Cancelled appointment follow-up

Hospital policies for cancelled appointments lacking clinical input to assess individual patient urgency, risking vulnerable patients.

144 items 9 sources
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Where this theme appears

Cancelled appointment follow-up has been flagged across 9 independent accountability sources:

22 PFD reports 3 committee recs 2 CQC actions 4 PPO recs 3 IMB reports 15 IMB recs 1 Article 2 learning point 25 PHSO decisions 69 LGO/SPSO decisions

When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.

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Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.

Amanda Hawkins
26 Nov 2014 · Staffordshire (South)
Concerns: Patient vulnerability was exacerbated by service changes and failures in coordinating care, including sending critical appointment letters directly to a patient unable to understand them, and a lack of follow-up on missed appointments.
Response (Dudley Walsall NHS Trust): The Trust will ensure outpatient letters from CRS North medical teams are copied to the care coordinator. A working group led by the Head of Recovery Services is looking at …
Overdue
Suzanne Greenwood
09 Oct 2015 · Manchester (West)
Concerns: Lack of systems and protocols for contacting patients who miss appointments, informing GPs of non-attendance or discharge, and ensuring continuity of care when patients are lost to follow-up.
Response (Priory Group): The Priory Group amended its policy regarding independent doctors, requiring prompt GP contact for missed appointments and detailed discharge letters. The amended policy has been circulated, discussed at meetings, and …
Responded
Shelia Stokes
09 Dec 2016 · Nottinghamshire
Concerns: Systemic delays plagued patient care, including following up on missed appointments, acting on alerts, and an inadequate protocol for obtaining custom-made grafts, all exacerbated by an incomplete internal investigation.
Response (Sherwood Forest Hospitals NHS Trust): Sherwood Forest Hospitals NHS Trust has determined that following referral of Mrs. S to the vascular team, a letter was sent to Mrs. Stokes on 15 July 2015. Following this …
Response (Radiology Department): The Radiology Department will review and modify its XXXX policy to take account of electronic reporting and a referrer acknowledgement system.
Responded
Ann Hardman
10 Oct 2016 · Isle of Wight
Concerns: The DVT scan protocol relies on GP referrals for follow-up, risking patients missing re-scans. An automatic re-booking system from the ultrasound department is needed to improve compliance.
Response (Isle of Wight NHS Trust): The Isle of Wight NHS Trust now books a repeat ultrasound scan for patients with a D-Dimer positive blood result but a negative initial scan, and will inform the GP …
Responded
Luke Moulding
13 Apr 2017 · Bedfordshire and Luton
Concerns: A critical "opt-in" follow-up letter was not sent after a psychiatric consultation, and the current system of typing letters rather than using pre-printed materials caused significant delays.
Response (East London NHS Trust): The Trust has updated its Operational Policy for CMHT, now requiring opt-in letters to be sent within 5 working days, subject to local audit. This followed a serious incident review …
Responded
Michael Halfpenny
01 Jun 2017 · Leicester City and Leicestershire South
Concerns: A GP referral for vascular screening was sent to the wrong department and refused, with no follow-up. Both GP practice and hospital screening teams lacked awareness and proper systems for managing screening referrals.
Response (Glenfield Surgery): The surgery will raise the case as a discussion point in a practice meeting, make all doctors aware of self-referrals, and produce posters to put up in the waiting room …
Response (University Hospitals of Leicester NHS Trust): The Trust has reviewed the process for rejecting imaging referrals and is strengthening the relevant guideline to include a clear statement of why the rejection was made. A new system …
Response (East Leicestershire and Rutland Clincial Commisioning Group): The CCG has enclosed the signed final report regarding the Serious Incident investigation into this case and confirmed that they have contacted the family to share the report.
Responded
Robert Power
09 Jul 2018 · Gloucestershire
Concerns: A patient was "lost to follow-up" for eight years after an incorrect diagnosis, highlighting a risk of future deaths if outpatient care is not consistently maintained.
Response (North Bristol NHS Trust): The Trust acknowledges receipt of the coroner's letter and confirms that the Trust now works under different systems than in 2008 with processes to arrange follow-up appointments; they have no …
Responded
John Lee
19 Oct 2018 · Mid Kent and Medway
Concerns: A clerical error severely delayed an urgent vascular appointment, changing an elective procedure to an emergency and contributing to the patient's death, highlighting issues with ambiguous terminology and inadequate checking systems.
Overdue
Connor Davies
29 Nov 2019 · South Wales Central
Concerns: Repeated cancellation of consultant psychiatrist appointments without clinical input on patient urgency meant individuals at serious need could "fall through the net," as a preventative system was not yet operational.
Response: The University Health Board has developed an action plan to address the matters raised during the inquest and all outstanding actions are being implemented by the Mental Health Directorate.
Responded
Gemma Azhar
11 Feb 2020 · West Sussex
Concerns: Repeated mental health appointment cancellations by administrators, without clinical follow-up, left patients at risk. The "formal position" for duty worker contact after cancellations lacks proper policy, training, or consistent application.
Response (Sussex Community NHS Foundation Trust): Sussex Community NHS Foundation Trust has reviewed its Time to Talk Service procedures. A new Standard Operating Procedure (SOP) was developed regarding the use of the 'Reasonable Adjustments Alert' on …
Responded
Imre Thomas
04 Apr 2021 · Lancashire and Blackburn with Darwen
Concerns: Cancelled hospital appointments put vulnerable prisoners at risk, highlighting a need to investigate organizing special prison clinics for hospital consultants.
Overdue
Hannah Bampfylde
05 May 2021 · Surrey
Concerns: Poor communication protocols meant Hannah's GP was unaware of her non-engagement with mental health services. The engagement policy lacked clarity on re-booking appointments and escalating non-attendance, allowing newly referred patients to slip through the system.
Response (Sussex Partnership NHS Foundation Trust): Since September 2020, the Referral Co-ordinator is the person who books any further initial assessment appointments and not the Team Administrator. The requirement to notify the GP is stated in …
Responded
Stephen Barton
01 Oct 2021 · Staffordshire South
Concerns: The NHS lacks a system for tracking non-cancer outpatient appointments, unlike cancer cases. Implementing such a system could prevent unnecessary deaths and improve administrative efficiency.
Overdue
Hugo Carlos
01 Feb 2023 · Berkshire
Concerns: The GP clinical system lacks a scheduled task feature for future alerts, burdening patients with follow-up responsibility and risking missed essential investigations.
Overdue
Rachelle Ross
17 Feb 2023 · Newcastle upon Tyne and North Tyneside
Concerns: GP IT systems lack automatic flags for patients who miss national smear test invitations, leading to inconsistent follow-up and reduced patient safety.
Response (Response NHS England): NHS England acknowledges the concerns raised regarding the lack of automatic flags for non-responders to cervical screening in GP systems, clarifies the routine invitation process, and highlights ongoing work to …
Response (TPP LTD): TPP confirms that SystmOne has an automatic alert for cervical smears, irrespective of whether a patient has had one, but GPs are not informed when patients don't respond to invitations …
Response (EMIS): EMIS expresses condolences and states that their system already meets the recommendation of including an automatic flag/alert when a patient fails to attend for cervical screening as part of the …
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges concerns about patient record systems and alerts for non-responders for smear tests and states NHS England is creating a new IT Cervical …
Responded
Jacqueline Cobain
25 Mar 2024 · London Inner (South)
Concerns: Concerning responses to an automatic questionnaire were not reviewed by a clinician until after the patient's death because the appointment had been cancelled; there is no system or protocol to alert a clinician to review concerning responses when the assessment appointment is not for several days/weeks.
Response (South London and Maudsley NHS Foundation Trust): South London and Maudsley NHS Foundation Trust acknowledges the concerns raised but argues that it is clinically reasonable to honor a patient's cancellation and rebooking request without chasing them, and …
Responded
Paul Bradley
26 Jan 2024 · Worcestershire
Concerns: Despite the patient being documented as hard of hearing, the urological appointment was offered by telephone; there was no clear system in place to follow up on a patient who missed an important urology appointment, and there was no clear system in place to ensure that the teams involved communicated with each other.
Response (Worcestershire Acute Hospitals): Worcestershire Acute Hospitals NHS Trust is developing multiple new strategies and operating procedures to address the concerns, including streamlining MDT processes, developing a SOP for monitoring cancerous lesions, a risk …
Responded
Sara Grinnell
17 Sep 2024 · South Wales Central
Concerns: Extensive and repeated delays in urgent gynaecology appointments, relying only on written correspondence, resulted in a significant 24-month diagnostic delay. There were missed opportunities to escalate urgency upon re-referral.
Response (Cwm Taf Morgannwg University Health Board): Cwm Taf Morgannwg University Health Board is undertaking several actions to address referral delays including implementation of a new RTT pathway, harm review process, and workforce improvements including securing administrative …
Responded
Lady Lola Crouch
21 Feb 2025 · Essex
Concerns: The patient was not informed of potential malignancy findings from a CT scan, leading to missed follow-up. Additionally, insufficient medical staffing caused delayed responses to urgent patient deterioration.
Response (Mid South Essex NHS Trust): The trust has reiterated the NEWS and local clinical escalation process to the new residents as part of the standard induction process and established a hospital out of hours service …
Responded
Joseph Powell
17 May 2025 · Cheshire
Concerns: GPs failing to proactively book follow-up appointments for mental health patients, instead requiring them to self-book, often results in missed care and medication for vulnerable individuals.
Response (Royal College of General Practitioners): The RCGP will highlight the case to the Mental Health Special Interest Group (SIG) to support further promotion of safety planning in suicide prevention for people with mental health conditions …
Responded
Milos Jankovic
01 Oct 2025 · East London
Concerns: Inadequate follow-up for Barrett’s oesophagus in primary care, including a lack of routine recall and prompts for GPs to consider endoscopy, is leading to missed surveillance and preventable cancers.
Response (Health and Social Services of Wales): The Cabinet Secretary disagrees that GPs should be engaged in recalling individuals or that their clinical record systems should be amended to include prompts to recommend surveillance and suggests the …
Responded
Caitlin Imber
24 Oct 2025 · North Wales (East and Central)
Concerns: CAMHS closed a referral for a vulnerable child due to missing contact information without making further enquiries, causing a significant and potentially dangerous delay in support.
Response (Betsi Cadwaladr University Health Board): CAMHS has changed its standard operating procedure to offer appointments even when contact numbers are missing from referrals, and is undertaking an audit to confirm these changes are embedded in …
Responded
#12 — NHS England failed to reduce outpatient follow-up appointments, abandoning its 25% target
Public Accounts Committee
Recommendation: NHSE has aimed to free up capacity in outpatient services to allow more patients from the waiting list to be seen. In 2022, NHSE set a target to reduce outpatient follow-up appointments by 25% compared with 2019–20 levels by March …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Recommendation implemented 2.2 DHSC and NHS England undertook a review of programme governance to ensure the right structures are in place to deliver the ERP, which was …
Accepted
#9 —
Health and Social Care Committee
Recommendation: It is not acceptable for patients awaiting planned treatment or feeling the debilitating effects of long covid to feel “abandoned” by the NHS. We appreciate the uncertainty about the length of future waiting lists, but this is no excuse for …
Gov response: The Government agrees that communication with patients is essential. NHS England has been working to improve communication with patients waiting for treatment, and has published guidance for providers on how to do this effectively. This …
Under Consideration
#14 —
Public Accounts Committee
Recommendation: The Department and NHSE&I are now managing a large, growing and diverse set of challenges to elective and cancer care on top of the ongoing pandemic. We asked how the Department and NHSE&I expected the accelerated and expanded vaccine booster …
Not Addressed
Buckley Hall (2020)
HMP Buckley Hall, a Category C training prison with an operational capacity of 459, received positive HMIP inspection results and was ranked highly among UK prisons. Staff efforts to keep prisoners safe during the COVID-19 lockdown were commended, with minimal positive cases. Key concerns included high rates of cancelled external medical appointments, under-completion of key worker sessions due to staffing pressures, and the lack of in-cell telephones. The regime was significantly restricted during lockdown, causing boredom, though out-of-cell time increased by the reporting year's end.
PRISON Key concerns
Deerbolt (2020)
HMP & YOI Deerbolt experienced a significant improvement in atmosphere and performance following staff shortages and a change in management, aided by a reduced operational capacity. The COVID-19 lockdown led to a reduction in violence and improved safety perceptions for vulnerable prisoners, but severely curtailed all rehabilitative and educational activities. Key concerns include the lack of rehabilitation during lockdown, the need for better remote learning, and systemic issues around gang-related transfers and appropriate facilities for segregation reviews.
PRISON Key concerns
Forest Bank (2020)
HMP Forest Bank, a Category B male prison, faced significant challenges during its transition to a main Reception prison and the COVID-19 pandemic. The Board commended staff and management for their efforts in maintaining safety and humane treatment amidst staffing shortages and a heavily restricted regime. While healthcare provision was generally good and education adapted well to in-cell learning, concerns remained regarding the impact of restrictions on purposeful activity, appropriate transfers for long-term prisoners, property issues, and increased drug smuggling.
PRISON Key concerns
Berwyn (2020)
Did not attend appointments, DNA
NHS / Healthcare Provider
Wormwood Scrubs (2020)
Will the minister instigate, at a national level, a policy which will ensure that prisoners who have had their hospital appointments cancelled, through no fault of their own, are not returned to the start of the appointments process?
Ministry of Justice
Buckley Hall (2020)
Reduce the number of cancelled outside medical appointments (see paragraph 6.1.4)
Governor / Director
Bedford (2021)
Over a quarter of health appointments were missed because the prison was unable to deliver prisoners to the healthcare area, which is both a waste of healthcare resources and really unhelpful for prisoners.
Governor / Director
Foston Hall (2023)
A significant number of healthcare appointments are missed. What can be done to improve communication to prisoners about appointments and enable their attendance?
Governor / Director
Wymott (2020)
The Board remains concerned about the regular cancellation of prisoner forums, particularly the healthcare forum (see also section 3.4).
Governor / Director
Berwyn (2023)
The Board would like to see measures to improve attendance at medical appointments.
Governor / Director
Swaleside (2020)
There is an unacceptable number of cancelled outside hospital appointments which, apart from the distress that it causes patients, places a burden on the public purse and wastes NHS time which could usefully be used for other patients (see section 6.1).
HMPPS
Ranby (2020)
What action will the Governor take to reduce the level of missed healthcare appointments?
Governor / Director
Parc (2022)
There continued to be a high level of failed appointments for healthcare, again indicating a need to examine the appointments system to establish where the process is failing.
Governor / Director
Thorn Cross (2024)
To continue to reduce the number of men who do not turn up for their healthcare appointments.
Governor / Director
Hollesley Bay (2024)
DNAs (did not attends) continue to be a problem for the healthcare department. The Board requests that a further review of the management of the appointments process is undertaken.
Governor / Director
Foston Hall (2024)
What else can be done to reduce the number of missed internal healthcare appointments?
Governor / Director
Erlestoke (2025)
What guarantees can be given that there will be sufficient funding for escorts to take prisoners to hospital appointments, to avoid the numerous cancellations that have taken place over the last year?
HMPPS
Wormwood Scrubs (2020)
Given the Board’s concerns relating to the provision of healthcare services, will the Governor ensure: (i) regular meetings of the strategic healthcare partnership? (ii) a fit-for-purpose healthcare complaints system, delivering timely and appropriate responses, with agreed deadlines? (iii) a significant reduction in the number of cancelled hospital appointments?
Governor / Director
P-002678 — A practice in the Norfolk area
Mrs U complains the Practice did not refer her to the fertility clinic when it said it would and only made the referral when she chased it nine months later.
NHS in England Partly Upheld Jun 2024
P-003442 — A dental practice in the Trafford area
Mr A complains about the Practice cancelling a number of his appointments without notice and refusing to complete his treatment plan between September 2023 and February 2024.
NHS in England Mar 2025
P-003529 — A practice in the Croydon area
Ms O complains her referral to another endocrinology team was not sent to the correct hospital, which resulted in her waiting ten months for the referral.
NHS in England Not Upheld Apr 2025
P-004361 — University Hospitals Birmingham NHS Foundation Trust
Mr A complains the Trust removed him from the waiting list for an ENT (Ear, Nose and Throat) appointment in August 2024 after it incorrectly said Mr A had missed multiple calls. He also complains the Trust incorrectly advised him, and his wife, that it had re-listed him for his …
NHS in England Nov 2025
P-004613 — Whittington Health NHS Trust
Mr I complains the Trust rejected three referrals from his GP to have his toenails trimmed and during an appointment in July 2024 did not assess his medical needs on whether he should have his toenails trimmed.
NHS in England Jan 2026
P-001437 — Hampshire Hospitals NHS Foundation Trust
Mr A complains about the care and treatment he received from Hampshire Hospitals NHS Foundation Trust. Between October 2019 and March 2020 he complains the Trust cancelled his discectomy surgery several times.
NHS in England Partly Upheld Jun 2022
P-001822 — Ashford and St Peter's Hospitals NHS Foundation Trust
Dr O complains the Trust did not request urgent gastrological investigations as agreed in her outpatient appointment.
NHS in England Feb 2023
P-001905 — County Durham and Darlington NHS Foundation Trust
Miss O complains the Trust did not follow up on an appointment and book more surgery.
NHS in England Mar 2023
P-002580 — A practice in the Liverpool area
Mrs B complains the Practice did not provide her with a timely referral to hospital in August 2022 after a pharmacist told her she had a possible cancerous growth on her face.
NHS in England May 2024
P-002633 — An independent provider in the West Berkshire area
Mr A complains about the care and lack of dental treatment he had from the Practice in August and September 2021. He says it failed to make him an appointment when he reported pain and it did not give him pain relief while he waited for an appointment or after …
NHS in England May 2024
P-002687 — A practice in the Kent area
Mrs L complains that in February 2023 the Practice did not process a rheumatology referral for her.
NHS in England Jun 2024
P-002694 — Kent Community Health NHS Foundation Trust
Mrs P complains Kent Community Health NHS Foundation Trust delayed providing physiotherapy for her daughter following leg surgery, did not put a goal focussed plan in place and then inappropriately downgraded the level of support she needed.
NHS in England Partly Upheld Jun 2024
P-002968 — A practice in the Kent area
Mrs U complains the Practice failed to advise her an orthopaedic referral was rejected between January 2023 and February 2024.
NHS in England Sep 2024
P-003415 — A practice in the Barnet area
Mr B complains the Practice failed to make a referral following a request from his neurosurgeon on 2 June 2023.
NHS in England Mar 2025
P-002669 — A practice in the Suffolk area (the Surgery)
Mrs A complains the Surgery did not act on her requests to chase secondary care for an update on her mother's treatment and it delayed arranging tests and treatment.
NHS in England Jun 2024
P-002672 — A practice in the Lincolnshire area
Ms R complains the Practice ignored her requests for face-to-face appointments and cancelled appointments at the last minute, it did not act on the results of tests or recommendations from referrals, it ignored her symptoms and said they were psychosomatic and failed to add, alter or remove significant information in …
NHS in England Jun 2024
P-002957 — An independent provider in the East Riding of …
Mr R complains the Hospital cancelled his surgery because it had not completed the correct pre-assessment checks.
NHS in England Sep 2024
P-003240 — Manchester University NHS Foundation Trust
Mr T complains about the Trust from 2020 until 2023 saying its record keeping was not up to date, it did not let him know about a cancelled appointment, it took too long to refer him and it sent him lots of unnecessary letters about appointments and cancellations.
NHS in England Dec 2024
P-003323 — The Royal Wolverhampton NHS Trust
Mrs O complains the Trust removed her from its waiting list without telling her.
NHS in England Feb 2025
P-003493 — An independent provider in the Sheffield area
Ms L complains the Trust incorrectly declined to carry out a hysterectomy in February 2024. She also complains about the Trust’s poor communication on the day of her cancelled surgery and the days following it.
NHS in England Apr 2025
P-002621 — A practice in the Cambridgeshire area
Mrs E complains the Practice failed to act on a scan report which found she had a 10cm dermoid cyst.
NHS in England May 2024
P-004154 — University Hospitals of North Midlands NHS Trust
Mrs G complains the Trust did not arrange the appropriate follow up care for her husband Mr B.
NHS in England Oct 2025
P-004459 — Northern Care Alliance NHS Foundation Trust
Mrs B complains the Trust failed to provide appropriate care to her husband in November 2019. She says it cancelled tests, missed referrals, had inaccurate records, and poor communication.
NHS in England Dec 2025
P-002358 — Harrogate and District NHS Foundation Trust
Mrs U complains about the Trust's management of her knee injury between April 2021 and June 2022.
NHS in England Dec 2023
P-002381 — University Hospital Southampton NHS Foundation Trust
Mrs E complains about the Trust and its post-operative care after knee surgery in July 2022. She complains there was a delay in the Trust doing an X-ray, it failed to give her ice after surgery and it inserted a catheter that she did not want. She also complains about …
NHS in England Dec 2023
NIPSO-202002974 — South Eastern Health and Social Care Trust
A man’s cancer treatment was interrupted by the Covid pandemic in March 2020. We found that he should have been reviewed by clinicians as soon as possible after the resumption of face-to-face appointments.
NIPSO (NI Public Service… Health & Social Care Upheld Sep 2024
21-011-833 — Sheffield City Council
Summary: We will not investigate this complaint about a cancelled pest control appointment and incorrect advice about when a refund for that service would be made. This is because the Council has resolved the matter to the satisfaction of the complainant.
LGO (Local Government & … Environment And Regulation Upheld Feb 2022
201204744 — Forth Valley NHS Board
Mr C, who is a prisoner, complained that he was not seen by the prison dental hygienist after being advised that he would be seen again in three months. He was also unhappy that it took nearly four months for him to see the dentist after he reported that a …
SPSO (Scottish Public Se… Health Upheld Dec 2013
201600464 — Lothian NHS Board - Acute Division
Mr C was referred by his GP for a possible hernia operation. Mr C complained to us that the board failed to arrange his operation within the 12-week treatment time guarantee under the Patients Rights (Scotland) Act and that they failed to advise him of his rights under that Act. …
SPSO (Scottish Public Se… Health Partly Upheld Nov 2016
201508175 — Lanarkshire NHS Board
Mrs C complained about the care that her late husband (Mr A) received at Monklands Hospital after attending the emergency department. Mr A was to be admitted to a private room but none was available. He remained in A&E until a suitable room was found. Mr A was later moved …
SPSO (Scottish Public Se… Health Partly Upheld Dec 2016
201602805 — Highland NHS Board
Mr C was referred to a urologist at Raigmore Hospital to have his history of erectile dysfunction and low testosterone investigated. Mr C raised a complaint nine months later as he had not received an appointment and was distressed by his ongoing symptoms. The board informed Mr C that there …
SPSO (Scottish Public Se… Health Upheld May 2017
PSOW-202200121 — Betsi Cadwaladr University Health Board
Miss X complained although she had complained about the treatment she received in hospital back in February 2022, she had not received a response. The Ombudsman was concerned that Miss X had not yet received a response to her concerns, and she contacted the Health Board. As an alternative to …
PSOW (Public Services Om… Health May 2022
PSOW-202400587 — Swansea Bay University Health Board
Mr A complained that he had waited for 6 years for knee replacement surgery from the Health Board and that it had not replied to his complaint. The investigation found that it was unclear whether the Health Board had received Mr A’s complaint and that it had not been investigated …
PSOW (Public Services Om… Health Jun 2024
PSOW-202401319 — Betsi Cadwaladr University Health Board
Mr C complained about the care and treatment he received from Betsi Cadwaladr University Health Board (“the Health Board”). Specifically, whether his colorectal prolapse had been managed appropriately by the Colorectal Team from the time of initial referral in February 2022 to May 2024. The investigation found that Mr C’s …
PSOW (Public Services Om… Health Not Upheld Jul 2025
PSOW-202502124 — Cardiff and Vale University Health Board
Mr A complained that the Cardiff and Vale University Health Board failed to send referral letters to his new GP so that he could continue his treatment outside of Wales. The Ombudsman found that the Health Board issued a referral letter to Mr A’s new GP in March 2025 but …
PSOW (Public Services Om… Health Aug 2025
201004170 — A medical practice, Greater Glasgow and Clyde NHS …
Ms C made a GP appointment for her daughter, who was unwell. When, however, her daughter became more unwell Ms C phoned to request a GP home visit on an earlier date. She did not specifically cancel the booked appointment. As their records showed that she had not kept an …
SPSO (Scottish Public Se… Health Jun 2011
201201028 — A Medical Practice in the Lanarkshire NHS Board …
Mr C complained that his medical practice failed to provide appropriate care and treatment when he had an eye infection and unreasonably refused to allow him to see a GP. Mr C developed an eye infection, and called his practice on a Friday to request an appointment. He was told …
SPSO (Scottish Public Se… Health Partly Upheld Mar 2013
201605507 — Greater Glasgow and Clyde NHS Board - Acute …
Mr C complained that there was an unreasonable delay in the board providing him with treatment on his right eye. Mr C is diabetic and was referred to Gartnavel General Eye Hospital when he began having problems with the vision in his right eye. Mr C was seen by the …
SPSO (Scottish Public Se… Health Upheld Jul 2017
201602519 — Greater Glasgow and Clyde NHS Board - Acute …
Mr C complained about delays in being seen by the gastroenterology (medicine of the digestive system) department at the New Victoria Hospital. He considered that there was an unreasonable delay in contacting him after he was referred by his GP and that the board's communication in relation to appointments was …
SPSO (Scottish Public Se… Health Partly Upheld Jul 2017
201702683 — Golden Jubilee National Hospital
Mr C had a scan at the Golden Jubilee National Hospital. A mass was discovered on his lung, which could have been either a spread of his existing bowel cancer or a new lung cancer. His consultant arranged some tests to help determine which it was, but because they were …
SPSO (Scottish Public Se… Health Upheld Jan 2018
201606971 — Shetland NHS Board
Miss C complained that the board unreasonably removed her from a waiting list for orthodontic treatment. She also complained that they had failed to tell her that she had been removed from the waiting list and had not provided her with a reasonable explanation of why she had been removed. …
SPSO (Scottish Public Se… Health Partly Upheld Jan 2018
201802999 — An NHS Board
Ms C complained about the board's assessment of a referral that was made for her child (Child A) to the child and adolescent mental health services. Ms C considered that it was clear from the referral that Child A had not been appropriately assessed by the GP and that the …
SPSO (Scottish Public Se… Health Partly Upheld Jul 2019
PSOW-202104566 — Cardiff and Vale University Health Board
Mr P complained that Cardiff and Vale University Health Board did not manage a neurodevelopmental referral in respect of his daughter, B, appropriately. He was also concerned that the Health Board had failed to provide him with adequate information about the referral process and B’s place on the waiting list. …
PSOW (Public Services Om… Health Jan 2022
PSOW-202300457 — Cardiff and Vale University Health Board
Mr X complained that Cardiff and Vale University Health Board had failed to provide him with further surgery and had not issued a formal complaint response. The Ombudsman decided that the Health Board had failed to provide Mr X with a formal complaint response, which caused frustration to Mr X …
PSOW (Public Services Om… Health Jun 2023
PSOW-202404527 — Betsi Cadwaladr University Health Board
Mr A complained about the care and treatment given to him by Betsi Cadwaladr University Health Board (“the Health Board”). He said that although he attended hospital for planned treatment, this did not take place. Mr A said that his condition has deteriorated and causes discomfort and pain. Mr A …
PSOW (Public Services Om… Health Oct 2024
PSOW-202404816 — Betsi Cadwaladr University Health Board
Mr H complained about not receiving a medical appointment to remove a lump from his head. Mr H complained to the Health Board noting on the top of his letter that it was a formal complaint. The Ombudsman found that Mr H had been referred as a routine patient and …
PSOW (Public Services Om… Health Oct 2024
PSOW-202502465 — Cardiff and Vale University Health Board
Miss G complained that Cardiff and Vale University Health Board failed to address one aspect of her complaint, relating to issues with contacting it, made in June 2025. The Ombudsman found that the Health Board failed to address this aspect of her complaint. This caused additional frustration and uncertainty for …
PSOW (Public Services Om… Health Sep 2025
PSOW-202505683 — Powys Teaching Health Board
Mrs A complained to Powys Teaching Health Board regarding the impact a policy change had on her. The Ombudsman found that the Health Board had not directly responded to Mrs A and did not address every issue she had raised. The Ombudsman considered that this caused Mrs A frustration due …
PSOW (Public Services Om… Health Nov 2025
PSOW-202504920 — Swansea Bay University Health Board
Mr A complained that his place on the waiting list for surgery was reset when he rearranged an appointment. The Ombudsman recognised the language used in the complaint response may have led to confusion. However, as Mr A gave prior notice of his inability to attend a mutually agreed appointment, …
PSOW (Public Services Om… Health Jan 2026
201102499 — Lothian NHS Board
Mrs C had worsening hearing loss in both ears, with narrow ear canals that made use of in-ear hearing aids painful and intolerable. She complained that the board failed to refer her to the correct consultant at the right time, and that there was an unreasonable delay of a year …
SPSO (Scottish Public Se… Health Partly Upheld Oct 2012
201202345 — Lothian NHS Board
Mrs C complained that she experienced an unreasonable delay in receiving appointment notification letters from the board. After she was referred to a respiratory clinic by her GP, the board wrote inviting her to an appointment at the clinic. Mrs C did not receive this letter until after the time …
SPSO (Scottish Public Se… Health Upheld May 2013
201204300 — Lothian NHS Board
Ms C's dentist referred her to the board's dental institute for treatment to remove the roots of a broken wisdom tooth. Ms C complained that there was unacceptable delay in providing an appointment at the institute; and that the lack of communication about the waiting time was unreasonable. After investigating, …
SPSO (Scottish Public Se… Health Not Upheld Jun 2013
201508735 — Tayside NHS Board
Mrs C learned that she had a gene mutation which increased the risk of breast and ovarian cancer. She decided to have surgery to remove both breasts to reduce the risk of developing breast cancer, and reconstruction surgery. Her surgery was cancelled on the morning she was due to be …
SPSO (Scottish Public Se… Health Jun 2016
201606782 — A Medical Practice in the Greater Glasgow and …
Mr C complained that his GP practice failed to provide him with a GP appointment and a medical certificate for sickness absence. Mr C said he could not get a same day appointment when he phoned the practice in the mornings. We found there were other means of getting an …
SPSO (Scottish Public Se… Health Not Upheld Oct 2017
201608877 — Fife NHS Board
Mr C complained about the length of time it had taken the board to provide him with treatment for varicose veins. Mr C was referred to vascular surgery at Victoria Hospital by his GP. Around four months later he saw a vascular consultant who said that he needed a special …
SPSO (Scottish Public Se… Health Partly Upheld Feb 2018
201700482 — Greater Glasgow and Clyde NHS Board - Acute …
Mr C complained that the board failed to provide him with clinic appointments within a reasonable timescale. He also raised concern that the board failed to provide him with adequate notice of the cancellation and rescheduling of appointments, and he was unhappy with the board's handling of his complaint. The …
SPSO (Scottish Public Se… Health Partly Upheld Apr 2018
201609412 — Lanarkshire NHS Board
Mrs C, who is an advocacy and support worker, complained on behalf of her client (Mrs A). Mrs A was unhappy about delays in getting confirmation of an appointment with a consultant ophthalmologist (a doctor who deals with injuries and conditions in and around the eye). Mrs A was also …
SPSO (Scottish Public Se… Health Partly Upheld Apr 2018
201708551 — Tayside NHS Board
Mrs C was referred by her GP to the orthopaedic department (the area of medicine which deals with the musculoskeletal system) at Ninewells Hospital for consideration of knee replacement surgery. However, there were problems with the communications from the board which resulted in her missing a scheduled out-patient clinic appointment. …
SPSO (Scottish Public Se… Health Not Upheld Sep 2018
201700671 — Ayrshire and Arran NHS Board
Mr C attended University Hospital Crosshouse after sustaining a tear in the anterior cruciate ligament (a ligament in the knee) and damaged cartilage (connective tissue). Mr C complained that the board took too long to provide appropriate treatment following a referral from his GP, failed to provide a reasonable standard …
SPSO (Scottish Public Se… Health Upheld Oct 2018
201804379 — Tayside NHS Board
Ms C complained that Ninewells Hospital failed to provide her with reasonable care and treatment when she was admitted for investigations by the gastroenterology (branch of medicine which deals with disorders of the stomach and intestines) team. We took independent advice from a consultant gastroenterologist. We found that the treatment …
SPSO (Scottish Public Se… Health Partly Upheld Nov 2019
201900596 — Grampian NHS Board
Ms C complained that the board delayed in arranging the surgery she needed. She was entered onto the list for surgery at a gynaecology (medicine of the female genital tract and its disorders) out-patient clinic, but said that she was told months later that they were only carrying out surgery …
SPSO (Scottish Public Se… Health Upheld Jul 2020
201908887 — Highland NHS Board
C complained on behalf of their child (A) who has a background of low mood and anxiety. C complained about the assessments of A by two paediatric consultants. C also complained that the Child Adolescent Mental Health Service (CAMHS) unreasonably rejected referrals from A’s GP due to social work’s involvement …
SPSO (Scottish Public Se… Health Partly Upheld Nov 2021
201810251 — Highland NHS Board
C complained that the board failed to provide their child (A) with orthognathic treatment (orthognathics is a specialist subset of dentistry which involves surgical correction of growth issues with the jaw and lower face) within a reasonable timescale. A's teeth were overcrowded to the extent that they caused pain in …
SPSO (Scottish Public Se… Health Upheld Dec 2021
201907379 — Lothian NHS Board - Acute Division
C complained about delays in treatment that was meant to be provided to their late spouse (A). They told us that A had been referred to the board from another area for heart surgery, but that this took so long to arrange, A's condition deteriorated to a point that surgery …
SPSO (Scottish Public Se… Health Not Upheld May 2022
202004806 — Greater Glasgow and Clyde NHS Board - Acute …
C complained about their waiting time for hip replacement surgery. C was initially added onto the waiting list for surgery but was later removed after C advised the board of their personal circumstances. A couple of months later, C was added back onto the waiting list for surgery but, after …
SPSO (Scottish Public Se… Health Upheld Jul 2022
202302835 — Greater Glasgow and Clyde NHS Board - Acute …
C complained about the care and treatment received by their young child (A). A had a complex congenital (from birth) heart condition. C complained to the board after A received heart surgery, which had been part of the treatment planned for A. C complained that the board did not reasonably …
SPSO (Scottish Public Se… Health Upheld Dec 2024
202303181 — Forth Valley NHS Board
C complained about delays in the care and treatment provided to their spouse (A) who was diagnosed with lung cancer following an abnormal chest X-ray. C said that there was a delay in A being provided with a CT scan result by the respiratory consultant, and a further wait to …
SPSO (Scottish Public Se… Health Upheld Jan 2025
NIPSO-gp-practice-addresses-appointment-booking-system-after-patients — GP
NIPSO (NI Public Service… Health & Social Care Apr 2021
PSOW-202305250 — Aneurin Bevan University Health Board
Mr A complained that the Health Board refused to warn patients referred to the Erectile Dysfunction Therapy clinic in advance that they would be expected to be examined and counselled by female clinicians. He said that the Health Board hid the fact that it would be a female clinician by …
PSOW (Public Services Om… Health Jan 2024
PSOW-202301069 — Aneurin Bevan University Health Board
Mrs X complained that Aneurin Bevan University Health Board (“the Health Board”) failed to offer her treatment with the drug fampridine after its approval for NHS use in Wales in December 2019. Fampridine may help certain patients who have multiple sclerosis. I upheld the complaint. My investigation found that, despite …
PSOW (Public Services Om… Health Feb 2024
PSOW-202310379 — Betsi Cadwaladr University Health Board
Mr A complained that Betsi Cadwaladr University Health Board failed to respond to the complaint he made to it in June 2023. The Ombudsman decided that there had been a significant delay by the Health Board to respond to Mr A’s concerns and this had caused inconvenience and frustration for …
PSOW (Public Services Om… Health Apr 2024
PSOW-202400981 — Hywel Dda University Health Board
Ms B complained, with the help of a Complaints Advocate, about the standard of care provided by the Health Board. The investigation considered whether the care and treatment provided at the Early Pregnancy Assessment Unit (“EPAU”) on 21 March 2023 was clinically appropriate, and whether the subsequent Community Midwife Team …
PSOW (Public Services Om… Health Upheld Jan 2025
PSOW-202407137 — Hywel Dda University Health Board
Mrs A complained about Hywel Dda University Health Board (“the Health Board’s”) failure to provide her mother with timely Ophthalmology clinic appointments to treat her age-related eye disease. The Ombudsman noted that whilst the Health Board in its complaint response had provided an explanation about the timing of appointments and …
PSOW (Public Services Om… Health Feb 2025
201204154 — Tayside NHS Board
Mr C is unable to cut his own toenails, and complained that the board failed to provide him with an appropriate regular service for this. He explained that delays in having his toenails cut impacted on his mobility and caused him discomfort. Our independent medical adviser noted that it was …
SPSO (Scottish Public Se… Health Not Upheld Apr 2013
201508820 — Golden Jubilee National Hospital
Mrs C complained about a decision taken by the board to cancel her heart surgery and the lack of communication to her about this decision. She was also concerned that her complaint had not been dealt with appropriately because members of the complaints team had been involved with the decision …
SPSO (Scottish Public Se… Health Partly Upheld Sep 2016
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