. The GP Practice was invited to consider the points of learning in relation to Mrs A’s June 2023 consultation.

Miss A complained that the Practice ignored her complaints and reasonable adjustments and did not provide her with a long covid diagnosis, despite assurances. At assessment, it was found that the Practice did not adhere to Miss A’s reasonable adjustments, that Miss A had not received a copy of the Practice’s complaint response and that the Practice had not had a chance to respond to the complaint regarding a long covid diagnosis. The Ombudsman decided to settle the complaint without investigation. The Practice agreed, within 1 week, to resend its complaint response to Miss A, and, within 4 weeks, to provide a complaint response in respect of the long covid diagnosis, apologise for not adhering to Miss A’s reasonable adjustments, and to place a note on Miss A’s medical record detailing her reasonable adjustments.

Miss A complained that the Surgery failed to respond to the complaint she submitted to it in October 2025. The Ombudsman found that the Surgery had failed to consider the complaint via the complaint procedure and formally respond to Miss A. The Ombudsman said this caused uncertainty and frustration for Miss A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Surgery’s agreement to, within 4 weeks, provide the formal complaint response which will also include an apology and explanation for the delay in responding.

Mr A complained that the Practice used its Zero Tolerance Policy to remove him from the Practice list because he submitted a formal complaint. Mr A said that the Practice gave him the incorrect contact details to submit his complaint. He described having to make multiple attempts to obtain the correct details to submit his concerns. The Ombudsman decided that the Practice had documented its reasons for removing Mr A from the Practice list, but it failed to inform him of the reasons in writing at the time. Whilst the Practice acknowledged that it provided Mr A with the incorrect contact details to submit his complaint, it had not acknowledged or addressed the difficulties he had in trying to obtain the correct details. The Ombudsman said that this caused delays and frustration for Mr A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to apologise to Mr A for failing to inform him in writing of the reasons he was removed from the Practice list at the time, and for failing to acknowledge or address the difficulties he had in obtaining correct contact details to submit his complaint. The Practice also agreed to ensure that relevant contact details are available in its Complaints Policy, and to confirm with the Health Board the process and responsibility of notifying patients of the reasons for removal from the Practice list.

Mr D complained that a GP Practice in the area of Cardiff and Vale University Health Board failed to respond to a complaint he raised in July 2024. The Ombudsman found that the Practice failed issue a formal complaint response until the intervention of her office in August 2025. This caused additional frustration and uncertainty for Mr D. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to, within 2 weeks, write to Mr D to apologise for the delay and offer a £150 redress payment.

We commenced an investigation of Mr B’s complaint against a GP Practice in the area of Cardiff and Vale University Health Board (“the Surgery”) to determine whether the Surgery: • Delayed processing information it received from Mr B’s son (Mr C) about a Shared Care Agreement (“SCA”) which delayed his referral to the Community Mental Health Team (“the CMHT”). • Was able to demonstrate it properly considered Mr B’s request for reimbursement of costs for privately funded medication for the period of delay. In response to the investigation, the Surgery accepted shortcomings in the handling of information provided by Mr C about the SCA. It recognised this delayed Mr C’s referral to the CMHT and resulted in him paying for private medication longer than he would have, had the information been processed sooner. The Surgery agreed to a proposal to address Mr B’s concerns. The Ombudsman determined that the actions it had agreed to take were proportionate to reach a voluntary settlement of Mr B’s complaint and would deliver an appropriate outcome. On this basis, the investigation was closed. The Surgery agreed to: • Provide a written apology for the administrative failings identified in processing paperwork which caused a delay in a CMHT referral. • Re-consider reimbursement of costs incurred for privately funded medication during the period of delay in Mr C being referred to the CMHT and confirm the outcome of the review with Mr B.

Mr X complained that the Surgery failed to respond to his complaint referred to it by the Ombudsman in August 2024. The Ombudsman found that there had been a failure by the Surgery to respond to the complaint, and this had caused frustration and uncertainty for Mr X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Surgery’s agreement to, within 3 weeks, write to Mr X with an apology and explanation for the delay, issue its complaint response and a redress payment of £150 should be offered for the delay and need to approach the Ombudsman.

Mr X complained that the GP Surgery had failed to respond to his complaint. The Ombudsman decided that there had been a significant delay by the Surgery to respond to Mr X’s complaint. She said this caused inconvenience and frustration for Mr X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Surgery to, within 3 weeks, provide Mr X with a written apology and an explanation for the delays, offer a redress payment of £75 in recognition of the poor handling of the complaint and to provide a complaint response.

Mrs A complained that her child’s GP failed to make a referral to hospital, for assessment of possible neuro-developmental issues, following a consultation in October 2022. Mrs A complained that the GP Practice did not realise the error until July 2023 and that since the hospital would not backdate the referral, her child’s assessment had been delayed by at least 9 months. Mrs A also complained that she had not received a written response to her formal complaint. The GP Practice accepted it had made errors, both in failing to make the referral and failing to respond to Mrs A’s complaint, both of which were administrative oversights. The Ombudsman decided to settle the complaint without investigation. The GP Practice agreed to the Ombudsman’s proposed settlement to definitively establish whether the hospital would backdate the referral, send Mrs A a letter of apology and explanation, reviews its complaints procedure and provide complaint handling training for all its staff.

The Ombudsman set out to investigate Ms D’s complaint about whether appropriate clinical care was provided by the Practice, in relation to her post-natal care during a consultation in January 2024. The investigation also considered whether any delays in handling and responding to the complaint were acceptable. In response to the Ombudsman’s investigation, the Practice confirmed that it was not contractually required to carry out a formal post-natal check-up on the date being investigated. The Ombudsman found no indication that the Practice had failed to provide appropriate post-natal care in that respect. However, Ms D had been concerned about contrary information provided when she booked her appointment, and the Practice accepted that information available to patients on the Practice’s website indicated a post-natal check-up would occur. The Ombudsman concluded that this was potentially misleading for patients and was a failing that was not addressed in the complaint response to Ms D. The Practice confirmed actions that it had taken, and would take, to ensure staff and GPs were conveying appropriate information to patients, and to update its website information. The Practice had already apologised for the delay Ms D experienced in receiving a response to her complaint. In its comments to the Ombudsman, it also provided an explanation and reassurances that complaint handling delays had been the result of exceptional administrative difficulties during a recent merger with another practice. It confirmed that those difficulties had now resolved and that it was now able to keep up with its administrative workload again. In relation to the first matter, the Practice agreed to offer Ms D an apology that information was not made clearer beforehand, and to provide confirmation/further explanation to her about the actions the Practice has taken/will take. The Ombudsman considered this action to be appropriate. In respect of the second complaint point, the Ombudsman considere

Ms P complained that between June and August 2023, her wounds were not appropriately cared for by nursing staff at the Surgery and the risk of infection was not addressed. She also complained that nursing staff did not seek additional input at appropriate times. Ms P said that her wounds took longer to heal than they should have done. The Ombudsman’s investigation found that her wounds were appropriately cared for, the risk of infection was addressed and additional input was sought at appropriate times. The complaint was not upheld.

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.

Ms W complained that the Surgery had failed to respond to her complaint about her husband’s missing prescription. 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 W. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Surgery to apologise to Ms W and provide her with a complaint response, which includes an explanation for the failure, within 2 weeks.

Mrs A complained about the care provided to her late sister by Cardiff and Vale University Health Board and a GP Practice. The Ombudsman found that Mrs A complained to the Health Board in 2022, but she had not received a formal response to her complaints under the Putting Things Right NHS complaints process. She said that this caused uncertainty for Mrs A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Heath Board’s agreement to, within 30 working days: • provide a formal complaint response to Mrs A, to include a response from the GP Practice. • apologise to Mrs A and offer her a payment of £250 to reflect the uncertainty caused.

Miss C complained that her GP Practice failed to respond to a complaint she had raised, in February 2023, appropriately and in a timely manner. We found that the complaints procedure which was in place at the time was not in line with relevant legislation, and the handling of Miss C’s complaint was poor. She did not receive a response for 9 months, and several of her requests for contact and updates on the status of her complaint went unacknowledged. These failings amounted to an injustice for Miss C, because it exacerbated her feelings of distress from the initial circumstances of the complaint and led to her feeling ignored and dismissed by the Practice. It also caused her more time and trouble than would normally be expected when raising a complaint. The Practice had changed its approach to complaints since the time of the events and demonstrated that this had already had a positive influence on complaint resolution. However, we found that no action had been taken to redress the injustice to Miss C or to adequately address the persistent communication failures. In addition, although the Practice had revised its complaint procedure, the new version remained non-compliant with relevant legislation. The Practice agreed to apologise to Miss C and offered her £300 in recognition of the persistent communication failures, and to revise its new complaints procedure to ensure that it was fully compliant with relevant complaint regulations. It also agreed to source and arrange complaint handling training for relevant staff, and to ensure that all staff in the Practice are full informed of their responsibilities in relation to complaint handling.

Miss H complained that Whitchurch Road Surgery failed to address her concerns about alleged malpractice and malicious referrals in its complaint response. The Ombudsman found that whilst the Surgery had issued a complaint response it had failed to adequately address her concerns. She said that this caused frustration and uncertainty to Miss H. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Surgery’s agreement to write to Miss H with an apology for the failure identified and to issue a further complaint response.

Ms N complained that a GP surgery in the Cardiff and Vale University Health Board area (“the Surgery”) failed to address her concerns that it issued a letter containing medical information to her shared home address without an addressee. The Ombudsman found that the Surgery omitted to address this aspect of her complaint which caused additional frustration to Ms N. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Surgery’s agreement to write to Ms N with its apology and explanation of what went wrong.

Mrs S complained that although she submitted a complaint toa GP practice within the Cardiff & Vale University Health Board area, she had not received a complaint response. The Ombudsman found that Mrs S had submitted her complaint in June 2023 and had not received regular or meaningful updates. She concluded that the GP practice failed to act in accordance with its statutory complaint’s procedure. She said this caused frustration to Mrs S. She decided to settle the complaint without an investigation. As an alternative to an investigation, the Ombudsman sought and gained the GP practice’s agreement to provide Mrs S with an apology and explanation for the delay and issue a formal complaint response within 2 weeks.

Mr X complained that he had been mistreated by his GP Surgery for 14 years. He said that although he had raised his concerns regarding prescription issues, had a meeting with the Practice Manager, and contacted the Ombudsman previously, he was still encountering issues going forward. The Ombudsman found that although the GP Surgery had been in contact with Mr X regarding his issues, it had not issued him with a complaint response in line with its statutory complaints procedure. She said this caused frustration and confusion to Mr X. She decided to settle the complaint without an investigation. The GP Surgery agreed to provide Mr X with an apology and complaint response within 30 working days.

Ms A complained that it took approximately 6months for the Practice to prescribe medications prescribed by her former GP Practice in England. She complained that the Practice would not carry out a gene test, did not obtain her paper notes and about the attitude of Reception staff. She also complained that a prescription was not available for collection at the Pharmacy. The evidence suggested that a shared care agreement (SCA) was required before the Practice could prescribe certain medications. The time taken for the referral to and assessment from the Community Mental Health Team was responsible for any perceived delay. The evidence did not suggest the Practice had refused to carry out the gene test. The Practice had apologised for the attitude of its Reception staff and confirmed that training on SCA patients was to take place. It had taken action to resolve any repeat prescription collection issues. However, the Ombudsman was concerned that Ms A’s paper notes had not been obtained. The Ombudsman sought and obtained the Practice’s agreement to, within one month, obtain the paper notes and transfer any missing information to Ms A’s electronic notes on its patient records system. This action was accepted as an alternative to an investigation.

Mr A complained about the care and management his wife, Mrs A, received from a GP Practice (“the Surgery”) in the area of Cardiff & Vale University Health Board following her initial contact with the Surgery about pain and swelling on her lower legs. He also complained about the delayed diagnosis of tendonitis and her subsequent treatment. Mr A was concerned that the GPs used telephone consultations, as opposed to a face-to-face consultation, to diagnose his wife’s leg condition. The Ombudsman found that the GPs telephone and face-to-face consultations were reasonable. Mrs A’s clinical picture was complex, and her presenting symptoms, which evolved, were not typical of tendonitis. She found that whilst the delay in diagnosis was unfortunate, the Ombudsman was satisfied that the Surgery’s management and care of Mrs A’s leg related complaint was appropriate at the time. The Ombudsman was satisfied that it was reasonable for Mrs A’s first consultation to have been held remotely and that a face-to-face appointment would not have led to a different outcome and that that these events took place during the COVID-19 pandemic when national guidance promoted remote consultations except in the most urgent of cases. She was also satisfied that subsequent face to face consultations sought to treat Mrs A appropriately. The Ombudsman did not uphold Mr A’s complaint.

Miss A complained about the care and treatment provided for her late sister, Miss B, by the GPs and staff at the Surgery. Miss A said that the Surgery failed to refer Miss B for urgent investigations for suspected endometrial cancer (cancer of the womb lining) and to provide appropriate treatment and support during her illness. Miss A also said that the Surgery failed to verify Miss B’s date of death before completing her death certificate which was wrong and had to be altered. Finally, Miss A raised concerns about the Surgery’s handling of a complaint made by Miss B before she died. The investigation found that Miss B’s care and treatment had generally been appropriate. Miss B’s age, menstrual history and presentation along with normal investigation findings gave rise to a low suspicion for endometrial cancer and urgent investigations were not indicated. The Surgery had established Miss B’s date of death from information provided by Miss A and later altered the date on the original death certificate at her request. Although there was no requirement for the Surgery to do more to verify the date of death, it was invited to reflect on what had happened in view of the subsequent delay and distress that was caused to Miss A. These aspects of the complaint were not upheld. The Surgery said it had prepared a written response to Miss B’s complaint but had decided not to send it as she was about to start cancer treatment. However, the records showed that the Surgery’s complaint investigation was incomplete. Consequently, the Surgery had missed the opportunity to identify any learning and improvement from the complaint and to reassure Miss B about her ongoing care. The complaint was upheld and the Ombudsman recommended that the Surgery should apologise to Miss A for failing to respond to her sister’s concerns.

Mr X was 78 years old, suffered with type 2 diabetes (on insulin), idiopathic pulmonary arterial hypertension, heart failure, previous lung and colon cancers, atrial fibrillation, and osteoarthritis. Mrs X complained about the treatment her late husband, Mr X, received from the family GP on 17 February 2021 and from the OOHGP on 21 February. On 9 February 2021 Mr X was administered the COVID-19 vaccination (“the vaccination”). Mrs X said that Mr X’s vaccination made him unwell and that both GPS ignored her concern about Mr X’s condition being because of the vaccination. The Ombudsman found that concerns about the vaccination were not raised at the consultations. She also found that there was no indication that Mr X’s presentations were linked to the vaccination and that even had a link been suspected, it would not have influenced his management. The Ombudsman found that both consultations and treatments were to a reasonable standard. The complaint was not upheld.

Ms D complained about the decision of a GP Practice in the area of Cardiff and Vale University Health Board to remove her name from its patient list. She said that the Practice had not taken that decision properly because it made it before discussing its concerns with her, prior to giving her a warning and without taking into account all the relevant facts. The Ombudsman found that the Practice did not take its decision to remove Ms D’s name from its patient list properly. She made that finding, in relation to the decision-making process, for four reasons. Firstly, she was of the view that the Practice did not have full knowledge of the facts. Secondly, she was not satisfied that it considered giving Ms D a warning in accordance with relevant guidance. Thirdly, she was of the view that it did not complete a significant event analysis (a way of formally analysing an incident for learning purposes), as required by its “Violent and Aggressive Patient Policy” (“the Policy”). Finally, she noted that it was unable, despite relevant legislation and guidance, to provide any documentary or video evidence of the meeting in which it made this decision. She considered that those failings had caused Ms D a significant injustice in the form of uncertainty and distress. She upheld Ms D’s complaint. The Ombudsman recommended that the Practice should apologise to Ms D for mistakes related to its decision to remove her name from its patient list and for its failure to demonstrate that it took that decision properly. She asked it to inform the NHS Wales Shared Services Partnership (this body carries out GP registration duties on behalf of the Health Board) that it had not given Ms D a warning, as stated when it asked the Partnership to remove Ms D’s name from its patient list. She recommended that it should also ask the Partnership to update its records accordingly. She asked it to revise the Policy in light of the failings identified. The Practice indicated that it would implement th