SPSO Individual Decisions

C complained that the practice failed to provide them with reasonable care and treatment. C attended the practice with symptoms of an ear infection. C said that they were not prescribed appropriate medication and were unreasonably diagnosed with an outer ear infection. C felt that a swab that was taken damaged their ear. We took independent advice from a GP. We found that while their communication could have been better, the practice provided reasonable care and treatment in line with the history and information available at the time, and the relevant guidance. The evidence does not suggest that the ear swab caused C’s hearing loss and the practice's rationale for performing the swab was in line with local guidance. We found that the treatment provided was reasonable. We did not uphold C's complaint. Related reading View Decision Report 202409557 as a PDF (24.16 KB) Updated: September 17, 2025

C complained that their GP practice failed to provide them with reasonable care and treatment. C attended the practice with loss of appetite, vomiting, concentrated urine, poor fluid intake, a temperature of 38.7 degrees, and a high heart rate. C was prescribed antibiotics and given advice on what to do if their condition worsened. C’s condition deteriorated and they attended the practice again. C was referred for a chest x-ray and diagnosed with empyema (pockets of pus that have collected inside a body cavity). C’s condition was life-threatening and they remain impacted by it. In their response to the complaint, the practice arranged an independent review of C's treatment by a respiratory consultant. They noted that C had a significant tachycardia (heart rate exceeding 100 beats per minute at rest). The practice said that this could have been discussed with the Acute Medical Unit at the time. However, it was likely that they would have advised to treat C at home rather than to admit them. We took independent advice from a GP. We found that C’s presentation and clinical examination findings were suggestive of pneumonia at least, and indicated that they were at high risk of sepsis. We found that C should have been admitted to hospital rather than sent home with antibiotics. Therefore, we upheld C's complaint. During the course of our investigation the practice confirmed further reflection and learning. We were satisfied that in doing so they had appropriately addressed the failings in C’s care.

C complained about the care and treatment that their late sibling (A) received from the practice. A attended the practice with back pain and was given painkillers. Clinical staff noted comments on A’s appearance and demeanour during the appointment. They also noted that they considered A to be drug seeking. A died a few days later. C complained that the examination was not thorough enough and that clinicians missed the fact that a lung infection was the cause of A’s symptoms. The practice said that they considered the examination to be reasonable, that they felt that A did not present with typical signs of respiratory concern and so auscultation (listening to the lungs) was not indicated. They did not identify anything that could have been done differently. We took independent clinical advice from an advanced nurse practitioner. We considered that there were enough complicating factors in A’s history and presentation to warrant a more thorough examination of A. Therefore, the examination carried out was unreasonable. We found that the opinion that A was drug-seeking was premature as no differential diagnoses were considered or ruled out. We also noted that an adverse event review was not carried out which we considered to be unreasonable. Therefore, we upheld C’s complaint.

C complained about the care and treatment that they received from the practice prior to their diagnosis of an abdominal cyst, which was surgically removed some years after C first attended the practice with symptoms. C complained that they did not receive a referral for an ultrasound scan until many months after first attending the practice with symptoms. C also complained that four different doctors were involved in their care and that the practice’s complaint handling was unreasonable. We took independent GP advice. C’s case was complex and challenging due to the nature of C’s cyst, C’s other diagnoses and the timing of C’s consultations during the COVID-19 pandemic. Nevertheless, we found that there was a missed opportunity for the practice to refer C to the colorectal service based on the positive result of a qFIT test (a test to detect blood in the stool) when C first attended the practice with symptoms, based on the National Institute for Health and Care Excellence (NICE) guidance. We found that there was a further missed opportunity for the practice to consider referring C to secondary care based on C’s subsequent positive qFIT test result, which was taken many months after the first positive qFIT test. We also found that there were delays in the practice contacting C after receiving the result of the subsequent qFIT test and when the practice received the result of C’s ultrasound. We found that, given the state of NHS services at the time C attended the practice, there was not likely a significant delay in C receiving a diagnosis or surgery for their cyst. On balance, we upheld C’s complaint about their care and treatment from the practice. We found that the practice’s complaints handling was unreasonable, because the first complaint response did not address the issues C raised as a complaint. We upheld C’s complaint about the practice’s complaints handling.

C complained about the practice's care and treatment of their parent (A) who died as a result of sepsis several days after being admitted to hospital. According to the death certificate, one of the underlying causes of A's death from sepsis was an infected grade four sacral ulcer (an injury that breaks down the skin and underlying tissue, grade 4 is the most severe type) that had been there for several months. C complained that in the period preceding admission to hospital, GPs from the practice never assessed A's sacral ulcer, despite C's requests for them to do so. C complained about a house visit consultation carried out by a GP (GP1) when the family suspected A may have sepsis. They complained about GP1's decision to prescribe oral antibiotics even though A was known to have swallowing problems. C also complained about the GP's refusal to assess the ulcer visually and their decision not to arrange admission to hospital. C also complained about a telephone consultation a few days later, in which a GP (GP 2) declined to carry out a house visit and arranged admission to hospital on a non-urgent basis. We took independent advice from a GP. We accepted GP1's clinical assessment that oral antibiotics were appropriate. However, we were critical of GP1's failure to record observations during the house visit, noting that in the absence of these records it was not possible to establish the basis on which GP1 concluded A did not have sepsis. We found it unreasonable that GP2 declined to carry out a house visit or arrange urgent admission to hospital, even though this may not have changed the ultimate outcome for A. We found there were omissions in the records in relation to anticipatory care/palliative care planning. There was also a lack of recorded discussions with A's family. Taking all of this into account we upheld C's complaint.

C complained that they did not receive appropriate care and treatment from their GP practice in relation to the diagnosis and treatment of menopause symptoms. C felt the practice did not take their menopause symptoms seriously and that GPs were not up to date with current guidance when C was offered antidepressants in response to menopause symptoms. As such, C complained that the practice failed to recognise and appropriately treat the symptoms of menopause, leading to a delay in diagnosis and treatment. The practice considered that the care and treatment provided to C had been reasonable. We took independent advice from a GP. We found that there had been a number of missed opportunities to diagnose menopause, that consideration had not been given to the relevant NICE Guideline NG23 (National Institute for Health and Care Excellence guideline on Menopause: Diagnosis and Management), and that GPs had failed to consider alternative hormone replacement treatment (HRT) preparations during a period of national shortage. This led to a delay in the diagnosis and treatment of C's menopause. As such, we upheld C's complaint.

C complained to the practice about a delay in prescribing them with medication for high blood pressure, and as a result C suffered a heart attack. C said that they had attended the practice on a number of occasions within a few months with recurring chest pains, breathlessness and dizziness. C had their blood pressure read and electrocardiograms (ECGs) taken a number of times. C saw a GP and reported chest pain and dizziness. The GP put this down to muscle spasm and arranged another ECG and blood pressure reading. C was then given tablets for their blood pressure. The following day, C was admitted to hospital to have a stent inserted as they had suffered a heart attack. The practice explained that C had had a number of contacts within a few months, and was seen by 11 GPs. Most of the contacts related to C's respiratory problems of Chronic Obstructive Pulmonary Disease (COPD). C's blood pressure was discussed with a GP and further readings were arranged either at the practice or read by C at their home and telephoned to the practice. It was when C reported chest pain a few months later that further investigations were conducted and the decision was taken to provide antihypertensive medication (used to lower high blood pressure). We took independent clinical advice from a GP. We found that the practice had provided a reasonable standard of treatment to C. Their blood pressure readings were monitored both in the practice and at home and subsequently, arrangements were made to prescribe medication when it was appropriate to do so. We did not uphold the complaint. Related reading View Decision Report 202000476 as a PDF (24.52 KB) Updated: April 20, 2022

C complained on behalf of their parent (A). A had dementia, lived in their own home and took a number of medications. C raised concerns that A was not able to take their medication safely without supervision. We took independent advice from a GP. We found that the primary responsibility of the practice was to prescribe appropriate medication for A's condition. They also had a role in assessing A's mental state and making appropriate referrals to other specialists. In terms of those responsibilities, we found that there was no evidence of failure on the practice's part. There was a problem with one of A's prescriptions when they changed pharmacy. The practice addressed this problem quickly and an appropriate apology was given. As such, we did not uphold the complaint. Related reading View Decision Report 202003178 as a PDF (24.12 KB) Updated: December 22, 2021

C complained about the treatment which they received from the practice. C said that they were ill and had been discharged from hospital following a diagnosis of pancreatitis (inflammation of the pancreas). C saw a GP twice in one month, who diagnosed gastric issues and prescribed Peptac (medication for heartburn/indigestion). C said that they continued to worsen and saw the GP again, who again felt the problem was gastric issues and increased the dosage of Omeprazole (medication for heartburn/indigestion). C said that their condition again worsened and two days later C was admitted to hospital as an emergency where it was found that they had a pancreatic infection, and C remained as an in-patient for some weeks. C felt that their concerns had been dismissed and that, had appropriate treatment been given, their condition would not have been so severe or life-threatening. We took independent advice from a GP. We found that the practice had provided appropriate care and treatment in view of C's reported symptoms and medical history. There was no clinical requirement that C should have been admitted to hospital at an earlier date. We did not uphold the complaint. Related reading View Decision Report 202002252 as a PDF (24.28 KB) Updated: January 20, 2021

Mrs C complained that the practice had failed to properly investigate a series of complaints she had made about entries in her and her children's medical records. Mrs C believed the practice's conclusions were unreasonable given the available evidence. Mrs C also complained that the practice failed to communicate appropriately with her. We took independent advice from an adviser on general practice medicine. We found that the practice had reasonably and appropriately investigated the complaints brought to it by Mrs C and had communicated reasonably with her. Some of the medical record entries that Mrs C objected to were the opinions of the GP following their encounter with her. We considered that it was reasonable for medical records to contain subjective opinion and it was not possible to amend or delete the entries Mrs C was concerned about. In addition, the practice had offered Mrs C the opportunity to place notes in her medical records, indicating that she disagreed with the content or tone of the entries. Mrs C had not responded to these offers. We did not uphold any of Mrs C's complaints. Related reading View Decision Report 201804064 as a PDF (24.23 KB) Updated: October 21, 2020

Ms C complained to us about the care and treatment she received from her GP practice. She said that staff at the practice had not listened to her and had not provided reasonable care and treatment for her adhesions, diarrhoea and Myalgic Encephalomyelitis (ME; a long-term illness with a wide range of symptoms including extreme tiredness). She also said that the practice seemed fixated by her having depression and that she needed bereavement counselling or antidepressants without understanding her situation. We took independent advice from a GP. We found that there was no evidence that staff had not listened to Ms C and that they had provided reasonable care and treatment in relation to her adhesions, diarrhoea and ME. It was also reasonable for the practice to offer Ms C bereavement counselling along with other treatment in relation to this. We considered that the care and treatment provided to Ms C was reasonable and we did not uphold the complaint. Related reading View Decision Report 201807031 as a PDF (24.15 KB) Updated: July 22, 2020

Ms C complained to us about the practice after she was diagnosed with secondary breast cancer in her lymph nodes. She had been attending the practice with a number of separate symptoms including a drooping right eye, fatigue; pain in her right shoulder, a rasping voice, vomiting and fainting. She did not consider that these symptoms were ever properly considered as a whole, which may have prompted an earlier diagnosis. She was also concerned that there was a failure to appropriately ready her for the diagnosis, claiming she had been repeatedly reassured her symptoms did not point towards a serious diagnosis. We took independent advice from a GP. We found that the symptoms were relatively common and were not suggestive of a cancer diagnosis. Given this, we considered that the practice's communication with Ms C had been reasonable. We did not uphold either of Ms C's complaints. Related reading View Decision Report 201903361 as a PDF (24.16 KB) Updated: June 17, 2020

Ms C complained on behalf of her late uncle (Mr A) about the care and treatment he received from his GP practice. Ms C complained that the practice failed to treat Mr A as an urgent patient, even though he was experiencing symptoms that could have been caused by a stroke. We took independent medical advice from a GP. We found that when Mr A contacted the practice, he did not provide information that suggested it was an emergency and it was reasonable that the GP arranged to see him later that week. However, the next day, Mr A's wife (Ms B) contacted the practice with concerns about Mr A's condition worsening and she spoke to another GP. Ms B asked for Mr A to be seen earlier but this was refused. We found that during this phone call, the GP failed to carry out an appropriate assessment of Mr A's condition, did not communicate reasonably, and inappropriately failed to see Mr A urgently, even though the symptoms Ms B described could have been caused by a stroke. We upheld Ms C's complaint.

Mr C complained to us on behalf of his late father (Mr A) who was diagnosed with and subsequently died as a result of septic arthritis (a serious type of joint infection). Mr C complained that the practice failed to provide reasonable care and treatment in relation to Mr A's shoulder pain, including providing phone consultations rather than face-to-face assessments and that the practice did not refer Mr A for x-ray or to orthopaedics (specialism that deals with diseases and injuries of the musculoskeletal system). Mr C considered that this had caused delays with Mr A being diagnosed with joint sepsis. We found that the practice's consultations and care and treatment that Mr A received were reasonable, including referring Mr A to physiotherapy. Therefore, we did not uphold this complaint. Related reading View Decision Report 201808146 as a PDF (24.1 KB) Updated: March 18, 2020

Miss C complained to us that the medical practice had failed to provide her with appropriate care and treatment. She had attended the practice for a medical certificate following her recent attendance at A&E where she was diagnosed with a fractured finger and had her fingers strapped. Miss C said that the practice failed to manage her care appropriately in liaising with hospital staff and delayed making a referral to the hand clinic. Related reading View Decision Report 201805197 as a PDF (23.51 KB) Updated: June 19, 2019

Mr C complained about the information which a GP entered on a form for Employment Support Allowance (ESA). The GP had included historical information in Mr C's medical records, which Mr C felt was not relevant. We took independent medical advice from a GP. We found that although the information was contained in Mr C's medical records, it was not relevant to the reasons why Mr C was unable to work at that time. The form does not ask for a summary of a patient's past medical history but rather about the patient's current medical conditions which may be a barrier to them being fit for employment. We upheld the complaint.

Ms C complained about the care provided to her late mother (Mrs A) by the practice. Mrs A had attended the practice on a number of occasions with chest pains, confusion, arm weakness and sight problems. Mrs A also had a history of high cholesterol (a fatty substance found in the body that can increase risk of health conditions) and a family history of heart problems. Mrs A later died at home and Ms C felt that the GPs involved in her care should have made earlier referrals to hospital specialists. We took independent medical advice from a GP. We found that although Mrs A had attended the practice on a number of occasions before her death, she had not reported chest pain for a period of six months and it was felt reasonable that the staff had assumed her previously reported symptoms had resolved. During previous consultations with GPs they had considered a number of diagnoses and prescribed appropriate medication for the symptoms which were reported. There were also attendances at hospital where scan results were reported as being normal. Therefore, we did not uphold Ms C's complaint. However, we provided feedback to the practice that on one occasion, there was a need to make a referral to cardiology for further investigation and to provide Mrs A with safety netting advice. While there was no evidence that this would have prevented Mrs A's death, it may have led to an earlier diagnosis of heart problems and allowed treatment options if required. Related reading View Decision Report 201800557 as a PDF (24.08 KB) Updated: May 22, 2019

Mr C complained that the practice unreasonably removed him from the patient list. Mr C had been in correspondence with the practice about matters not connected with his NHS treatment. Mr C received a letter from the practice in which the suggestion was made that perhaps it would be for the benefit of all concerned that he should move to another GP practice. Mr C was dissatisfied with the practice letter and wrote back to them asking for more clarification. He then received a further letter from the practice advising him that they had requested that the health board remove him from their patient list due to a breakdown in the relationship between himself and the practice. Mr C complained about his removal from the list and the fact that he was not given any specific information about why he was removed. We took into account the contractual regulations and relevant guidance regarding the removal of patients from the practice list. This sets out that, other than in cases involving violence or aggression, a patient whose behaviour is giving cause for concern should be given a written warning informing them that they will be removed from the practice list if they do not alter their behaviour. The warning should last for 12 months. While the practice did have concerns about Mr C's correspondence, staff did not formally bring them to Mr C's attention in line with the regulations and guidance and, therefore, he was unaware of the practice's concerns. We upheld the complaint.

Ms C, an advocacy worker, complained on behalf of her client (Ms A) about the care and treatment provided by the practice. Ms C complained that there had been unreasonable delays in the diagnosis of Ms A's bladder cancer and that a urology referral should have been made earlier. We took independent advice from a GP. We found that the referral to urology (the branch of medicine that specialises in the male and female urinary tract, and the male reproductive organs) had been made at the appropriate point and that the care provided to Ms A was reasonable for the symptoms she reported across the period covered by the complaint. We did not uphold Ms C's complaint. Related reading View Decision Report 201800504 as a PDF (23.66 KB) Updated: January 23, 2019

Mr C and Ms C complained about the care and treatment provided to their late son (Mr A) and about the practice's response to their complaint. Mr A had a history of mental ill-health and attended his GP practice concerned about a deterioration in his mental health. Shortly after his last attendance at the practice, Mr A completed suicide. Mr C and Ms C were concerned that the GP who cared for Mr A failed unreasonably to recognise that he was at significant risk of suicide and refer him immediately for psychiatric in-patient care. We took independent advice from a GP adviser. We found that the standard of medical care and treatment provided to Mr A in the weeks leading up to his death was reasonable and that his death could not have been predicted or avoided by the GP. We also found that the practice responded to Mr C and Ms C's complaint reasonably. We did not uphold either complaint. Related reading View Decision Report 201706197 as a PDF (11.01 KB) Updated: December 2, 2018

Ms C complained that the care and treatment she received from her medical practice was unreasonable. Ms C said that she called the practice for an emergency appointment because she was experiencing extreme pain, and that it was only after she called a number of times that she was given an appointment. She was diagnosed with a vaginal swelling, given antibiotics and advised what to do should her condition worsen. Ms C was seen again at the practice the next day, when it was decided that she should be admitted to hospital. Ms C complained that there had been a delay in offering her a GP appointment, and that she had been incorrectly treated with antibiotics rather than referred to hospital. We took independent advice from a GP adviser. We found that Ms C was given an appointment within a reasonable time. We also found that it was in accordance with General Medical Council good practice advice that she was given antibiotics and advice in the first instance. We did not uphold the complaint. Related reading View Decision Report 201708061 as a PDF (11.05 KB) Updated: December 2, 2018

Mrs C complained to us that the practice had failed to provide her with appropriate care and treatment. She had reported to her GP that she was feeling down since the death of a relative and that she had self harmed. She was also concerned about a mouth infection. Mrs C said that the GP showed no interest, telling her to attend a dentist for the mouth problem and that she should wait for contact from the mental health services, who were already in contact with Mrs C. The GP told Mrs C that it was her responsibility to chase up the mental health services. We took independent advice from a GP adviser. We found that it was appropriate for the GP to have referred Mrs C to her dentist as it would not be within a GP's remit to treat patients with dental problems. We also found that, when Mrs C attended the GP, there was no clinical indication for an immediate referral to the mental health services. The department within the mental health services which Mrs C was already attending operated a self-referral facility and there was no need for the GP to make a formal referral. We did not uphold the complaint. Related reading View Decision Report 201709126 as a PDF (11.12 KB) Updated: December 2, 2018

Mr C complained that his GP unreasonably stopped his diabetic medication, and that the practice later inapppropriately removed him from their patient list. Mr C subseuqently withdrew his complaint and no findings were reached. We closed our case. Related reading View Decision Report 201706941 as a PDF (10.72 KB) Updated: December 2, 2018

Mr C complained that the practice had failed to provide appropriate care and treatment to his daughter (Miss A). He said that the practice had failed to provide Miss A with an emergency appointment when a phone call was made to them one morning advising them that Miss A was showing symptoms of severe mental health issues, including self-harm and suicidal thoughts. The practice said that they were unable to see Miss A until later in the evening and gave advice that Miss A should attend the local accident and emergency department. Miss A was taken to the hospital and subsequently was transferred to another hospital for patients with mental health issues. Mr C believed that the practice should have made arrangements to see Miss A as an emergency that morning rather than her having to wait a number of hours at the hospital for an assessment. Mr C also complained about a previous consultation Miss A had with a GP at the practice where she was complaining about depression. Mr C said Miss A was not given any medication, but advised to make another appointment and to bring her mother with her and that a discussion would take place then about medication. Mr C felt that, as Miss C was of adult age, she did not require her mother to be there. We took independent advice from an adviser in general practice medicine and concluded that the practice had provided a reasonable level of care. We found that the practice gave appropriate advice that Miss A should attend the nearest accident and emergency department as this way she was seen quicker than had she waited for the first available practice consultation slot later that day. We also concluded that a reasonable clinical assessment had been carried out at a previous GP consultation where the GP had taken an appropriate history and gave Miss A reasonable advice. Miss A had mentioned to the GP that her mother may not agree with the GP's proposed treatment plan and it was decided that she should make a review appointment af

Mr C complained on behalf of his late wife (Mrs A) about the care and treatment she received from her GP practice. Mrs A attended the practice with stomach pains but it was not until two years after her pain began that she was diagnosed with cholangiocarcinoma (CCA, a very rare cancer of the bileduct). Mr C complained that the practice had delayed in carrying out appropriate tests and investigations. The practice said that Mrs A had been treated and cared for reasonably. They explained the rarity of her illness and said that that her symptoms had not been specific for a diagnosis of CCA. Mr C was unhappy with this response and brought his complaint to us. We took independent advice from a GP. We found that, as well as Mrs A's illness being extremely rare, it was also very difficult to diagnose at an early stage and was often found incidentally. Mrs A initially attended the practice with abdominal pain for which she was appropriately treated. There was no indication at that time for further investigations and Mrs A noted an improvement. She did not return to the practice with abdominal pain until two years later. At this time, all her liver tests were normal; and showed no cause for concern. However, as her symptoms worsened, she was admitted to hospital and was diagnosed with CCA. We found that the care and treatment Mrs A received from the practice was reasonable and, therefore, we did not uphold this complaint. Related reading View Decision Report 201703356 as a PDF (11.29 KB) Updated: December 2, 2018