GP Continuity of Care Breakdown
Failures in delivering continuity of care within GP practices, often due to contract limitations, leading to delayed diagnoses.
491 items
8 sources
2 inquiries
Source spread
Where this theme appears
GP Continuity of Care Breakdown has been flagged across 8 independent accountability sources:
2 inquiry recs
70 PFD reports
33 committee recs
2 PPO recs
4 IMB recs
62 PHSO decisions
317 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
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.
Inquiry Recommendations (2)
LAMI-72 — Ensure identified GP for children with deliberate harm concerns discharged from hospital.
Recommendation: No child about whom there are concerns about deliberate harm should be discharged from hospital back into the community without an identified GP. Responsibility for ensuring this happens rests with the hospital consultant under whose care the child has been …
Unknown
2 — Patient-focused correspondence
Recommendation: We recommend that it should be standard practice that consultants in both the NHS and the independent sector should write to patients, outlining their condition and treatment, in simple language, and copy this letter to the patient's GP, rather than …
Gov response: Accepted. The Academy of Medical Royal Colleges updated their 2018 guidance 'Please write to me' in light of this recommendation. Guidance emphasises writing directly to patients, copying in GPs, using clear language. NHS England is …
Accepted
No update 2+ yrs
PFD Reports (70) — showing 50 strongest matches
Jill Sinson
Concerns: The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, and staff neglected to review critical records or consultant advice.
Overdue
Terence O’Connell
Concerns: A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not being seen, alongside a lack of vital clinical monitoring for two days.
Response (Gabbandco): The care home disputes that there was a communication breakdown between the care home, district nurses, and the out-of-hours GP service, asserting that communication breakdown was between district nurses and …
Response: The University Health Board has implemented a clear and accurate message sheet, SBAR (Situation, Background, Assessment, Recommendation), for switchboard staff to record out-of-hours requests for District Nurses in greater detail.
Overdue
Dorothy Townley
Concerns: Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures for urgent blood tests compromised patient care.
Response (Royal College of General Practitioners): The Royal College of General Practitioners provides context on its role, training, and advice to members, highlighting relevant sections of the GP Curriculum related to communication between professionals and patient …
Responded
Jonathan Thorpe
Concerns: A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate assessment of his ongoing mental health needs.
Overdue
Pauline Meredith
Concerns: Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent patient, and a GP's perceived reluctance to address family concerns. Delayed involvement of mental health services was also noted.
Response (Browning Street Surgery): The practice will endeavor to identify patients with additional complex needs for specific discussion at practice meetings to improve service to patients. They will also aim to maximise the health …
Overdue
Julia Dell
Concerns: The medical service received from primary care was exemplary during the period examined, with no concerns identified in the provided text.
Overdue
Teresa Lonergan
Concerns: The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare professionals, enabling a fatal overdose.
Overdue
David Chatburn
Concerns: The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic issues included bureaucratic barriers to mental health referrals and non-medical triage.
Response (Department of Health): The Department of Health acknowledges the concerns raised regarding the patient's care and referral process, and notes that patients with a mental health condition have the same legal rights as …
Overdue
Leslie Harding
Concerns: There was a failure to take prompt action and ensure robust treatment for a patient with a suspected life-threatening pulmonary embolus over a critical period.
Response (Oakside Surgery): The doctor has decided to adopt a system of writing notes using the computer appointment system and a ring-bound notebook. The practice is composing a letter informing people of the …
Responded
Andrey Wakefield
Concerns: Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant risk to ongoing patient care.
Response (University Hospital of North Staffordshire): A solution is being rolled out in three phases to improve communication of discharge information between the hospital and GPs, including remote implementation, training, IT support and standard operating procedures. …
Responded
Darren Arnoup
Concerns: Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and suicidal ideation following discharge and communication to the GP.
Response: The medical centre will develop clear lines of communication with NCH&C staff, alert GPs to referrals related to mental health or substance misuse, and ensure GPs fully document any areas …
Overdue
Courtney Mills
Concerns: Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in obtaining critical medication, putting the patient at risk of withdrawal.
Response (Waterside Medical Centre): Waterside Medical Centre acknowledges the concerns and details their prior communications with the hospital and pharmacy regarding the patient's medication, suggesting the delay was due to the medication's limited availability …
Response (Portsmouth Hospitals NHS Trust): Portsmouth Hospitals NHS Trust states that the Clonidine medication was not prescribed by them and that the hospital would have supplied it if approached. They suggest that the Royal Pharmaceutical …
Responded
Daniel McCallum Keane
Concerns: The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a diabetic patient, critically failed to ensure appropriate care and follow-up.
Response (Department of Health): The Department of Health has passed concerns about a GP's conduct to the GMC and CQC; NHS England is addressing transfers of care with its patient safety expert group and …
Responded
Audrey Garland
Concerns: Failures by GP and District Nursing services to recognize and appropriately treat severe ulcers, combined with a lack of arranged hospital transport, resulted in inadequate care and examination.
Response: Blackpool Teaching Hospitals NHS Foundation Trust held focus group meetings and discussed the Coroner's concerns with the District Nursing Team, resulting in an action plan monitored by the Head of …
Overdue
Joan Richardson
Concerns: The GP practice failed to provide emergency care during training closure, delaying assessment of an obviously unwell patient by 24 hours, which contributed to her death.
Response (Leeds West Clinical Commissioning Group): The CCG will send a letter to all GP practices reiterating their obligations regarding safe medical cover during training sessions and emphasizing the need for clear communication regarding access to …
Overdue
Margaret Pegnall
Concerns: A GP practice had a vague domestic abuse flowchart focused on depression, lacked a specific domestic abuse questionnaire, and had no system for escalating urgent patient calls.
Overdue
Ryan Singh Bhogal
Concerns: GP practice lacked continuity of care and 'Red Flag' identification for a child with prolonged illness, while the hospital failed to adequately review GP medical records during admission.
Response (The Royal Wolverhampton NHS Trust): The Royal Wolverhampton NHS Trust will introduce a Standard Operating Procedure (SOP) by June 30th, 2016, providing guidance to clinicians on gathering relevant patient information, including accessing GP records. Compliance …
Overdue
Richard Parkes
Concerns: Poor GP record-keeping and a rigid policy of refusing to see late patients, even those with known complex medical histories, posed inherent risks to patient care continuity.
Overdue
Christopher Stubbs
Concerns: The abrupt cessation of critical medication upon hospital discharge, with a follow-up GP review failing to occur, highlighted a need to improve systems for acting on discharge summaries regarding patient medication.
Overdue
Elsie Raper
Concerns: A patient's severe tibia and fibula fractures remained undiagnosed for four days despite regular medical visits, leading to extreme pain and contributing to her death.
Response (elsie Raper): The surgery will implement several actions, including investigation of falls in elderly patients and prompt referral for x-rays, as well as regular reviews of factors contributing to falls and discussion …
Response (Four Seasons Health Care): Four Seasons Health Care has initiated 24-hour falls observation charts, completed a list of all residents with a confirmed diagnosis of osteoporosis, reviewed and rewritten residents' care plans to incorporate …
Responded
Ernest Higgs
Concerns: Confusion arose from unrecorded GP advice in multi-disciplinary notes and unconfirmed telephone advice. Conflicting information between care providers also caused significant delays in diagnostic testing.
Response (Epsom and St Helier University Hospital NHS Trust): The Trust will include a statement within the newsletter sent to GPs within the Trust's catchment area reminding them of 24-hour access to the Trust's pathology department. They will also …
Response (Surrey Downs Clinical Commissioning Group): The CCG's Quality Committee has undertaken an in-depth analysis of the issues relating to nursing and residential care home quality, which will lead to changes in the way they commission …
Response (The Ashlea Medical Practice): The practice has drafted a policy regarding telephone advice to nursing homes, and will audit responses to nursing home phone requests 6 months after implementation. They are waiting for BMA …
Responded
Patrick McGagh
Concerns: A patient was discharged without a discharge letter or prescribed antibiotics being provided to his GP or care staff, leaving them unaware of his medication needs.
Response (Manchester University NHS Foundation Trust): UHSM has undertaken a retrospective audit within the ED of the discharge prescriptions, reiterated to all staff within the ED and CDU the importance of ensuring that patients requiring medication …
Responded
Miles Abel
Concerns: The procedure for GPs to refer patients to the Community Mental Health Team lacked an audit trail to confirm faxes were sent, and follow-up phone calls were not always made.
Responded
Timothy Jones
Concerns: GP practice had poor record-keeping, unclear home visit request procedures, misclassified clinical tasks as 'admin', and a policy discouraging home visits for complex patients, leading to inadequate assessment.
Response (Solihull Clinical Commissioning Group): The CCG will send a communication and learning alert to all Solihull member practices highlighting concerns and learning in relation to recording requests for home visits, GP home visit policies, …
Overdue
Ruth Milne
Concerns: Concerns about the lack of continuity and appropriateness of GP medical staff, and whether vital recommendations from a 2015 safeguarding report have been fully implemented.
Response (Ruth Milne): Lincolnshire Community Health Services reports on actions taken following a safeguarding report, including establishing leg ulcer clinics, integrating specialist nurses, reviewing caseloads, and providing training on leg ulcer care and …
Overdue
Dean Rowland
Concerns: Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed significant risks.
Response (South Staffordshire and Shropshire Healthcare): The Trust states that the CMHT conducted a sufficiently detailed assessment of Mr. Rowland's needs and appropriately discharged him, providing resources for future support and contact information.
Response (Peel Medical Practice): Peel Medical Practice has instituted a duty doctor and telephone triage system to improve access for patients needing appointments or telephone consultations sooner than routine appointments.
Responded
Christopher Fairhurst
Concerns: Systemic GP shortages, reliance on locums, and insufficient training are causing reduced patient access, poor continuity of care, and insufficient consultation times. Struggling specialist mental health services are also unsafely raising referral thresholds.
Overdue
Ernest Smith
Concerns: The system for managing GP correspondence and medication review requests remains flawed. There is also no clear system to update GPs when patients are not under the medical team, risking unrecognised disengagement.
Response (Surrey NHS Trust): The Adult Mental Health Division has created an action plan to address the coroner's concerns, which will be monitored at monthly Quality Assurance Group meetings and shared with other service …
Responded
Penelope Benton
Concerns: The General Practitioner was not informed of a previous tramadol overdose in the hospital discharge letter, preventing complete medical history.
Response (Dudley and Walsall NHS Trust): The Trust will conduct a review of its standards around discharge communications and reiterate the importance to medical staff that incidents and risk factors are included within discharge letters where …
Responded
Sarah Kiff
Concerns: GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes for reviewing test results were inadequate.
Response (Stonefield Street Surgery): The practice has produced annual audit reports around new cancer diagnoses for several years; the practice has a new written policy around methodology for undertaking HVS and the recording of …
Responded
Lindsey Hassall
Concerns: There was no record of police information to mental health practitioners, delayed and destroyed patient notes, inaccessible documentation, and a GP's incorrect assumption about referrals.
Response: Pennine Care has prepared a plan to ensure that staff record information from a verbal handover from the police on a paper history sheet. A new policy has been implemented …
Overdue
Maureen Campbell-Scott
Concerns: A referral was sent to the wrong team and then lost, causing a four-month delay in assessment. There were also delays in delivering clinic letters to the GP, and prescribing did not always follow the psychiatric team's directions.
Response (NELFT): NELFT has been liaising with Fullwell Cross Medical Centre and Redbridge CCG and progress has been made to address concerns and they are reconvening a meeting with primary care colleagues …
Overdue
Graeme Mathieson
Concerns: GPs face unmanageable time constraints without proper triage, and professionals are confused about mental health patient pathways, especially after incorrect discharge from services.
Overdue
Nigel Handscomb
Concerns: Incomplete and inaccurate GP consultation notes, made several hours after the fact, failed to record critical patient information, including examination findings and medication adherence, alongside unrecorded verbal instructions.
Overdue
Robin McEwan
Concerns: Disconnected communication between private therapy and GPs, lack of guidance on self-help resources, and insufficient involvement of family support for suicidal patients were identified.
Response (Harrogate CCG): The CCG will review the primary care referral process for private counselling, look at developing Mental Health & Psychological First Aid within Primary Care and the CCGs, and further develop …
Responded
Ruth Edwards
Concerns: Patient discharge after an overdose failed to include psychiatric liaison assessment, passing critical responsibility to the family. Inadequate history-taking led to underestimated risk, and insufficient GP medication reviews created an overdose risk.
Response (West Quay Centre): The practice has taken on a full-time Clinical Pharmacist to oversee repeat and acute prescribing, and patient monitoring. They achieved an NHS award for quality improvement in this area.
Response: The University Health Board conducted an internal review and will remind staff of the importance of full and diligent information taking. The matter of medication reviews has been raised with …
Responded
Jacqueline Elliott
Concerns: Inadequate medication review processes, poor documentation, high-volume painkiller prescribing despite overdose history, and lack of continuity of care led to reliance on painkillers.
Response (Trafford CCG and Department of Health and Social Care): The CCG provides context on medication management practices, GP workload challenges and national initiatives to increase the GP workforce, but doesn't describe specific local actions.
Responded
George Thompson
Concerns: Insufficient doctor staffing meant no home visits could be undertaken even if clinically indicated, due to one doctor covering all duties and emergencies.
Response (H.T Practice): The practice will arrange telephone triage training, provide one-on-one training on systems and processes, re-communicate the operational manual, and create a formal channel for team members to raise concerns about …
Responded
Sophie Holman
Concerns: Fragmented asthma care lacked coordinated records, long-term management plans, and guideline adherence, resulting in missed risk factors, excessive medication, and no clear clinical responsibility.
Response (NHS England): NHS England confirms that the Trust involved has been contacted and has reviewed the concerns raised. They will also contact the Royal College of General Practice and the Royal College …
Overdue
Peter Garvin
Concerns: Poor communication between the CMHT and GP, a lack of local mental health beds, and a policy to discharge NHS patients seeking private care negatively impacted patient care. A carer's assessment was also not offered.
Response (CNWL NHS Trust): CNWL NHS Trust has drawn up a protocol for staff working with patients who seek advice or treatment from a private clinician, setting out how to work with private sector …
Overdue
Andrew McCall
Concerns: A critical lack of verification for patients' methadone prescriptions by GPs, who rely on self-declaration, led to potentially harmful prescribing of other medications for drug-seeking behavior.
Response (NHS England): NHS England will contact Addiction Dependency Solutions to review processes for collecting/verifying GP data and information sharing. They will also write to all Staffordshire GP practices to highlight risks and …
Responded
Roger Wood
Concerns: A critical AAA scan result was not acted upon by the GP, and the updated referral policy still relies on GP action rather than direct automatic referral, risking similar failures.
Overdue
Margaret Sales
Concerns: Records were not always completed as required, nurses had difficulty contacting on-call medical staff, and a referral to the Home Enteral Nutrition service was not placed with the GP after a previous discharge.
Response (Queen Elizabeth Hospital Kings Lynn): The Queen Elizabeth Hospital Kings Lynn provided a medical records audit across the Trust's wards. They also have updated falls risk assessments and management plans to include contacting Mental Health …
Responded
Anita Mandalia
Concerns: The provided text is incomplete and does not contain specific concerns for summarization.
Overdue
Siwan Smith
Concerns: Medical centre reception staff failed to adequately assess a distressed patient's urgent mental health needs, not providing an emergency appointment or clinical callback, raising concerns about future risk to patients.
Response (Taffs Well Medical Centre): The practice has implemented pop-up alerts for patients with mental health history, prioritizes appointments for patients with mental health concerns, and uses the e-consult platform to assess mental health risk.
Responded
Sameena Javed
Concerns: The GP practice lacked written procedures for administrative staff to escalate critical incoming correspondence to medical staff, risking important actions being overlooked.
Overdue
Nichola Lomax
Concerns: Doctors lacked training on eating disorder guidance (MARSIPAN) and pathways to specialist advice. Restrictive referral criteria for community services led to inadequate monitoring by non-specialist GPs.
Response (Response regarding Nichola Lomax): The Greater Manchester Health and Social Care Partnership (GMHSCP) will present learning from the case at the Greater Manchester Quality Board and cascade it to professionals through governance and learning …
Overdue
Brian Wareham
Concerns: A significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged without adequate information or support regarding complex medical conditions.
Response (The Richmond Clinic): The Richmond Clinic investigated the matter, met with the Health Board, explored communication options between primary and secondary care, and ensured all clinical staff are aware of them. They have …
Response (Aneurin Bevan University Health Board): The Health Board has established a single point of access Flow Centre for urgent referrals for admission, launched direct access telephone advice lines, and created a directory of "bypass numbers". …
Responded
Carol Cole
Concerns: A flawed process for sharing Public Protection Notices (PPNs) with GPs in the Dorset Council area meant crucial mental health concerns were not received, leading to missed patient assessments.
Response (Dorset Police): Dorset Council will fund a co-located member of staff in the MASH to share PPNs with GPs. A further review with Health partners commenced on 12 April 2022 to review …
Response (Dorset Council): Dorset Council amended its internal process on 25/02/22 so that the Adult Access Team forward PPNs to relevant agencies or professionals regardless of whether the person is known or not …
Responded
Maria McGauran
Concerns: The surgery failed to conduct a medication review or consider alternative pain management, despite long-standing family concerns about the patient's excessive use and hoarding of codeine.
Response (Alvaston Medical Centre): Alvaston Medical Centre recruited two clinical pharmacists to conduct patient medication reviews, particularly for controlled drugs, and ensures high-risk scheduled drugs are not part of repeat prescriptions, with a robust …
Responded
Committee Recommendations (33)
#25 — NHS England is optimistic about future diagnostics, but GP engagement on prescribing is needed.
Recommendation: NHS England told us that it is more optimistic about the future use of diagnostics. It told us that there would be “an explosion” of point of care diagnostic tests as well as a very bright future for their use …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: Spring 2027 4.2 The government is working to fulfil Outcome 6 of the NAP, which commits to cross-sector working to develop diagnostics as a …
Accepted
#2 — Lack of continuity of care fragments support for people with severe mental illness
Recommendation: Continuity of care is a necessity for people with severe mental illness. It is essential to the delivery of high-quality care. When it is present, it prevents crisis, builds trust, and supports recovery. When it is absent, it fragments support, …
No Published Response
#30 — Necessity for re-implementing personal lists in the NHS GP contract from 2030.
Recommendation: NHS England should re-implement personal lists in the GP contract from 2030 onwards. (Paragraph 103) General practice and new NHS organisations
Gov response: Do not accept. For the reasons stated in our response to recommendation 17, we do not accept this recommendation. However, as previously mentioned in that response, and as per our response to recommendation 15, we …
Not Accepted
#28 — NHS England's crucial role championing personal list model and setting 2027 ambition.
Recommendation: As part of wider efforts to improve continuity of care NHS England should champion the personal list model rather than dismissing it as unachievable. NHS England should set a stretching ambition that by 2027 80% of practices have returned to …
Gov response: Partially accept. The Department partially accepts this recommendation. We will continue to consider this option, but further exploration is needed before the government can commit to accelerate plans to allow GP partners to operate as …
Partially Accepted
#27 — Personal lists are essential for improving continuity of care in NHS general practice.
Recommendation: Personal lists are the best way to deliver continuity of care and are therefore an essential component of improving the levels of continuity provided in NHS general practice. We recognise the pressures in general practice but we believe that delivering …
Gov response: Partially accept. The Department partially accepts this recommendation. In 2019, the General Practice Premises Policy Review2 highlighted the challenges faced by GPs and the wider NHS in terms of property ownership and liabilities. Stakeholders including …
Partially Accepted
#26 — Additional funding required for continuity leads and administrative staff in Primary Care Networks.
Recommendation: NHS England should provide Primary Care Networks with additional funding to appoint a ‘continuity lead’ for at least one session per week, and additional admin staff funding to support the lead in the role. The role of the continuity lead …
Gov response: Partially accept. The Department partially accepts this recommendation. The Government confirms there is currently no policy to abolish the partnership model, which is the majority model for general practice delivery and works well in many …
Partially Accepted
#25 — National continuity of care measure required for all GP practices by 2024.
Recommendation: NHS England should introduce a national measure of continuity of care to be reported by all GP practices by 2024. The new measure should be based on existing models such as the Usual Provider Continuity Index and the St Leonard’s …
Gov response: Accept. The Department accepts this recommendation. The Fuller stocktake also noted the importance of organisational support, and made a recommendation to Integrated Care Systems (ICSs) to co-design and put in place appropriate infrastructure and support …
Under Consideration
#24 — Routine measurement of continuity of care is essential for improvement efforts and targeted support.
Recommendation: Unless continuity of care is routinely measured GP practices and Primary Care Networks will be unable to identify where to focus improvement efforts. NHS England will also be unable to effectively target support without establishing a baseline for the provision …
Gov response: Partially Accept. The Department partially accepts this recommendation. GP practices receive funding from a range of sources, including those distributed according to the Carr-Hill Formula and funding delivered to Primary Care Networks. NHS England keeps …
Partially Accepted
#23 — Government and NHS England must acknowledge declining continuity of care and prioritise its reversal.
Recommendation: The Government and NHS England must acknowledge the decline in continuity of care in recent years and make it an explicit national priority to reverse this decline.
Gov response: Partially accept. The Department partially accepts this recommendation. We appreciate the sentiment of sharing the rewards of cost reductions where primary care has had a part to play. NHS England can provide light touch support …
Partially Accepted
#22 — All patients benefit from continuity of care, even without expressed preference for it.
Recommendation: We recognise that continuity of care is valued differently by different patients. However, just because a patient does not necessarily express a preference for continuity of care, it does not mean that they will not benefit from receiving it. It …
Gov response: Partially accept. We accept this recommendation in part and agree with the Committee about the importance of collecting and understanding outcomes data. We will look at ways to strengthen data collection and monitoring of outcomes …
Partially Accepted
#21 — Continuity of care is a vital, evidence-backed goal benefiting NHS general practice patients and GPs.
Recommendation: We believe that continuity of care is one of the most important goals for NHS general practice. There is a wealth of evidence that higher levels of continuity of care in general practice are better for both patients and GPs …
Gov response: Partially accept. The Department recognises the Committee’s concern that there are too many micro- incentives in general practice. Reflecting this in the short-term, for 2023/24 there will be a 25% reduction in QOF indicators (from …
Partially Accepted
#20 — Declining continuity of care in general practice is concerning and inadequately prioritised nationally.
Recommendation: We are extremely concerned about declining provision of continuity of care in general practice. We recognise the enormous pressure that GP services are under but it is unacceptable that one of the defining standards of general practice has been allowed …
Gov response: Accept. The Department accepts this recommendation and agrees that this should be a priority for Integrated Care Systems. NHS England have already issued a framework to support conversations between Integrated Care System teams and GP …
Accepted
#15 —
Recommendation: The number of missing referrals and the size of the waiting list make for a daunting situation when it comes to the needs of patients. Thinking about the recent changes to GPs’ workload to allow them to focus on booster …
Not Addressed
#20 —
Recommendation: The renewal of the Women’s Health Strategy must include an objective accompanied by clear actions to improve the level of awareness among all primary care practitioners of menstrual health conditions, including that symptoms can begin at puberty. This will require …
Response Pending
#29 — Examine limiting patient list sizes to 2500, reducing to 1850 over five years.
Recommendation: The Government should examine the possibility of limiting the list size of patients to, for example, 2500 on a list, which would slowly reduce to a figure of around 1850 over five years as more GPs are recruited as planned. …
Gov response: Do not accept. We recognise that GP to patient ratios and the size of patient lists can vary across England. However, as independent contractors, it is for each general practice to determine the size and …
Not Accepted
#16 — Medicine shortages reinforce public concerns about GP referrals from community pharmacies.
Recommendation: Public concerns about being referred back to the GP if they use community pharmacy to access healthcare should ring alarm bells for the Government. It is encouraging that this does not seem to be the experience within Pharmacy First, but …
Gov response: The Additional Role Reimbursement Scheme funding is currently under review as part of the consultation on the 2025/26 GP contract arrangements. Final arrangements will be published once the consultation has concluded.
Partially Accepted
#11 —
Recommendation: The very large numbers of people who have not presented for healthcare, or were not able to obtain it, during the pandemic, as well as those who have already been on waiting lists for long periods of time present a …
Not Addressed
#15 —
Recommendation: NHSE’s elective recovery programme includes plans for: • GPs to handle many elective cases previously dealt with by hospital doctors. Instead of referring some patients for elective care, GPs manage them within the 24 C&AG’s Report, paras 7, 1.15; Autumn …
Gov response: 4.2 The actions in the NHS published Delivery Plan are targeted at increasing activity, managing demand or increasing productivity and NHS England carefully monitors progress against delivery targets at regular intervals. 4.3 The 2023-24 priorities …
Not Addressed
#19 —
Recommendation: Dismissal of women’s period problems and the normalisation of period-related pain in primary care is now recognised as a concern by the healthcare sector. However, there is little evidence of systemic improvement. Young women and girls are still reporting their …
Response Pending
#14 —
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
#2 —
Recommendation: GPs will be the first port of call for many women who are experiencing perimenopause or menopause. It is vital that women can trust their GPs and that GPs feel confident and well-equipped in diagnosing a condition that affects half …
Gov response: 18. The government accepts this recommendation in part. 19. It is the government’s ambition, as set out in the Women’s Health Strategy, that healthcare professionals in primary care are well informed about the menopause, and …
Partially Accepted
#2 — Acknowledge general practice crisis and detail short-term steps to improve patient safety and access.
Recommendation: In response to this Report the Government and NHS England should be clear in acknowledging that there is a crisis in general practice and set out in more detail the steps they are taking in response to this crisis in …
Gov response: Partially accept. The Department partially accepts this recommendation. We agree with the need to explore solutions to problems which constrain primary care, particularly given the high levels of demand and workforce pressures. However, we do …
Partially Accepted
#1 — General practice in crisis due to poor patient access and safety risks, unacknowledged by government.
Recommendation: The first step to solving a problem is to acknowledge it and we believe that general practice is in crisis. It is clear from the latest GP Patient survey results that despite the best efforts of GPs, the elastic has …
Gov response: Partially accept. The Department partially accepts this recommendation. We recognise that some people are facing challenges trying to access general practice services in a timely way, and general practice teams have been working immensely hard …
Partially Accepted
#28 —
Recommendation: The Government Equalities Office and Department for Health and Social Care should develop a healthcare strategy for transgender and non-binary people within the next year. The strategy should include: • improved and mandatory training for GPs around treating trans and …
Gov response: 29. For clarity, we are using the term ‘spouse’ to refer to legally-recognised partners within either a marriage or civil partnership.
Under Consideration
#45 — Accelerate plans for GP partners to operate as LLPs to limit financial risk exposure.
Recommendation: The Government should accelerate plans to allow GP partners to operate as Limited Liability Partnerships or other similar models which limit the amount of risk to which GP partners are exposed. (Paragraph 144) 46 The future of general practice
Gov response: Partially accept. The Department partially accepts this recommendation. We will continue to consider this option, but further exploration is needed before the government can commit to accelerate plans to allow GP partners to operate as …
Not Addressed
#44 — Consider adopting Scottish GP premises model and increase investment in general practice estate.
Recommendation: The Government should consider adopting the approach to GP premises taken in Scotland and conduct its own analysis of whether this would be viable for general practice in England. More widely the Government must make additional investment available for the …
Gov response: Partially accept. The Department partially accepts this recommendation. In 2019, the General Practice Premises Policy Review2 highlighted the challenges faced by GPs and the wider NHS in terms of property ownership and liabilities. Stakeholders including …
Partially Accepted
#43 — GP premises remain a significant burden, hindering retention and undermining patient care.
Recommendation: Despite the risk associated with GP premises continuing to be a significant burden on existing GP partners and a barrier to entry for potential new partners, little progress appears to have been made on this issue. Until the Government grips …
Gov response: Partially accept. The Department partially accepts this recommendation. In 2019, the General Practice Premises Policy Review2 highlighted the challenges faced by GPs and the wider NHS in terms of property ownership and liabilities. Stakeholders including …
Partially Accepted
#42 — Reaffirm Government commitment to GP partnership model and detail support for its future.
Recommendation: In response to this Report the Government should reaffirm its commitment to maintaining the GP partnership model and explain how it will take forward our recommendations to better support the partnership model, alongside ongoing work to enable other models of …
Gov response: Partially accept. The Department partially accepts this recommendation. The Government confirms there is currently no policy to abolish the partnership model, which is the majority model for general practice delivery and works well in many …
Partially Accepted
#41 — GP partners faced regrettable uncertainty, now reassured Government will maintain partnership model.
Recommendation: It is regrettable that during a time of intense pressure for GPs, following a massive effort by GPs to lead the vital covid-19 vaccination programme, that GP partners were subjected to such open speculation and uncertainty about their futures. It …
Gov response: Partially accept. The Department partially accepts this recommendation. The Government confirms there is currently no policy to abolish the partnership model, which is the majority model for general practice delivery and works well in many …
Not Addressed
#12 — Further steps needed to address general practice administrative workload.
Recommendation: NHS England should take further steps to address the administrative workload in general practice, including by introducing e-prescribing in hospitals and focusing on the primary-secondary care interface by encouraging ICSs to provide a reporting tool for GPs to report inappropriate …
Gov response: Do not accept. The Department does not accept this recommendation as we are not able to establish requirements for a minimum fair share of administrative duties, as locums and practices enter into individual contractual arrangements. …
Not Accepted
#11 — General practice administrative workload remains unsustainable despite initial reduction efforts.
Recommendation: The Government and NHS England have made a start on reducing the administrative workload in general practice, and it is also encouraging to see some Integrated Care Systems agreeing to try to reduce the amount of work that is inappropriately …
Gov response: Partially accept. We recognise the importance of retention in growing the GP workforce, and partially accept this recommendation. To support retention, NHS England have in place the National GP Retention Scheme. This scheme is a …
Partially Accepted
#3 — Commission a review into short-term problems constraining primary care, including IT and administrative tasks.
Recommendation: The Government should commission a review into short-term problems that constrain primary care including, but not limited to: the interface between primary and secondary care, prescribing from signing to dispensing, administrative tasks e.g. reports and sick notes, day-to-day usability of …
Gov response: Partially accept. The Department partially accepts this recommendation. The Department recognises the importance of the future pipeline of GPs, which is critical for growing the number of doctors in general practice. This is why we …
Partially Accepted
#4 — Medicine shortages risk negating general practice capacity gains from Pharmacy First.
Recommendation: It is also especially worrying that shortages are resulting in patients being directed back into general practice. There is a serious risk that any capacity that general practice gains, through services like Pharmacy First, will be negated by the time …
Gov response: As above, the Human Medicines Regulations 2012 (HMRs 2012) require pharmacists to dispense “in accordance with a prescription”. This has been interpreted to mean supply of medicines must be the exact product and quantity prescribed …
Accepted
PPO Death in Custody Recommendations (2)
The healthcare provider
The healthcare provider should ensure there is a GP onsite in line with the primary care service specification for prisons in England.
The GP provider
The GP provider should review the prison GP wait times to ensure all is being done to bring it in line with community access to GPs.
IMB Recommendations (4)
Erlestoke (2020)
To the Governor, and Avon and Wiltshire Mental Health Partnership Trust: What is intended to be done to improve the waiting time for routine GP appointments? (see paragraph 8.6)
Other
Bronzefield (2023)
How does NHS England plan to address the Board’s concern regarding the lack of a GP physically present at the prison during the weekends, and the fact that there is only a substance misuse GP at the prison on Mondays?
NHS / Healthcare Provider
Bronzefield (2025)
How does NHS England propose to remedy the deficiency in GP cover in reception (6.1)?
NHS / Healthcare Provider
Gatwick IRC/RSTHF (2022)
Strengthen the encouragement given to arriving men to take up a Rule 34 appointment with the centre GP. Ensure that healthcare staff involved in initial assessments fully describe the purpose of the Rule 34 appointment (section 4.4.2).
NHS / Healthcare Provider
PHSO Casework Decisions (62)
P-003330 — A practice in the Dorset area
Mrs T complains the Practice denied her husband’s request for a home visit on19 July 2023, instead arranging a telephone consultation for 8 August with an unacceptable wait of 20 days for GP care. Mrs T complains the Practice then failed to arrange a home visit, despite agreement from the …
NHS in England
Feb 2025
P-003664 — A practice in the Forest of Dean area
Mrs N complains that when Mr N attended his GP practice with foot pain on 2 December 2024, the receptionist did not review his medical history or seek any clinical advice. He was advised to ring NHS 111 and was not seen by a GP.
NHS in England
Jul 2025
P-001352 — A medical practice in the Oldham area
Mr H complains that a medical practice in the Oldham area wrongly cancelled his GP appointment and the subsequent events resulted in him being removed from the patient register without warning.
NHS in England
Partly Upheld
Apr 2022
P-004554 — A practice in the Wokingham area
Mr L complains on behalf of his Father, Mr M about a GP practice in Reading regarding face-to-face appointments and lack of communication.
NHS in England
Dec 2025
P-002891 — A practice in the North Tyneside area
Miss P complains it took her GP over a year to refer her for investigations for weakness in her arm.
NHS in England
Aug 2024
P-003160 — A practice in the West Northamptonshire area
Ms B complains the Practice refused to send a GP to visit her father at home despite his deterioration and her mother’s difficulties in looking after him.
NHS in England
Upheld
Nov 2024
P-003538 — A practice in the Birmingham area
Ms P complains about her mother’s care in November 2022 and says there were issues with contacting the Practice and getting a face-to-face appointment. She also complains her mother’s diagnosis was incorrect and there were delays with the complaint handling.
NHS in England
May 2025
P-003704 — Oxford University Hospitals NHS Foundation Trust
Mrs T complains about her daughter's care and treatment in February 2023. She complains the Trust declined a referral from the GP, without considering the full scope of evidence.
NHS in England
Jul 2025
P-003714 — A practice in the Oldham area
Mrs A complains the Practice failed to provide face to face GP appointments for her mother.
NHS in England
Jul 2025
P-003984 — A practice in the City of Nottingham area
Ms P complains a GP Surgery in Nottingham refused to provide her HRT prescription and did not inform her before it reduced her prescription. She also complains it did not communicate with other organisations to support her prescription.
NHS in England
Sep 2025
P-004538 — A practice in the Norwich area
Miss M complains about aspects of her care and treatment by the Practice between May 2022 and March 2025. She complains the Practice did not take appropriate action to investigate and consider her ongoing menstrual symptoms and did not refer her for further input from a gynaecologist at the earliest …
NHS in England
Dec 2025
P-004667 — A practice in the North Yorkshire area
Mr T complains about the care and treatment his wife, Mrs T received at a GP Practice. He complains the Practice dismissed and failed to investigate her symptoms, and have to wait 12 months for an appointment with a specialist.
NHS in England
Jan 2026
P-004579 — A practice in the Broadland area
Mr H complains about aspects of care and treatment a GP Practice in the Norfolk area (the Practice) provided between December 2024 and February 2025. He says he had issues making appointments and obtaining antibiotics.
NHS in England
Jan 2026
P-001826 — A practice in the Calderdale area
Mrs A complains the Practice diagnosed her mother over the phone many times but her condition did not improve. She also complains the Practice's communication was poor.
NHS in England
Feb 2023
P-001872 — A practice in the Derbyshire area
Mrs A complains the Practice failed to identify and diagnose her arterial arteritis (inflammation of the arteries) from April to August 2021, despite her clear symptoms.
NHS in England
Mar 2023
P-001869 — A practice in the Warwickshire area
Mrs V complains the Practice failed to refer her for an urgent scan when she had post-menopausal bleeding.
NHS in England
Mar 2023
P-001964 — A practice in the Stockton-on-Tees area
Mrs O complains the Practice ignored her requests for an emergency appointment.
NHS in England
Apr 2023
P-002455 — A practice in the Lancashire area
Mrs H complains the Practice did not complete a referral to a specialist quickly enough for her father and did not complete a home visit the day he died. She also complains it gave incorrect information to the coroner.
NHS in England
Feb 2024
P-002521 — A practice in the Stockport area
Mr O complains that in October and November 2021 the Practice and the Trust failed to diagnose a stroke.
NHS in England
Mar 2024
P-002495 — A practice in the Devon area
Mrs R complains that GPs at the Practice missed several opportunities from early 2022 to spot the signs of cancer in her father.
NHS in England
Mar 2024
P-003224 — A practice in the Manchester area
Miss Q complains the Practice did not refer her appropriately or monitor her blood pressure as it should have done.
NHS in England
Dec 2024
P-003417 — A practice in the Sheffield area
Miss A complains about the delay she encountered registering with the Practice, about its staff being unprofessional and about its lack of medical support for her health conditions.
NHS in England
Mar 2025
P-003515 — A practice in the Leeds area
Miss T complains the Practice failed to provide a good standard of care for her father between January and November 2020.
NHS in England
Mar 2025
P-003773 — A practice in the Solihull area
Mr P complains the Practice did not make the appropriate referrals for his wife prior to her death.
NHS in England
Upheld
Aug 2025
P-004488 — A practice in the Wigan area
Ms E complains about the care and treatment she received when she attended her GP surgery on 7 and 10 January 2025. Ms E complains that the doctor did not prescribe antibiotics on 7 January when they diagnosed a viral infection despite her having a high temperature.
NHS in England
Dec 2025
P-004494 — A practice in the Braintree area
Mrs L complains about aspects of the care the Practice provided her husband, Mr L, prior to his death in July 2024. Mrs L is unhappy the Practice did not have a care plan in place, was not aware of how unwell he was, and did not test him for …
NHS in England
Dec 2025
P-004521 — A practice in the Croydon area
Miss K complains that the Practice did not approve the prescription exemption form that she submitted to it in a timely manner.
NHS in England
Dec 2025
P-004682 — A practice in the Leeds area
Mrs A complains about the care and treatment provided to her father, Mr R, by the Practice on 13 August 2024. She says Practice staff should have attended Mr R’s care home to provide him with a face-to-face consultation, and it failed to accurately diagnose and subsequently treat Mr R, …
NHS in England
Jan 2026
P-004683 — Royal Devon University Healthcare NHS Foundation Trust
Mrs S states a senior spinal fellow (SSF) at Royal Devon University Healthcare NHS Foundation Trust did not consider all her symptoms when deciding to discharge her from the spinal team. She also says a clinical letter written by the SSF did not reflect everything he said to her during …
NHS in England
Jan 2026
P-004698 — A practice in the Canterbury area
Mrs D says, at an appointment in April 2024, a GP at a practice in the Kent area did not fully investigate her mother, Mrs W's symptoms. She says the GP did not provide the right treatment or urgently refer her for appropriate further investigations.
NHS in England
Jan 2026
P-001801 — A practice in the Worcestershire area
Mrs U complains the Practice would not give her son B12 injections. She also complains it delayed making referrals, did not give her online access to her son's records and did not reply to her complaint.
NHS in England
Feb 2023
P-001820 — A practice in the Derbyshire area
Ms R complains a nurse at the Practice did not offer her father a face to face appointment, provided inappropriate treatment during a telephone consultation, and did not provide any follow up care.
NHS in England
Feb 2023
P-001928 — A practice in the Essex area
Mrs U complains about how the Practice managed her medication, referrals and stroke treatment. She also complains about the Practice's support and accessibility.
NHS in England
Apr 2023
P-003823 — A GP practice in the Doncaster area
Mrs C complains about the Practice's care after she had private surgery abroad.
NHS in England
Sep 2023
P-002397 — A practice in the Telford and Wrekin area
Mr H complains that his GP failed to recognise and tell him about the potential side-effects of a prescribed heart medication. He also complains he did not have face to face appointments.
NHS in England
Jan 2024
P-002658 — A practice in the Manchester area
Miss L complains the Practice did not refer her for hair loss treatment between September 2023 and February 2024. She also complains it removed her from its patient list.
NHS in England
Jun 2024
P-002663 — A practice in the Leicestershire area
Mrs I complains the Practice failed to physically examine her husband's penile cancer symptoms, prescribed him with incorrect medication and it was difficult to arrange face-to-face appointments.
NHS in England
Jun 2024
P-002670 — A practice in the Hartlepool area
Mrs E complains the Practice incorrectly referred her on a two-week pathway to the gastroenterology department at her local hospital instead of to the ear, nose and throat (ENT) department. She also says she was incorrectly removed from the patient register.
NHS in England
Jun 2024
P-003005 — A practice in the Exeter area
Miss O complains the Practice did not provide her mother with timely specialist support.
NHS in England
Sep 2024
P-002918 — A practice in the Hartlepool area
Miss R complains about the care and treatment the Practice gave her regarding hormone replacement therapy. She also complains the Practice were difficult to contact by phone.
NHS in England
Sep 2024
P-003031 — James Paget University Hospitals NHS Foundation Trust
Mrs A complains about her late husband’s care and treatment in 2021. She says delays in referral by the GP practice were followed by delays in diagnosis and treatment by the Trust.
NHS in England
Oct 2024
P-003023 — A practice in the Stratford-on-Avon area (GP Surgery …
Ms E complained about several NHS organisations regarding her removal from patient lists in 2020 and 2021.
NHS in England
Oct 2024
P-003258 — Royal Free London NHS Foundation Trust
Mr K complained about the care his mother received from her GP Practice and the Trust in the last weeks of her life.
NHS in England
Dec 2024
P-003483 — A practice in the Leeds area
Mrs O complains the Practice did not complete timely investigations into her husband’s symptoms between 3 March and 27 September 2021, leading to a delayed diagnosis.
NHS in England
Apr 2025
P-003789 — A practice in the Fenland area
Mr E complains about the conduct of a GP at the Practice between 2015 and 2018. He says this impacted on his care at an NHS Trust and he would like the GP to explain why they took these actions.
NHS in England
Aug 2025
P-003809 — A practice in the Wirral area
Mr B complains a GP Practice allowed him to register as a patient, but de-registered him soon after.
NHS in England
Aug 2025
P-003748 — A practice in the North Tyneside area
Mrs E complains that her husband’s GP failed to identify signs of brain cancer for three months before the diagnosis was confirmed.
NHS in England
Aug 2025
P-003735 — A practice in the Bromsgrove area
Mrs T complains that their spinal condition was not adequately managed by the GP Practice between September 2023 and May 2024. She says the follow-up care was poor.
NHS in England
Aug 2025
P-004293 — A practice in the Stockport area
Mr A complains about a GP Practice in Stockport. He complains the Practice did not refer him for further tests before and after he had a seizure and failed to provide an appointment on 6 June 2024.
NHS in England
Nov 2025
P-004326 — A practice in the Shropshire area
Dr A complains a GP Practice in Shropshire (the Practice) missed several opportunities to discover that his daughter, H was being bullied at school. He feels the Practice should have assigned H one specific GP for all appointments for consistency.
NHS in England
Nov 2025
LGO / SPSO Decisions (317)
PSOW-202501595 — A GP Practice in the area of Betsi …
We investigated a complaint brought by M’s mother, Mrs P, which focused on whether M’s consultations with clinicians at a GP practice (“the GP Practice”) in relation to abdominal symptoms between 11 March 2024 and 8 June 2024 were appropriately managed and whether there were any missed opportunities to diagnose …
PSOW (Public Services Om…
Health
Jan 2026
PSOW-202303749 — Aneurin Bevan University Health Board
Mrs B complained about the advice her husband Mr B received from an Advanced Nurse Practitioner (ANP) employed by the Out of Hours GP service, shortly before he was admitted to hospital and sadly died of neutropenic sepsis. Mrs B said that a home visit she requested should have been …
PSOW (Public Services Om…
Health
Upheld
Mar 2024
PSOW-202402918 — Betsi Cadwaladr University Health Board
Mr B complained that the Health Board had not responded to all the questions that he had raised with the GP Practice. He also was unhappy with the Health Board’s handling of his complaint, including the time taken to provide a response. He referred to the effect this had on …
PSOW (Public Services Om…
Health
Aug 2024
PSOW-202405171 — A GP Practice in the area of Hywel …
Mr A complained about how the Practice dealt with his complaint, how he was de-listed from the Practice, and the clinical treatment he received from the Practice. After assessment, the Ombudsman found that the Practice had not responded to Mr A’s complaints under the Putting Things Right process. The Ombudsman …
PSOW (Public Services Om…
Health
Jan 2025
PSOW-202407040 — Betsi Cadwaladr University Health Board
Ms C complained that she was unable to make an appointment with a GP Practice in the area of Betsi Cadwaladr University Health Board, which resulted in delays in reviewing her medication and issuing prescriptions The Ombudsman decided that the Practice had failed to recognise that the patient had made …
PSOW (Public Services Om…
Health
Feb 2025
PSOW-202408569 — A GP Practice in the area of Swansea …
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 …
PSOW (Public Services Om…
Health
Upheld
Nov 2025
201902987 — A Medical Practice in the Lanarkshire NHS Board …
C attended the practice to collect prescriptions and had a brief discussion with a member of staff. Subsequently, C received a letter from the practice informing them their registration with the practice had been terminated due to inappropriate behaviour. C considered the practice’s actions to be unreasonable. We found that …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2020
NIPSO-29583 — Lurgan Medical Practice
We found that a medical assessment performed during a home visit was carried out in line with good medical practice, but that the GP should have recorded what had been discussed with the patient and her family, and what they should do if her symptoms did not improve.
NIPSO (NI Public Service…
Health & Social Care
Dec 2020
NIPSO-gp-practice-addresses-appointment-booking-system-after-patients — GP
NIPSO (NI Public Service…
Health & Social Care
Apr 2021
NIPSO-201916274 — GP
We investigated whether an increase in a man’s prescription caused him to attend hospital the following day. We found the Practice’s increase in the dose fell within the prescribed limits.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Mar 2024
NIPSO-202004023 — GP
A woman complained that her GP failed to uphold a commitment to monitor her mental health problems. We partially upheld the complaint.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Mar 2025
NIPSO-202006812 — GP
A man complained that his GP should have provided him with medication following a private ADHD diagnosis.
NIPSO (NI Public Service…
Health & Social Care
Upheld
May 2025
NIPSO-202400471 — GP
A patient’s daughter complained he should not have had to wait for the results of blood tests before being sent to hospital. We found his GP acted appropriately.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Dec 2025
PSOW-202103895 — Betsi Cadwaladr University Health Board
Mrs X complained that she was admitted to hospital for 3 weeks due to a lack of treatment by a GP practice, which is managed by the Health Board, for a chest infection, which resulted in fluids subsiding to her heart and resultant breathing difficulties. She also complained about a …
PSOW (Public Services Om…
Health
Oct 2021
PSOW-202003164 — Cwm Taf Morgannwg University Health Board
Mr B complained about the care and treatment provided to his late brother, Mr F, by a GP Practice (“the Practice”) in the area of Cwm Taf Morgannwg University Health Board. Mr B complained that between 6 February 2017 and 2 January 2020, the Practice failed to carry out appropriate …
PSOW (Public Services Om…
Health
Not Upheld
Oct 2021
PSOW-202108137 — A GP Practice in the area of Aneurin …
Miss X complained that the Surgery changed the frequency of her prescriptions from monthly to fortnightly without explanation. The Ombudsman decided that the Surgery should provide Miss X with a “Putting Things Right” (the formal NHS complaints process in Wales) compliant written response (within 3 weeks) which should explain the …
PSOW (Public Services Om…
Health
Mar 2022
PSOW-202106424 — A GP Practice in the area of Aneurin …
Mrs H complained that her GP Practice failed to manage her diabetes appropriately and that it removed her from its patient list after she submitted a formal complaint. The Ombudsman considered that there was insufficient evidence of harm to justify investigating Mrs H’s clinical complaint. However, having considered advice from …
PSOW (Public Services Om…
Health
Mar 2022
PSOW-202200063 — A GP Practice in the area of Cardiff …
Mr X complained that despite making a formal complaint to the GP Practice in November 2021 about his medical records not being transferred, he had not received a response . The Ombudsman was concerned that Mr X had yet to receive a response to his concerns and contacted the GP …
PSOW (Public Services Om…
Health
Apr 2022
PSOW-202200632 — A GP Practice in the area of Aneurin …
Mr X complained that the Practice failed toappropriately change his pain relief medication as instructed by the hospitaland failed to issue a repeat prescription. The Ombudsman found that whilst the Practice responded to Mr X’s concerns, it had done so verbally. It had not offered its response in writing in …
PSOW (Public Services Om…
Health
Jul 2022
PSOW-202005677 — A GP Practice in the area of Hywel …
Mr X complained about the care provided to his mother, Mrs Y, by her GP Practice. He complained that: • There was a delay in providing Mrs Y with a clear and accurate diagnosis. • Mrs Y was not advised that the reason for a scan she received in January …
PSOW (Public Services Om…
Health
Upheld
Jul 2022
PSOW-202103875 — Cwm Taf Morgannwg University Health Board
Mr A complained about the treatment given to his mother, Mrs B, by the Practice. He stated that Mrs B had repeatedly raised concerns for 15 months before she was diagnosed with ovarian cancer, and if the Practice had responded appropriately, including offering her face-to-face consultations rather than telephone ones, …
PSOW (Public Services Om…
Health
Upheld
Aug 2022
PSOW-202200229 — A GP Practice in the area of Swansea …
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 …
PSOW (Public Services Om…
Health
Aug 2022
PSOW-202202701 — A GP Practice in the area of Cardiff …
Miss X complained that although she had raised her concernswith the GP Practice, she had not yet received a final response despitepromises that it would be issued to her. The Ombudsman was concerned that Miss X was yet to receive aresponse to her concerns and therefore contacted the GP Practice. …
PSOW (Public Services Om…
Health
Aug 2022
PSOW-202202532 — Betsi Cadwaladr University Health Board
Mr X complained about problems making appointments at his GP Practice (managed by the Health Board) and he said that staff were “awkward”, “demanding” and “argumentative” when returning his telephone calls. He also alleged that staff do not believe anything is wrong with him. He further raised concerns about the …
PSOW (Public Services Om…
Health
Aug 2022
PSOW-202104963 — A GP Practice in the area of Aneurin …
Ms A complained about her diagnosis and treatment by the GP Practice while she was going through a mental health crisis. The investigation considered whether the appointments provided to her were suitable, whether the Practice’s communication with Ms A regarding her requests for appointments was appropriate, whether the medications prescribed …
PSOW (Public Services Om…
Health
Not Upheld
Nov 2022
PSOW-202203324 — A GP Practice in the area of Hywel …
Mr S complained that the Surgery de-registered him from the practice due to him submitting a complaint. He further complained that despite him submitting his complaints, he had not received a full response. The Ombudsman was concerned that Mr S had not yet received a response to his concerns and …
PSOW (Public Services Om…
Health
Nov 2022
PSOW-202203494 — A GP Practice in the area of Betsi …
Mr X complained about his experience with the Practice, who he considered to be transphobic. The Practice refused to prescribe hormones, requested by the local gender team, without seeking further clarification, but he had not received any update or response regarding this. Mr X was dissatisfied with the complaint response …
PSOW (Public Services Om…
Health
Nov 2022
PSOW-202202905 — A GP Practice in the area of Betsi …
Mrs A complained that the GP Practice’s management and care of her late father Mr B’s deteriorating kidney function in 2022 was not to an appropriate standard. The Ombudsman’s investigation found that most of the appointments and interactions relating to Mr B’s care, together with the medication management of his …
PSOW (Public Services Om…
Health
Upheld
Sep 2023
PSOW-202202309 — A GP Practice in the area of Betsi …
Mrs A complained about the care and treatment that her late mother, Mrs B, received during the final weeks of her life while she was a resident in a care home in the area of Betsi Cadwaladr University Health Board. Mrs A complained that the Care Home failed to appropriately …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202204525 — Aneurin Bevan University Health Board
Mrs C complained about the care and management her late husband, Mr A, received from the GP Surgery (“the Surgery”) between May and November 2021. The Ombudsman investigated whether there were unacceptable delays in making appointments and telephone consultations for Mr A between May 2021 and 23 November 2021, and …
PSOW (Public Services Om…
Health
Not Upheld
Feb 2024
PSOW-202207050 — Aneurin Bevan University Health Board
Mr R complained about care and treatment provided to his late wife, Mrs R, by Aneurin Bevan University Health Board (“the Health Board”), a GP Practice (“the Practice”) in the area of the Health Board, and Gloucestershire Hospitals NHS Foundation Trust (“the First Trust”). The Public Services Ombudsman for Wales …
PSOW (Public Services Om…
Health
Not Upheld
Feb 2024
PSOW-202301750 — Cwm Taf Morgannwg University Health Board
Mr B complained that the Practice failed to provide appropriate care and treatment to his mother, Mrs B, shortly before she sadly died. Mr B complained that the Practice failed to call an ambulance or inform his sister, Mrs A, that their mother needed to be admitted to hospital. Mr …
PSOW (Public Services Om…
Health
Upheld
Feb 2024
PSOW-202307376 — A GP Practice in the area of Betsi …
Ms Y complained about the care a GP Practice in the area of Betsi Cadwaladr University Health Board, had provided to her. She specifically complained about comments made to her when she contacted the practice about her symptoms and said that the Practice did not provide appropriate support when she …
PSOW (Public Services Om…
Health
Feb 2024
PSOW-202308473 — A GP Practice in the area of Cardiff …
Ms N complained that a GP surgery in the Cardiff and Vale University Health Board area (“the Surgery”) failed to address her concerns that it issued a letter containing medical information to her shared home address without an addressee. The Ombudsman found that the Surgery omitted to address this aspect …
PSOW (Public Services Om…
Health
Feb 2024
PSOW-202106970 — A GP Practice in the area of Betsi …
Mrs B complained about the care and treatment provided to her by a GP Practice (“the Practice”) in the area of Betsi Cadwaladr University Health Board. The investigation considered whether the Practice misdiagnosed Mrs B’s symptoms, which led to a delay in the diagnosis of laryngopharyngeal reflux/silent reflux (when stomach …
PSOW (Public Services Om…
Health
Not Upheld
Mar 2024
PSOW-202108288 — A GP Practice in the area of Swansea …
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 …
PSOW (Public Services Om…
Health
Not Upheld
Mar 2024
PSOW-202208529 — Velindre University NHS Trust
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 …
PSOW (Public Services Om…
Health
Mar 2024
PSOW-202306840 — Health Education and Improvement Wales
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 …
PSOW (Public Services Om…
Health
Upheld
Mar 2024
PSOW-202308039 — Cwm Taf Morgannwg University Health Board
Messrs A & B complained that the Practice had decided not to investigate and provide a substantive response to the complaint they had made to it. The Ombudsman was concerned that the Practice had unfairly decided that the complaint to it was out of time and that it had declined …
PSOW (Public Services Om…
Health
Mar 2024
PSOW-202302575 — Aneurin Bevan University Health Board
Mrs A complained about the care and treatment provided by a GP Practice to her late mother, Mrs B, in July and August 2022. The Ombudsman investigated whether antibiotics should have been prescribed at or following a home visit on 25 July 2022, whether home visits should have been carried …
PSOW (Public Services Om…
Health
Not Upheld
Apr 2024
PSOW-202309245 — A GP Practice in the area of Cardiff …
Miss H complained that Whitchurch Road Surgery failed to address her concerns about alleged malpractice and malicious referrals in its complaint response. The Ombudsman found that whilst the Surgery had issued a complaint response it had failed to adequately address her concerns. She said that this caused frustration and uncertainty …
PSOW (Public Services Om…
Health
Apr 2024
PSOW-202310284 — A GP Practice in the area of Cardiff …
Mrs A complained about the care provided to her late sister by Cardiff and Vale University Health Board and a GP Practice. The Ombudsman found that Mrs A complained to the Health Board in 2022, but she had not received a formal response to her complaints under the Putting Things …
PSOW (Public Services Om…
Health
Apr 2024
PSOW-202302967 — A GP Practice in the area of Hywel …
Mr A’s complaint centred on the alleged delay by a GP Practice in the area of Hywel Dda University Health Board (“the GP Practice”) in October 2021 with diagnosing his father, Mr D, with spinal issues and kidney cancer. The Ombudsman did not find an undue delay in the GP …
PSOW (Public Services Om…
Health
Not Upheld
Jun 2024
PSOW-202309223 — A GP Practice in the area of Powys …
Ms A complained about the care and treatment that her late father, Mr B, received from the Practice, including that it did not adequately treat her father’s anaemia. The Ombudsman decided that although the Practice prescribed one month’s folic acid, no further investigation of Mr B’s folate level were carried …
PSOW (Public Services Om…
Health
Jun 2024
PSOW-202400818 — A GP Practice in the area of Aneurin …
Mr A complained about the GP Practice’s complaint response about his mother’s management and care in February 2024. Mr A also complained about a later period of care (in April ) that the GP Practice had not had an opportunity to consider. The Ombudsman exercised her discretion and decided to …
PSOW (Public Services Om…
Health
Jul 2024
PSOW-202401942 — A GP Practice in the area of Hywel …
Mrs B complained to her GP Practice about care and treatment she had received. This included concerns about a letter she had received from a GP, concerns about her pain management, incorrect information in hospital referrals and access to her medical records. Mrs B complained to the Ombudsman that the …
PSOW (Public Services Om…
Health
Jul 2024
PSOW-202309554 — A GP Practice in the area of Powys …
Mr A complained that a GP Practice in the Powys Teaching Health Board area (“the Practice”) failed to provide appropriate care and treatment in relation to his presenting symptoms. Mr A was later diagnosed with polymyalgia rheumatica. Mr A was particularly concerned that it was unreasonable for the Practice to …
PSOW (Public Services Om…
Health
Not Upheld
Dec 2024
PSOW-202402868 — A GP Practice in the area of Cardiff …
Ms P complained that between June and August 2023, her wounds were not appropriately cared for by nursing staff at the Surgery and the risk of infection was not addressed. She also complained that nursing staff did not seek additional input at appropriate times. Ms P said that her wounds …
PSOW (Public Services Om…
Health
Not Upheld
Dec 2024
PSOW-202303356 — A GP Practice in the area of Aneurin …
Ms D complained about the care and treatment provided to her grandmother, Mrs F. Specifically, the investigation considered whether, between June 2021 and June 2022, Mrs F’s GP Practice failed to take appropriate action which would have resulted in an earlier diagnosis of her bladder cancer. My investigation found that …
PSOW (Public Services Om…
Health
Jan 2025
PSOW-202309579 — Swansea Bay University Health Board
Mr F complained about the care provided to his late mother Mrs G. The investigation considered whether the action taken by the Acute Clinical Team in respect of his late mother’s blood test results between 25 May and 2 June 2023 was clinically appropriate. The investigation found that Mrs G’s …
PSOW (Public Services Om…
Health
Upheld
Jan 2025