PSOW Individual Decisions

Ms D complained about the standard of care provided to her late mother, Mrs E, by the GP Practice. Ms D complained that, following a home visit in April 2025, the GP did not arrange Mrs E’s admission to hospital. The Ombudsman’s investigation considered the clinical assessment of Mrs E at the home visit, and the action taken as a result of that assessment, including the decision not to arrange Mrs E’s admission to hospital. The Ombudsman found that the clinical assessment of Mrs E during the home visit was appropriate. However, the recording of the clinical findings should have been more detailed. This aspect of the complaint was therefore partly upheld, limited to the associated record keeping. The Ombudsman concluded that the decision not to arrange emergency admission to hospital for Mrs E was not unreasonable or outside of accepted clinical practice. This aspect of the complaint was not upheld.

Mr B complained, via an advocate, about a lack of complaint responses and about various aspects of the care and treatment provided to his wife, Mrs B, by a GP Practice in the Hywel Dda University Health Board area. The Ombudsman considered that Mr B had not had a full response to his complaints made in January and July 2025, which was an injustice. The Ombudsman contacted the Practice, which agreed to undertake the following actions to resolve the complaint. The Practice agreed that within 4 weeks, and in line with the Putting Things Right arrangements, it would investigate and respond fully and clearly to the concerns Mr B raised about it, with explanations of findings and outcomes set out in a manner appropriate for a layperson. The Ombudsman therefore decided to settle the complaint without investigation.

Miss C complained about a GP Practice in the area of Hywel Dda University Health Board. The complaint subject to investigation was whether, between April and August 2024, the GP Practice arranged clinically appropriate investigations/examinations in response to Miss C’s presenting symptoms and patient history. The Ombudsman’s investigation found that the GP Practice’s overall management and care of Miss C in respect of her knee-related complaints during the time period in question was of an appropriate clinical standard and in line with national guidelines. Accordingly, Miss C’s complaint was not upheld.

Ms X complained that the Surgery failed to provide a response to the complaint she submitted to it in February 2025. The Ombudsman found that the Surgery had failed to keep Ms X updated and it had failed to provide a response. The Ombudsman said this caused uncertainty and frustration for Ms X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Surgery’s agreement to, within 4 weeks, issues its complaint response, include an apology and explanation for the delay and to offer £100 financial redress in recognition of the delay and lack of updates.

Mrs A complained that the GP Practice had failed to provide appropriate care and treatment in relation to swabs and urine samples. She also had concerns about the safety of the swab that she had used, which had been placed in a charcoal solution, and that it might have been used on a previous patient. Mrs A was also dissatisfied with the GP Practice’s complaint handling and its complaint response. The Ombudsman’s investigation found that there was a missed opportunity to have stopped Mrs A using the swab when she initially contacted the GP Practice querying whether it was safe. The situation caused Mrs A considerable anxiety and for this reason, and to this extent only, this part of Mrs A’s complaint was upheld. The Ombudsman found no evidence that would suggest that the charcoal swab had been used or might have been used prior to Mrs A, nor was there any evidence that the charcoal was unsafe and may therefore have caused Mrs A physical harm. This aspect of Mrs A’s complaint was not upheld. The Ombudsman’s investigation did identify administrative shortcomings amounting to maladministration in the GP Practice’s complaint handling process, especially around record keeping. As a result the investigation process was not as robust as it could have been and this caused Mrs A an injustice. This part of Mrs A’s complaint was upheld. The GP Practice agreed with the Ombudsman’s recommendation that it review its handling of Mrs A’s complaint as a point of learning and that it develop an action plan to address any failings/additional failings identified, which it should share with the Ombudsman’s office.

Mr A complained to this office that the GP Practice had failed to address his concerns about the way he had been treated by it. Mr A had previously complained to the GP Practice in December 2024, via his Llais Advocate, but the GP Practice had not responded in writing to his complaint. The Ombudsman found that the GP Practice had failed to investigate and respond to Mr A’s complaint as it should have, under the Putting Things Right Arrangements. Instead of investigating this complaint, the Ombudsman sought and gained the GP Practice’s agreement to investigate and respond to Mr A’s complaint, in accordance with the Putting Things Arrangements, and to apologise to him for not having done so in the first instance. The GP Practice agreed to do this within 30 working days.

Mr A complained that a GP Practice in the area of Hywel Dda University Health Board (‘the Practice’) failed to respond to his request for a pre-booked appointment via letter, resulting in a delay in care and treatment. Mr A said that the Practice’s actions were contrary to information on its website, and that its decisions in relation to his requests were wrong. The Ombudsman decided that the Practice did not establish why Mr A was requesting pre-bookable appointments, and it declined his request without this information. The Practice had not clearly explained the reason for its decision, and this caused Mr A frustration because it appeared to be contrary to the information on the Practice’s website, ultimately resulting in a breakdown in the professional relationship. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement within 2 weeks, to apologise to Mr A that it did not establish the reason for his request and for making a decision without this information, to apologise that it did not provide a clear explanation for its decision, and how it appeared to be contrary to the information on its website. The Practice also agreed within 1 month, to review its procedures relating to patient requests for adjustments to ensure all options are explored, and clear reasons are recorded and communicated to the patient, and to ask the Health Board’s Primary Care and Equality, Diversity and Inclusion Team to consider the Practice’s approach to pre-bookable appointments to ensure it is appropriately addressing patients’ needs and accessibility.

Mr A complained about access to an appointment at a GP Practice in the Hywel Dda University Health Board area. He said that he was unable to access an appointment from September to November 2024. Mr A said he had concerns about the ongoing care and treatment accessible to him and about the response he had received from the Practice when he made a complaint about this matter. The Ombudsman found that, although the Practice had provided responses to Mr A, these did not meet expected standards set out in the Putting Things Right arrangements, and he remained unclear as to some aspects of the care and treatment available to him. The Ombudsman considered that Mr A had not had a full response to his complaint and contacted the Practice, which agreed to undertake the following actions to resolve the complaint and as an alternative to a formal investigation. The Ombudsman sought and gained the Practice’s agreement to, within 4 weeks, in line with the Putting Things Right arrangements, investigate and respond fully to the concerns Mr A raised in his complaint about the Practice.

Mr A complained about how the Practice dealt with his complaint, how he was de-listed from the Practice, and the clinical treatment he received from the Practice. After assessment, the Ombudsman found that the Practice had not responded to Mr A’s complaints under the Putting Things Right process. The Ombudsman found that this caused inconvenience and frustration to Mr A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to do the following: Within 1 month, the Practice should: • Provide Mr A with a PTR response for the complaints he’s raised.

Mrs A complained that from October 2022 to March 2023 a GP Practice in the Hywel Dda University Health Board area (“the Practice”) failed to provide appropriate care and treatment for her late mother in respect of her presenting symptoms, condition and past medical history (aortic heart valve replacement in 2007). Mrs A was particularly concerned that there were inappropriate delays and missed opportunities in treating her mother and referring her urgently to the heart failure clinic. Her mother sadly died in May 2023. The investigation found that while there were learning opportunities for the Practice, mainly regarding expediting investigations in deteriorating patients, the care provided had been of an appropriate standard. Importantly, the Practice had sought, in November 2022, to expedite an echocardiogram for Mrs A’s mother and this was the key investigation for her (in accordance with NICE (2021) National Guideline 208: “Heart valve disease presenting in adults: investigation and management”, which placed echocardiographic monitoring at the centre of management). The complaint was therefore not upheld.

Mrs B complained to her GP Practice about care and treatment she had received. This included concerns about a letter she had received from a GP, concerns about her pain management, incorrect information in hospital referrals and access to her medical records. Mrs B complained to the Ombudsman that the response she had received from the GP Practice was brief and did not fully address the concerns she had raised. The assessment of Mrs B’s complaint identified that some aspects of her complaint had not been sufficiently addressed by the GP Practice. The GP Practice agreed to issue a further response to Mrs B. This will include a response to her concerns about pain management and confirmation that her records have been updated to reflect her allergies and current height measurement. The Ombudsman considered the actions taken by the GP Practice were reasonable to settle this complaint and it was closed on that basis.

Mrs H complaint that the Surgery failed to provide a response to her complaint, which she made to it in January 2024. The Ombudsman found that whilst the Surgery had acknowledged the complaint, it had failed to provide a complaint response. The Ombudsman said that this caused frustration and uncertainty to Mrs H and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Surgery’s agreement to write to Mrs H with an apology and explanation for the delay in responding to her complaint and to issue a complaint response within 10 working days.

Mr A’s complaint centred on the alleged delay by a GP Practice in the area of Hywel Dda University Health Board (“the GP Practice”) in October 2021 with diagnosing his father, Mr D, with spinal issues and kidney cancer. The Ombudsman did not find an undue delay in the GP Practice carrying out investigations that led to the diagnosis of Mr D’s cancer. Based on Mr D’s clinical presentation, the conclusion that Mr D’s shoulder pain was musculoskeletal related and therefore required physiotherapy input (from the GP Practice’s in-house physiotherapist and later the physiotherapist team at the local hospital), was not unreasonable. By 21 February 2022 Mr D’s evolving symptoms, coupled with information from the specialist physiotherapist based at the local hospital, led the GP Practice to request a chest X-ray. Mr D was subsequently diagnosed with advanced renal cancer. The Ombudsman did not uphold Mr A’s complaint.

Ms W complained that the Surgery failed to provide a response to her complaint about a reduction in her medication. The Ombudsman found that the Surgery had failed to log Ms W’s concerns as a complaint. She said that this caused frustration and uncertainty to Ms W. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Surgery’s agreement to write to Ms W with an apology and explanation for the oversight, review its processes to prevent this happening again and issue a complaint response within 1 week.

Mr X complained about the care and treatment that he received from a GP Practice in the area of Hywel Dda University Health Board. Specifically, Mr X raised concerns about the care and treatment that he received in relation to chronic pain management and the reduction of his daily opioid dosage; bowel problems; and spinal and cranial problems. The investigation found that the care and treatment Mr X received was reasonable in all instances. The Ombudsman did not uphold the complaints. As no failings were identified, the Ombudsman did not make any recommendations regarding this complaint. 22 June 2023

Mr W complained about the care provided to his mother, Mrs Y, by her GP Practice. Specifically, Mr W complained that the Practice missed opportunities to diagnose Mrs Y’s pancreatic cancer. The Ombudsman’s investigation found that the care provided to Mrs Y on 13 April 2021 fell below expected standards because there was a failure to carry out appropriate clinical assessments. This did not, on balance, cause a delay in diagnosing Mrs Y’s pancreatic cancer and did not affect the course of her illness. However, the investigation found that the inadequate care would have caused additional distress to Mrs Y and her family and may have denied her the opportunity to receive end of life care in her home area. The Ombudsman therefore upheld the complaint. The Ombudsman recommended that the Practice should apologise to Mr W, share a copy of the investigation report with the GP concerned and complete an action plan to demonstrate that it had taken appropriate actions to learn lessons from the failings identified. The Ombudsman was pleased that the Practice agreed to implement these recommendations.

We investigated a complaint made by Mr A in relation to his treatment by a GP Practice (“the Practice”) in the area of Hywel Dda University Health Board, from the period November 2020 onwards. Specifically, whether Mr A’s treatment by the Practice was appropriate in light of his presenting symptoms and available medical history. On the basis of the information seen and the advice received, we found that the treatment given to Mr A by the Practice from November 2020 onwards (until the start of our investigation) was appropriate in light of his presenting symptoms and available medical history. The Ombudsman was satisfied that the care Mr A received, both in terms of the investigations undertaken and referrals made, did not fall below an appropriate standard. Accordingly the complaint was not upheld.

Mr A complained about the care and treatment he received from the Practice. The Ombudsman did not uphold Mr A’s complaint that after registering with the Practice, it failed to obtain his previous clinical records in a timely manner to gain an appropriate understanding of his clinical history. Mr A complained that appropriate consideration was not given to his previous diagnoses (anxiety and bipolar disorder) by the Practice GPs when considering his current clinical diagnosis, he was not appropriately diagnosed and was not offered appropriate treatment and/or referrals for secondary care in a timely manner, and there was a failure to communicate the NHS referrals process appropriately to assist him in making an informed decision about future treatment options. These complaints were not upheld. However, the Ombudsman invited the Practice to reflect on how it explains the referral process for NHS psychiatric care to patients who are awaiting a formal diagnosis. The Ombudsman found that, in relation to Mr A’s request for disclosure of his clinical records, the Practice failed to provide clear, consistent information and failed to maintain an accurate record of its handling of his information request. This complaint was upheld. The Ombudsman upheld Mr A’s complaint about a third party entry recorded in his clinical records to the extent that the encounter was not recorded in line with the Practice’s relevant guidance. The Ombudsman upheld Mr A’s complaint about the decision to de-register him from the Practice to the extent that the process to remove him was not done in accordance with recognised best practice. In relation to Mr A’s concerns that the Practice failed to deal with his complaint in accordance with the Putting Things Right (“PTR”) Process (NHS complaints process), the Ombudsman acknowledged the frustration due to the delay in dealing with his complaint. However, the Ombudsman recognised that the PTR Process made allowances for exceptional circumstances whic

Mr A complained about how a GP Practice in the Betsi Cadwaladr University Health Board area (“the Practice”) had ended a shared care agreement in respect of the provision of ADHD medication for Mr A. Mr A had been diagnosed privately and the shared care agreement had been between the private clinic and the Practice. Mr A was informed of the cancellation of the shared care agreement in October 2022. Since the agreement was ended, Mr A had to pay for the medication at a considerable monthly cost and there had been a risk that he would be unable to obtain the medication needed to manage his symptoms, as the private psychiatrist had intended to discharge him to the care of the Practice. Mr A complained about this matter via his CHC Advocate in November 2022. He did not receive a formal written complaint response to that complaint. The Ombudsman was concerned that the Practice had failed to respond properly to Mr A’s complaint. As an alternative to an investigation, the Ombudsman sought and gained the Practice’s agreement to apologise to Mr A for failing to respond to his complaint and to provide him with a formal written complaint response. It agreed to take these steps within 1 month.

Ms X complained about the care and treatment provided by the Practice to her young son. She said that the Practice failed to examine and correctly treat her son in relation to his severe breathing/nasal problems which were affecting his eating and sleeping. Ms X also complained that the Practice failed to correctly diagnose and treat her son in relation to his eye infection. The investigation found that the Practice carried out appropriate investigations into the symptoms described and made an appropriate referral to the Health Board’s Ear, Nose and Throat department (“the ENT”). (The Practice had also made a reasonable decision that the advice from ENT was adequate). The investigation found that the assessment and management of the child’s eye infection was reasonable. A swab was taken, an examination carried out and medication prescribed. Although antibiotics were prescribed a few days later, the Ombudsman was satisfied that this did not amount to unreasonable care and treatment, particularly as this appeared to have resolved the problem.

Mr N complained that between 26 November 2020 and August 2021, the GP Practice (“the Practice”) should have identified his cancer sooner. The investigation found that between 26 November 2020 and August 2021, the care provided to Mr N during the 3 contacts he had with the Practice were reasonable and appropriate. Accordingly, there was no evidence that the Practice should have identified Mr N’s cancer sooner. The Ombudsman did not uphold the complaint.

Ms L complained that despite raising concerns in June 2022, she had not received a response or resolution to her complaint. The Ombudsman concluded that the Surgery failed to comply with its statutory complaint’s procedure, and said this caused frustration to Ms L. As an alternative to an investigation, the Ombudsman sought and gained the Surgery’s agreement to write to Ms L and provide an apology and response within 30 working days.

Ms X complained about a letter sent to her by a GP Practice in the area of Hywel Dda University Health Board (“the Practice”) which warned her about her behaviour. Ms X said that the information contained in the letter contradicted her version of events and that of her Support Worker, present at the time. The Ombudsman found that there was a discrepancy in the version of events provided by the Practice and that provided by Ms X’s Support Worker. However, in the absence of other evidence, she was not able to reconcile the differing accounts in a way that would allow her to reach a definitive finding. That said, the Ombudsman considered that the statement of the Support Worker should form part of the Practice records to reflect the differing recollections. The Ombudsman contacted the Practice, and in resolution of Ms X’s complaint, it agreed to, within 10 working days, to provide Ms X with written confirmation that the statement of her Support Worker had been appended to the letter sent to her by the Practice, and formed part of the Practice records.

Mr S complained that the Surgery de-registered him from the practice due to him submitting a complaint. He further complained that despite him submitting his complaints, he had not received a full response. The Ombudsman was concerned that Mr S had not yet received a response to his concerns and therefore contacted the Surgery. As an alternative to an investigation, the Surgery agreed that it would write to Mr S and apologise for the concerns raised within 20 working days of the Ombudsman’s decision letter. The Surgery also agreed that to resolve the concerns raised by Mr S, it would propose a face-to-face meeting with him to action any concerns that were outstanding. The Ombudsman accepted this as a resolution to Mr S’s complaint.

Miss X complained that despite raising concerns with her GP Surgery in November 2021, it had not acted upon nor formally responded to her complaint. The Ombudsman contacted the GP Surgery, and it agreed to apologise for not acting on the concerns raised within a timely manner and issue a formal written response within 30 working days of the Ombudsman’s decision. The Ombudsman accepted this as a sufficient resolution of Miss X’s complaint.