A practice in the Lewisham area

4. Dr R complains about the care and treatment he received at the Practice between December 2024 and May 2025. He complains that:

• a nurse did not introduce herself during his two consultations with her • during both appointments with the named nurse, she misinformed him about how to attend an X-ray • the Practice’s response was unsatisfactory and did not take him seriously • he believes the Practice’s induction and training processes for clinicians are inadequate.

5. Dr R says he has been impacted physically and emotionally as a direct result of the delays in treatment. He says after the initial appointment for his X-ray never materialised, his condition worsened to the point he walked with a limp for a week in late February 2025. He explains he then began catching his right foot more often and stumbling, resulting in a nasty fall. Dr R also states this issue caused anxiety to him and his wife and he felt left in the dark by Practice staff. He says this issue also caused him to worry about the safety of other patients as they may not be assessed by a doctor or a properly trained clinician.

6. Dr R would like reassurances from the Practice it has taken his complaint seriously, and service improvements including staff training regarding the X-ray referral process. He would also like the Practice to ensure that all patients are properly introduced to their clinician and that patients are appropriately informed when they are not going to be seen by a GP

7. Dr R attended the Practice in December 2024 complaining of pain in his right ankle. He was seen by a practice nurse who did not introduce herself. She told him to await a letter as he would be invited to an X-ray appointment. This appointment letter did not arrive, and the Dr R’s condition worsened over the subsequent months.

8. He was seen by the same practice nurse in April 2025, who told him, again, to wait for an X-ray appointment to be sent to him. When Dr R raised this in a complaint to the Practice, he was given a GP appointment and a referral to a neurological pathway.

9. Dr R believes the Practice’s response was inadequate and does not assure him that training for its staff is sufficient.

12. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have found the Practice has already done enough to put right the impact of these events.

Issue 1: The nurse did not introduce herself during the consultation and misinformed Dr R about how to attend an X-ray in two consultations.

13. Dr R says he was not examined properly during his two consultations with a nurse at the Practice. He states during both appointments with the nurse, she misinformed him about how to attend an X-ray. He also told us that as the nurse did not introduce herself he did not know the level of qualifications she had when she treated him.

14. Dr R reported he had been impacted physically and emotionally as a direct result of the delays in treatment. After the initial appointment for his X-ray never came, his condition worsened, and this resulted in a nasty fall in the spring of 2025. Dr R also explained that he and his wife were extremely anxious about what was potentially wrong with him. He is also concerned the misinformation by the Practice will become an issue of patient safety for others.

15. The outcome sought by Dr R in relation to this part of his complaint is for the Practice to ensure all patients are properly introduced to their clinician. He would also like for patients to be informed when they are not going to be seen by a GP.

16. When considering this element of the complaint, we reviewed the Practice’s Charter which says: ‘Although we aim to offer you a choice of clinicians, and aim to offer continuity of care, you will accept this is not always possible and you will therefore be willing to see any clinician at the Practice’

17. We understand that Dr R will have found the circumstances of his appointments at the Practice frustrating, especially in light of the symptoms he had. However, the Practice does make patients aware in its charter that they may not have the ability to provide GPs to patients in every circumstance.

18. In addition, we can find no NHS policies nor guidance to suggest that the Practice, nor the clinician, should explain the level of qualification they have during the consultation. It is highlighted, however, in the charter that: ‘You will be able to make suggestions to improve the practice and services we provide through feedback to the team and/or to the Practice forum’.

19. The nurse practitioner has acknowledged she did misinform Dr R about how to attend an X-ray and about aspects of the Practice’s policies around walk-in appointments. The NMC’s Code of Practice highlights that nurses are expected to always practice in line with the best available evidence. To achieve this, they must: • make sure that any treatment, assistance or care for which they are responsible is delivered without undue delay

• make sure that any information or advice given is evidence-based including information relating to using any health and care products or services

20. When reviewing the complaint responses received from the Practice, we can see that it has apologised, and the nurse also sent Dr R a personal apology letter. This is more than we can ask for as an Ombudsman’s service as we cannot ask individual staff members to write personal apologies to complainants.

21. The nurse’s apology letter highlights that as she was a clinician working on a locum basis, she was not familiar with all the specific procedures and services provided at the Practice. The nurse has accepted fault and offered Dr R with an explanation as to how this error has occurred, apologising for his experience and the impact to him. We feel this demonstrates she has taken steps to improve her practice.

22. We consider that both apologies provided in writing to Dr R highlight that staff at the Practice have moved to rectify the maladministration in line with the NMC’s Code of Practice. The code tells staff to: • maintain the knowledge and skills you need for safe and effective practice

• explain fully and promptly what has happened, including the likely effects and apologise to the person affected and, where appropriate, their advocate, family or carers

• use all complaints as a form of feedback and an opportunity for reflection and learning to improve practice.

23. Therefore, reviewing the evidence provided, mistakes were made which did unfortunately impact Dr R, and we were sorry to hear of this. We consider the Practice has taken steps in line with the appropriate professional guidelines to apologise and remedy the injustice caused to Dr R. The apology from the nurse practitioner is clearly sincere and shows that she has learned from the complaint and taken steps to improve her practice in line with the Practice’s training expectations

Issue 2: The Practice’s training and induction processes for its clinical staff

24. Dr R says it was clear from his experience with the nurse and the complaint response that the Practice’s ‘processes of “induction and notification” are evidently inadequate’. As a result, he would like the Practice to show that it has reviewed and made improvements to the induction and notification processes mentioned in its response, so that staff at all levels are trained effectively.

25. It is important to note that we have investigative powers but that we cannot regulate in the same manner as the Care Quality Commission (CQC). Therefore, while we can assess the level of impact and review maladministration and service failures, we cannot change clinical decisions nor regulate the way in which a practice trains their staff. Therefore, it is not possible for us to achieve outcomes related to specific staffing or make judgements on how staff are specifically trained.

26. During our investigation we obtained the following documents from the Practice which were directly referenced in its response to Dr R and in the locum nurse’s apology letter to Dr R: • minutes from a staff meeting held in May 2025 relating to Dr R’s complaint.

• a copy of the Practice’s training guidance around the X-ray referral process for locum staff and the staff induction guidance which the nurse referred to in her letter.

27. In the Practice’s response it said, ‘we have discussed your complaint in our team meeting so that all our team can learn from your experience to minimise the likelihood of this happening to yourself or anyone else’. The minutes show that Dr R’s complaint was discussed and the team was reminded X-rays are a walk in appointment. It also reminded staff that locum clinicians should be handed the ‘Welcome Note’ pack on arrival to the Practice, and information regarding radiology appointments should be shared during induction with the clinician.

28. In the Practice’s response to Dr R, it said ‘we would like to reassure you that all staff whether that be clinical or non-clinical receive an induction and notification that our X-ray service is a walk in service as part of that induction’. After reviewing the locum staff ‘welcome pack’ documentation from the Practice, we can see it says, ‘Kings Lewisham and Guys all accept walk-in X ray requests and suspected fracture requests’. There is more information included in the document around how and when locum staff should make referrals.

29. Having reviewed these records provided by the Practice, we are satisfied it has taken the actions it detailed it would to put right the impact caused to Dr R.

30. We are also sufficiently reassured there are training measures in place for staff at the Practice to work towards continuous improvement. We have considered that the locum nurse practitioner who treated Dr R on both occasions states in her apology letter that she has ‘completed the necessary training and familiarised myself with the full range of services available to ensure this does not happen again with any future patients’.

31. This is in line with the NHS complaints standards which states that organisations should:

‘make sure people are kept involved and updated on how the organisation is taking forward all learning or improvements relevant to their complaint’

32. We are reassured that the nurse’s response, in addition to the Practice’s response and the documentation it has provided us with, indicate it has taken the appropriate actions to remedy the injustice caused to Dr R.

33. This should mitigate and minimise the risk of this happening again to future patients, which was one of the key concerns in this complaint.

Issue 3: The Practice’s complaint handling

34. Dr R explains the Practice’s response did not take him seriously and does not fully address the maladministration he experienced. Its patient charter says:

‘Your complaints will be investigated thoroughly and promptly as per the NHS complaints procedure. We endeavour to resolve complaints verbally but where a complaint requires investigation we will write to you with the outcome’.

35. We have considered whether the Practice’s response is in line with our NHS complaints standards, particularly ‘giving fair and accountable responses’ which states:

‘Wherever possible, staff explain why things went wrong and identify suitable ways to put things right for people. Staff give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned’.

36. The complaint response does address the key elements of Dr R’s complaint and offers explanations for how the Practice staff will work to rectify this. It also apologised for the error which occurred, and, in our view, it has been open and sincere when investigating this complaint. Importantly, we have seen evidence the Practice has acted accordingly after this complaint and that the steps it took to improve its practice after Dr R’s complaint have been carried out.

37. Taking all of this into account, it appears the Practice has acted in line with our NHS complaints standards. It meets our ‘principle of good complaint handling’ standards (which is also followed by NICE) and has upheld its own practice standards set out in its patient charter.

38. We recognise the significant concern and distress these events have caused Dr R and we hope our consideration provides some reassurance that the concerns he raised about the Practice have been carefully considered.

1. We have carefully considered Dr R’s complaint about the care and treatment he received at a GP Practice (the Practice) in the London Borough of Lewisham.

2. Between December 2024 and May 2025, Dr R was seen twice by a nurse who did not introduce herself during the consultations and misinformed him on both occasions about how to attend X-ray appointments. Dr R feels the Practice’s complaint response was unsatisfactory and its training processes for clinicians are not adequate. We appreciate this situation will have been distressing for Dr R as he and his wife were worried about his symptoms and felt there was a delay in his treatment. We hope our statement gives him reassurance we have thoroughly considered his concerns.

3. The evidence we have seen shows the Practice has done what we think it should to put right the impact caused to Dr R. The Practice has acknowledged it made mistakes, and has acted in line with our complaint standards, as well as the standards set out in its own patient charter in putting this right for Dr R.