PSOW Individual Decisions

Mrs B was concerned that, despite her husband, Mr B, experiencing significant pain in his abdomen and ribs in 2024, clinicians at the GP Practice missed signs of lung cancer symptoms, resulting in a delay in the diagnosis of his cancer. The investigation focused on whether clinicians at the GP Practice acted appropriately when Mr B presented with pain in his abdomen and ribs between July and August 2024. The investigation found that at each of the consultations between July and August 2024, the examinations, possible diagnoses, treatment and actions of the clinicians were within the range of acceptable clinical practice. There was no indication that Mr B should have been referred for a chest X-ray for possible suspected lung cancer before the end of August. The investigation also found that while clinicians appropriately considered Mr B’s history of prostate cancer, including a normal PSA reading in May 2024, prostate cancer was not the cause of Mr B’s lung cancer. The complaint was not upheld.

Mr C complained that a GP Practice in the area of Swansea Bay University Health Board (“the Practice”) had not ensured that his father, Mr A’s, prescriptions were processed correctly and in a timely manner. He further complained that the Practice had not handled his complaints in accordance with the NHS (Concerns and Redress Arrangements) (Wales) Regulations 2011 and associated guidance. The Ombudsman found that there had been frequent errors and discrepancies in the way the Practice processed Mr A’s prescriptions over a period of 14 months. The errors caused delays in supplying Mr A with the medical equipment he needed. The standard of record-keeping was poor and hampered the Practice’s effectiveness in monitoring how prescriptions were being processed. The Practice did not have an up-to-date complaints procedure, and it had failed to acknowledge and adequately respond to Mr C’s complaints. The Ombudsman upheld Mr C’s complaints. The Practice agreed to write to Mr C to apologise for the failings identified and take steps to ensure Mr A’s prescriptions were processed correctly in future. It also agreed to carry out an audit of similar cases, review its records management and complaints procedures, and provide training to staff involved in handling complaints.

Cwynodd Mrs A am y gofal a ddarparwyd gan y Feddygfa i’w phartner diweddar, Mr B, y diwrnod cyn iddo farw. Fe wnaethon ni ymchwilio i weld a oedd y Feddygfa wedi methu ag asesu a rheoli poen yn y frest Mr B yn briodol ar 27 Chwefror 2024. Canfu’r ymchwiliad fod y gofal a ddarparwyd i Mr B gan y Feddygfa ar 27 Chwefror o fewn yr ystod o ofal clinigol priodol. Ni ellid yn rhesymol ddisgwyl i’r meddyg teulu a welodd Mr B ragweld y byddai Mr B yn debygol o farw o ganlyniad i achos cardiaidd o fewn 24 awr, yn seiliedig ar ei symptomau ar adeg yr ymgynghoriad. Yn unol â hynny, ni chadarnhawyd y gŵyn.

Ms X complained that a GP Practice in the area of Swansea Bay University Health Board had failed to respond to the complaint she made to it in July 2024 about the care and treatment provided to her late mother. The Ombudsman found that there had been a significant delay in the Practice responding to the complaint. The Ombudsman said that the delay caused frustration to Ms X. The Ombudsman found that the Practice had written to Ms X in August 2025 and apologised to her for the delay and provided an explanation for it in a letter. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Practice’s agreement to issue the complaint response and to offer Ms X a redress payment of £250 in recognition of the significant delay in issuing the response within 6 weeks.

Miss A complained that the care and treatment provided to her in December 2023 was not clinically appropriate in view of her presenting symptoms. Miss A also raised concerns about the way the Practice handled her complaint including the timeliness and content of the response. The Ombudsman found that, although clinically appropriate care was provided by the Practice, it had not recorded specific, detailed safety advice given. On this basis, it could not be concluded that appropriate information was provided to Miss A. This was an injustice to Miss A as it may have led to a delay in her seeking further treatment for her later symptoms. In addition, due to the significant delay in responding to Miss A’s complaint, and that the response did not provide an explanation or apology for this, the Ombudsman upheld the complaint about how this was managed by the Practice. The Ombudsman recommended that, within 4 weeks, the Practice provide Miss A with a written meaningful apology for the failings identified regarding the lack of detail recorded about the safety netting advice given as well as for complaint handling. In addition, for the Practice to offer Miss A a redress payment of £250 to reflect the time and trouble with raising her complaint. The Ombudsman also recommended that the Practice shared the case with staff to reflect on the shortcomings identified in relation to the lack of specific and detailed documentation of safety netting advice.

Mr B complained that a GP Practice in the Swansea Bay University Health Board area (‘the Practice’) removed his access to a supply of ‘just in case’ antibiotics for his longstanding bilateral bronchiectasis. Mr B had a 7-day supply of antibiotics on repeat prescription but had not had a review of his bronchiectasis or antibiotic use since late 2019. The Practice realised in October 2023 that Mr B had requested 4 issues of antibiotics in the previous 12 months. The Practice Pharmacist attempted to contact Mr B but was unable to. The prescription was therefore altered the prescription so that Mr B could get 1 further prescription with advice that a GP should carry out a review. Mr B made an appointment in December 2023 as he was concerned about his more frequent antibiotic use, which coincided with the Practice wishing to review him. At this appointment the GP referred Mr B to a respiratory consultant for review and their opinion. The GP also removed the ‘just in case’ antibiotics and instead advised Mr B to seek urgent medical help if he felt he required these. The investigation found that the actions of the GP were within the range of appropriate clinical practice, and that the care and treatment provided by the Practice did not amount to service failure which caused a significant injustice or hardship to Mr B. Therefore, the complaint was not upheld.

Mr C complained about the care provided to his late mother, Mrs D, by her GP Practice (“the Practice”). Specifically, Mr C complained that there was a failure by the Practice in April and May 2023 to identify that Mrs D was at risk of deep vein thrombosis (“DVT” – a blood clot that develops within a deep vein in the body) and to take appropriate action. The investigation found that the care provided to Mrs D was appropriate and in line with clinical standards. There were no signs, symptoms or mention of DVT which should have prompted action or consideration of Mrs D’s previous history of venous insufficiency (where veins in the leg are damaged and do not work as efficiently as they should). The Ombudsman did not uphold this complaint.

Miss B complained about the care and treatment provided to her late sister, Miss A, by her GP Practice. The investigation considered whether the decision by Miss A’s GP not to prescribe her with antibiotics, following telephone consultations on 5 and 12 December 2022, was appropriate and whether it was appropriate for the GP to have concluded that a home visit was not necessary. The Ombudsman found that the decision by the GP not to prescribe Miss A with antibiotics following the telephone consultations on 5 and 12 December was not appropriate and furthermore, it was also inappropriate for the GP who spoke to Miss A during the consultations to have concluded that a home visit was not necessary. This was an injustice to Miss A as her presenting symptoms should have resulted in a hospital admission and subsequently, a thorough clinical assessment. Whilst the Ombudsman could not be certain whether Miss A’s outcome would have been any different, this uncertainty is an enduring injustice to Miss B and her family. The Ombudsman upheld the complaint. The Ombudsman recommended that the GP Practice apologise to Miss B, ensure the case is discussed with the GP in question and remind all of its GPs about the importance of recording detailed notes on assessments and examinations carried out on each patient.

Miss B complained about the care and treatment provided to her late son, Mr C, by a GP Practice in the area of Swansea Bay University Health Board. Specifically, the investigation considered whether appropriate clinical care and treatment was provided in relation to Mr C’s mental health between November 2021 and December 2022. The Ombudsman found that the Practice acted reasonably in relation to the mental health care and medication provided to Mr C. However, the clinical care provided by the Practice to Mr C fell below an appropriate standard, on the basis that it did not undertake an adequate or appropriate medication review on 3 August 2022. Although it was unlikely there was any reasonably foreseeable risk of Mr C’s overdose at the time his medication was reviewed, the level of uncertainty is an injustice to Mr C’s family. To that extent, the Ombudsman upheld this complaint. The Ombudsman recommended that the Practice provide Miss B with a written apology for the failures identified by the Ombudsman’s investigation, offer redress of £500 in recognition of failings identified, and share a copy of the investigation report with the Practice GPs. It was also recommended that the Practice review its medication review process to include reasonable attempts at patient contact where clinically indicated or indicated by relevant guidance.

Mr R complained about the care and treatment provided to his wife, Ms R, by a GP Practice in the area of Swansea Bay University Health Board. Specifically, the investigation considered whether a decision to prescribe naproxen (part of a group of medication knows as NSAIDs used to treat plan, inflammation and fever) without a proton pump inhibitor (“a PPI” – medication that reduces acid production in the stomach) was clinically appropriate and whether the prescribing of naproxen, without a PPI, likely caused Ms R to suffer a gastrointestinal bleed and/or stroke (where the blood supply to part of the brain is cut off, causing damage to the brain). The investigation found that Ms R was prescribed a high dose of naproxen and as such the prescription of a PPI should have been offered alongside it. The failure to prescribe a PPI placed Ms R at an avoidable increased risk of experiencing an adverse gastrointestinal event. This part of Mr R’s complaint was upheld. The investigation also found that it was more likely than not that the prescription of naproxen caused Ms R to suffer a gastrointestinal bleed. A prescription of a PPI alongside naproxen would have reduced the risk of this occurring. It can never be known for certain what the outcome for Ms R would have been had a PPI been prescribed with naproxen. This will be a source of lasting uncertainty, which is an injustice. This part of Mr R’s complaint was upheld. The Ombudsman sought and gained the GP Practice’s agreement to apologise to Mr R and Ms R for the failure to offer Ms R a PPI, and to offer them a payment of £500 in recognition of the uncertainty and distress caused by this failure. It also agreed to ensure the GP who prescribed naproxen to Ms R is familiar with NICE guidance on prescribing NSAIDS, in particular how to mitigate any risks this may present through the use of a PPI and the importance of discussing risks with patients.

Ms X complained that a Medical Centre in the area of Swansea Bay University Health Board failed to respond to her complaint submitted to it in October 2024 regarding her abdomen scans. Ms X also complained that it failed to follow its complaints process and had published incorrect contact details for making a complaint. The Ombudsman concluded that the Medical Centre had failed to formally respond to Ms X’s complaint, although noted that the Practice considered that the matter had been resolved during a GP consultation. The Ombudsman said the lack of response caused uncertainty, frustration, and inconvenience to Ms X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Medical Centre’s agreement to issue Ms X with a complaint response within 2 weeks. The response should also include an apology and an explanation for the delay.

Mrs A complained about the care and treatment provided to her late father by the Practice. Mrs A further complained about communication difficulties and the conduct and attitude of staff. Mrs A was dissatisfied with the complaint response provided by the Practice. The Ombudsman was concerned about the Practice’s complaint handling. The Practice had not responded to the first complaint made by Mrs A and its response to her second complaint did not adequately address the matters raised. This caused inconvenience, stress and upset for Mrs A and her family. The Ombudsman decided to settle the complaint without an investigation. The Practice agreed to, within 4 weeks, provide Mrs A with a written apology for the failure to investigate and provide a formal response to her first complaint, the delay in providing a formal response to her second complaint and the failure to fully address matters within its complaint response. The Practice also agreed to provide Mrs A with a further complaint response addressing all matters contained in her complaints.

Mr Y said that the GP Practice, in the area of Swansea Bay University Health Board (“the Practice”) had lost a letter from his late mother’s Optician referring her for further investigations. The Practice confirmed that it had received the letter, but did not explain why there was a 3-month delay in any action being taken. This was a service failure on the part of the Practice in dealing with correspondence. As the issue was not fully addressed in the complaint response received by Mr Y, it was not clear what the circumstances were that caused this failure. It cannot be known what the impact of this was on Mr Y’s mother, which is an injustice to him as he will be left with lasting uncertainty about this. The Practice agreed that, within 1 month, it would apologise to Mr Y for not acting more promptly on the Optician’s referral and the uncertainty this caused. It also agreed, within 2 months, to investigate the circumstances that led to the referral not being acted on and make any necessary changes to prevent this happening again. It agreed any proposed actions will be shared with the Ombudsman.

Mr Y complained that the Practice had not responded to his complaint about the care and treatment provided to his late mother. The Ombudsman found that it had been 6 months since the Practice acknowledged the complaint, but it had not investigated or provided a response. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to apologise to Mr Y and provide a complaint response, within 10 working days.

Mr B complained because he was unhappy with the actions of a GP Practice in the area of Swansea Bay University Health Board (“the Practice”) following the way he was spoken to during a telephone call with a doctor. He was unhappy that his written complaint was responded to by the same doctor. The Ombudsman decided that it was not appropriate for Mr B’s complaint to be responded to by the person named as the subject of the complaint. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to write to Mr B within 10 working days to apologise for how his complaint was dealt with, and to explain the changes the Practice has made to prevent a repeat occurrence.

The Ombudsman investigated a complaint from Mr Y about the way that a trainee GP at the Practice had managed the care of his late wife, Mrs Y, when she had contacted the Practice complaining of a history of 10 days constipation and abdominal pain. A telephone appointment was arranged with the trainee GP who was of the opinion that Mrs Y was suffering from constipation as a result of low fluid intake. He did not arrange to see Mrs Y but told her that if she displayed any “red flag” symptoms she should attend the Emergency Department. 4 days later Mrs Y was admitted to hospital and underwent investigations which identified that she had a bowel perforation in 2 places. Sadly, despite undergoing surgery, Mrs Y died2 days later multi-organ failure, sepsis and perforated colon. The Ombudsman found that there was a failure to take clinically appropriate action and to arrange a face-to-face consultation with Mrs Y, based on the symptoms she presented with during the telephone consultation on 19 July 2021. It was considered, that on balance, a more thorough assessment or clinical examination may have changed the diagnosis of constipation or may have led to a consideration that Mrs Y was suffering from a more serious underlying cause for the constipation, that needed further investigation. The Ombudsman upheld the complaint and recommended that the Practice apologise to Mr Y as it was responsible for the service being delivered to their patients. The Ombudsman did not identify an issue with the manner the trainee GP was being supervised. The Ombudsman would have made a number of recommendations to ensure that the trainee GP reflected and learned from this event to ensure the same shortcomings did not happen again. However, since Health Education and Improvement Wales had already ensured that all relevant actions had been undertaken as part of its usual processes, the Ombudsman was satisfied that no further recommendations were required to ensure future learning and improvemen

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

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

Mrs A complained that a GP Practice in the area of Swansea Bay University Health Board had failed to respond to her complaint, made to the Practice in September 2022, about the care provided to her late mother. The Ombudsman found that there had been an unacceptable delay in the Practice responding to Mrs A’s complaint and it had failed to provide Mrs A with regular and/or meaningful updates, causing frustration to her. The Ombudsman contacted the Practice and it agreed to complete the following actions within 8 weeks: apologise to Mrs A for the delay in responding to her complaint, explain the reasons for the delay, issue the complaint response and pay Mrs A £250 in recognition of the significant delay, the failure to provide meaningful updates and for the time and trouble in making her complaint. The Ombudsman accepted the above actions as an alternative to a formal investigation.

Mrs D complained that SA1 Medical Centre failed to process her prescriptions and that her complaint had not been answered. The Ombudsman found that the Centre had no record of the complaint which was sent by email to the correct address. She said this caused additional frustration to Mrs D. The Ombudsman decided to settlement the complaint without an investigation and sought the Centre’s agreement to formally log the complaint and respond directly to Mrs D.

Mrs C complained that the Surgery had failed to respond to the complaint she made in August 2022 and had not provided her with a copy of a call recording she had requested. The Ombudsman decided that there had been a significant delay by the Surgery to respond to the complaint and request for the call recording. She said this caused inconvenience and frustration for Mrs C. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Surgery to apologise to Mrs C and provide her with £50 redress for the failure to respond to her complaint. The Surgery also agreed to provide Mrs C with a complaint response and copy of the call recording within 3 weeks.

Ms A complained about the decision of the Surgery to remove her name from its patient list without warning. The assessment found that there was insufficient evidence that the decision to remove Ms A from the list was taken properly. In particular, the Surgery did not appear to have documented its decision not to issue a warning or the decision making on the removal. The Ombudsman found that there was likely to have been uncertainty and distress caused to Ms A, as a result of the Surgery’s decision to remove her name from the patient list. Accordingly, the Ombudsman sought and gained the Surgery’s agreement to provide a written apology. The Surgery also agreed to revise its policy in line with relevant guidance and legislation, to issue and record a warning to patients and to properly document its decision to remove a patient’s name from its list. The Surgery agreed to take these actions within a 30 working day period.

Mrs F complained to the Ombudsman (via her Community Health Council advocate) about the GP’s action in respect of wrong information in her medical record. She also had concerns with test results, x-rays and referrals, as well as errors with her medication. The Ombudsman found that the GP’s actions were sufficient in respect of concerns around test results, x-rays and referrals. The Ombudsman also found that the action taken by the GP to resolve errors with her medication was proportionate. However, the Ombudsman was concerned that whilst action to correct Mrs F’s medical record was ongoing, and that a meeting had taken place regarding this, the inaccuracies were still not resolved. The Ombudsman sought and gained the GP’s agreement to review Mrs F’s medical records to ensure that all information is rectified, to provide Mrs F with the revised records to review and, if necessary, arrange a further meeting to discuss identified discrepancies, within 20 working days.

Mr X complained that he had not received a response from the Practice following the complaint he made in March 2022 regarding the care and treatment he received for his shoulder pain. The Ombudsman found that the Practice had failed to provide regular and meaningful updates and had not issued its complaint response. The Practice agreed to complete the following in settlement of Mr X’s complaint within 4 weeks, as an alternative to the Ombudsman investigating it: a) Write to Mr X with an apology for the failure to provide regular and meaningful updates b) provide an explanation for this oversight c) Issue a complaint response.

Mrs A complained about care and treatment provided to her late husband in December 2020 and January 2021. She was unhappy that he was examined in the car park, was not prescribed further medication or offered oxygen and was not referred to hospital. Mrs A did not accept the explanations provided by the Practice. The Ombudsman found that the care provided by the Practice was within the range of appropriate clinical practice at the time and that the explanations given were reasonable. The Ombudsman was concerned that Mr A had not been invited for apneumococcal vaccine, which he was entitled to due to his age and health conditions. The Practice appeared to have an ad hoc system for offering such vaccinations when patients attended. The Ombudsman sought and gained the Practice’s agreement to, within 20 working days, provide Mrs A with an apology for its failure to offer Mr A the pneumococcal vaccination and to review the Practice’s procedures for offering pneumococcal vaccination to patients and consider whether the approach is adequate, particularly in light of the pandemic and reduced face-to-face contacts with patients.