A practice in the City of Brighton and Hove area

3. Mr M complains a GP practice in the Brighton and Hove area (the Practice) did not adequately communicate changes in his medication.

4. Mr M told us the way the Practice communicated caused him distress.

5. As an outcome to his complaint, Mr M wants the Practice to improve the way it communicates medication changes.

6. Mr M had an injury in 1988 that caused damage to his spine. After trying various pain medications, Mr M settled on morphine. Mr M has taken a daily dosage of morphine for the last thirty years.

7. On 7 April 2025 Mr M received a letter from the Practice saying his morphine would be reduced to 30mg twice per day. He had been taking 60mg twice per day. The Practice created a plan showing this reduction would happen over the next six months.

8. The letter offered Mr M a phone call with a pharmacist to discuss the morphine reduction on 22 May 2025.

9. Mrs M complained to the Practice on Mr M’s behalf on 12 April 2025.

10. On 27 May 2025 Mr M had an appointment with a GP at the Practice to discuss the morphine reduction. The GP agreed Mr M should have a trial reduction lasting two weeks. Mr M was told if he was in lots of pain he could take extra paracetamol.

11. Mr M’s morphine was reduced by 5mg for the two-week trial reduction. On 3 July 2025 Mr M had a follow up appointment at the Practice. Mr M told the Practice the pain had been unbearable, and he had been unable to move. The Practice agreed to return Mr M’s morphine prescription to the original dosage of 60mg twice per day.

Issue 1 – The Practice did not adequately communicate Mr M’s change in medication.

14. The Practice have offered a resolution for Mr M’s compliant. We consider this resolution meets Mr M’s desired outcome. We have decided this is a satisfactory conclusion for this complaint and we will not be investigating further.

15. Mrs M told us when Mr M received the letter from the Practice saying his medication would be reduced, he was extremely distressed. She said Mr M was worried he might have to go to Hospital with withdrawal symptoms once the medication change began. He was worried about the pain he might be in if his medication was decreased. We can see Mr M experienced significant distress as an impact of receiving the letter from the Practice.

16. The Practice explained the change in morphine medication was due to a change in NHS, NICE, and Faculty of Medicine guidance. This guidance says taking morphine over a long period of time carries significant risk and has limited benefit. It also explained it had identified Mr M as a patient on a high morphine dosage.

17. We explained to the Practice the letter caused Mr M considerable distress and upset. The Practice representative told us it aims for best medical practice, and it was disappointed to hear its communication caused distress.

18. The Practice considered different ways it might communicate medication changes in the future. It explained face-to-face conversations with every patient are not possible due to the volume of patients and the pressures on the NHS. The Practice explained it is happy to arrange face-to-face conversations if a patient is particularly anxious about proposed medication changes. We can see in Mr M’s case he was offered an in-person appointment.

19. The Practice also considered it could phone patients to tell them about medication changes. It explained this can make patients feel ambushed. It can catch patients off guard causing distress, and they can leave the call with unanswered questions.

20. The Practice considered a letter was the best way to communicate medication changes. This gives patients a chance to process the information in their own time and think about any questions or concerns they may have. The Practice explained in future, it will always follow this up with a phone call to make sure the patient can have their questions answered.

21. The Practice told us it is going to amend its medication change letter to make it more empathetic. It will reassure patients they will be supported through the medication reduction, and any changes will only be done with their consent and co-operation.

22. The Complaint Standards say staff should actively listen and demonstrate a clear understanding of the complainant’s issues and the outcomes they are seeking. It also says staff should look for ways to resolve complaints at the earliest opportunity, to be accountable for their actions and take learning from complaints to improve services.

23. We can see the Practice listened to the complaint Mr M raised. In our phone call with the Practice, the member of staff made an effort to understand Mr M’s complaint and the impact the letter had on him.

24. The Practice have taken learning from Mr M’s complaint by considering how they could improve their communication. The Practice considered different methods of communicating medication changes including phone calls and face-to-face appointments. The Practice have considered letters are the most appropriate method, and they have identified this can be improved by amending the letter and following it up with a phone call.

25. The Practice’s proposal demonstrates understanding, learning and willingness to put complaints right. This is in line with the Complaint Standards.

26. We have considered Mr M’s evidence of the impact the letter had on him. We have also considered the Practice’s evidence of their proposed improvements.

27. We consider the actions the Practice have proposed will remedy this complaint for Mr M and other service users, and they are in line with Mr M’s wishes. For this reason, we will not be taking further action on this complaint.

Conclusion

28. We can see the Practice have had a valuable opportunity to improve their communication by reflecting on Mr M’s complaint. We would like to thank Mr M for bringing this complaint to us.

29. The Practice have agreed a deadline of 30 January 2026 to complete their service improvements. We thank the Practice for their co-operation in this process.

1. We have carefully considered Mr M’s complaint about the Practice. We have decided not to take further action on his complaint because the Practice have agreed a resolution for Mr M’s complaint.

2. We thank Mr M and his representative, Mrs M, for bringing this complaint to us and telling us about their experience.