Clinical treatment outside hospital : A GP Practice in the area of Hywel Dda University Health Board

Mr A complained about the care and treatment he received from the Practice. The Ombudsman did not uphold Mr A’s complaint that after registering with the Practice, it failed to obtain his previous clinical records in a timely manner to gain an appropriate understanding of his clinical history.

Mr A complained that appropriate consideration was not given to his previous diagnoses (anxiety and bipolar disorder) by the Practice GPs when considering his current clinical diagnosis, he was not appropriately diagnosed and was not offered appropriate treatment and/or referrals for secondary care in a timely manner, and there was a failure to communicate the NHS referrals process appropriately to assist him in making an informed decision about future treatment options. These complaints were not upheld. However, the Ombudsman invited the Practice to reflect on how it explains the referral process for NHS psychiatric care to patients who are awaiting a formal diagnosis.

The Ombudsman found that, in relation to Mr A’s request for disclosure of his clinical records, the Practice failed to provide clear, consistent information and failed to maintain an accurate record of its handling of his information request. This complaint was upheld.

The Ombudsman upheld Mr A’s complaint about a third party entry recorded in his clinical records to the extent that the encounter was not recorded in line with the Practice’s relevant guidance.

The Ombudsman upheld Mr A’s complaint about the decision to de-register him from the Practice to the extent that the process to remove him was not done in accordance with recognised best practice.

In relation to Mr A’s concerns that the Practice failed to deal with his complaint in accordance with the Putting Things Right (“PTR”) Process (NHS complaints process), the Ombudsman acknowledged the frustration due to the delay in dealing with his complaint. However, the Ombudsman recognised that the PTR Process made allowances for exceptional circumstances which may impact on the ability to conclude a complaints investigation within the stipulated timescales. The COVID-19 pandemic clearly impacted in this case, and she was satisfied, in the circumstances, that this constituted an exceptional circumstance that could not be foreseen. The complaint was not upheld but the Practice was invited to reflect on how it managed patients’ expectations during the course of complaint investigations.