A practice in the Reading area

4. Mrs K complains about aspects of the care and service she received from the Practice. She specifically complains that:

• it made a prescription error regarding her steroid inhaler in summer 2024, which she made it aware of, but it did not deal with this as a patient safety matter • it did not respond to her complaint from August 2024 until October 2024 • in autumn 2024, it did not perform a coeliac disease test as agreed but performed a cholesterol test that she had not agreed to • it has contacted her husband on numerous occasions providing him with information regarding her healthcare without her knowledge.

5. Mrs K says the above matters have caused her to lose faith in the Practice and to lose privacy. She says the failure to do the coeliac test means she will have to again endure the pain and discomfort of a six-week gluten diet.

6. She is seeking an apology, service improvements and a financial payment.

7. Mrs K attempted to collect her regularly prescribed 250mg steroid inhaler in summer 2024 before her current inhaler ran out. She was informed by the pharmacy team that the item was out of stock, but alternative inhalers were available if she could secure a new prescription from her GP.

8. Mrs K attended the Practice later the same day to request an alternative prescription. Shortly after, a GP contacted Mrs K’s husband to discuss the request further. The GP approved a prescription for two 125mg steroid inhalers later that day.

9. Mrs K collected the two inhalers the same day, but the dispensing pharmacist made her aware that the instructions of the amount to take were not the correct equivalent. So, while the dosage of the inhaler had changed, the instructions about how to take it had not been changed on the prescription.

10. After collecting the inhalers, Mrs K went back to the Practice to report the error but was unable to speak to anyone. She therefore emailed her complaint to the Practice later that evening.

11. The Practice responded to Mrs K’s complaint in September, a month after Mrs K had submitted the complaint. She contacted it chasing a response and so it resent it to her the following month.

12. Mrs K attended the Practice in autumn 2024 for blood samples to be taken after she had discussed abdominal concerns with a GP in a previous appointment. It was agreed a coeliac test would be completed. This test was not completed but a cholesterol test was.

Prescription Error

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

Incorrect instructions

17. Mrs K complains the Practice made a prescription error regarding her steroid inhaler in summer 2024.

18. Our Principles say that when mistakes happen, organisations should acknowledge them, apologise, explain what went wrong, and put things right quickly and effectively.

19. In its complaint response, the Practice explained the dosage of the new inhalers was correct, but it acknowledged the instructions on how to use them were not. It apologised for any confusion caused and said it was a typing mistake due to human error, which it has corrected for future prescriptions.

20. We think there is an indication of a failing in the Practice’s instructions for how to take the inhaler. We do not think this had a clinical impact on Mrs K as she was made aware of the matter by the pharmacy at the time of collection. We acknowledge that Mrs K remains unhappy with how the Practice managed the prescription error issue. We also acknowledge the matter has contributed to her losing faith in the Practice. We recognise how worrying and distressing this is for her.

21. The Practice’s complaint investigation report confirms it held a multidisciplinary team meeting (MDT) to discuss the cause of Mrs K’s complaint at the beginning of September 2024. From this we can see it identified the root cause of the error to be a human error. It therefore took action to remind all prescribing clinicians of the importance of thoroughly checking prescriptions to ensure any amendments to instructions are accurate.

22. We have considered the Practice’s investigation. We contacted the Practice to request a copy of the Practice policy. It provided a copy of the policy in late October 2025. We spoke to the Practice on 13 November 2025, as we could not see the Practice had taken the actions outlined in the policy.

23. During this discussion, the Practice informed us the Practice policy was not documented at the time of the events complained about. It said that because of Mrs K’s complaint, it now has the written policy in place to ensure its clinicians follow the correct process going forward.

24. The Practice’s policy defines a prescribing error as ‘a failure in the prescribing process that leads to, or had the potential to lead to, harm to the patient’. It gives examples including: the incorrect drug, dose, frequency or route, inappropriate prescribing (e.g. allergy, contraindication, interaction), omission of essential medications, and duplication of therapy.

25. The policy states that following actions should be taken immediately when an error is identified:

• assess the patient for harm or risk of harm • correct the error (e.g. stop/change medication).

• inform the patient/carer promptly and provide explanation and reassurance – third parties must be informed if prescribing medication under shared care agreement

26. We consider the Practice’s acknowledgement and explanation of the error, and its apology are fair and reasonable actions to take. Furthermore, we also consider the Practice has taken learning from Mrs K’s complaint and has ensured that a policy is now in place to investigate any future prescribing errors. The Practice appears to have acted in line our Principles and has taken fair and reasonable steps to remedy this element of Mrs K’s complaint.

Patient safety matter

27. Mrs K complains the Practice did not deal with the prescription error as a patient safety matter.

28. Section 20 of the GMC Standards says if a medical professional receives information regarding safety concerns, they have a responsibility to act on it promptly and professionally. The Standards say they can do this by:

• putting the matter right, if possible • investigating and dealing with the concern locally • referring serious or repeated incidents or complaints to senior management or the relevant regulatory authority.

29. As set out above, we think the Practice took action put things right after Mrs K had alerted it to the error. We also think the Practice investigated the issue locally and took steps to try and prevent a similar event happening in the future.

30. We are of the view that prescription errors should be dealt with promptly and professionally as in some cases they can lead to serious harm. Thankfully, in Mrs K’s case, she did not come to any harm and because of this, we are satisfied that it was not a serious incident. We have also seen no indication this was a repeat incident.

31. The Practice’s policy, put in place after these events, states that when reporting the error, clinicians should complete an incident report using the Significant Events form or Prescribing Errors form if the error is not considered a significant event. They should also notify the Practice’s clinical governance lead or prescribing lead, and they should consider duty of candour obligations if the error caused significant harm.

32. While the Practice did not take these actions at the time of the events complained about, we are reassured that the Practice has now put a policy in place to address this.

33. In summary, we think the Practice appears to have acted in line with the GMC Standards, as it investigated the concerns and took steps to put things right. We are also satisfied the Practice now has a documented process in place confirming that actions clinicians are required to take should a future prescribing error occur. We have seen no indication this was a serious or repeated incident, so we do not think the Practice needed to take further action. We hope Mrs K is reassured by this.

Complaint response

34. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any indication that something has gone wrong.

35. Mrs K complains the Practice did not respond to her 7 August 2024 complaint until15 October 2024.

36. The Practice’s Complaints Policy states it will investigate the complaint and aim to provide a written response within 28 days of receipt. The NHS Complaint Regulations say organisations have six months from receiving the complaint to provide a response.

37. The evidence available shows that the Practice responded to Mrs K on 6 September, but that for some reason, Mrs K did not receive it.

38. Mrs K emailed the Practice on 14 October stating she had not yet received a full response to her complaint. The Practice responded the next day copying in an email it sent to her on 6 September. It had attached the complaint response to this original email.

39. Mrs K has explained to us that she and her husband have their own internet server in their property and so can view all incoming and outgoing emails. She informed us that they have checked the server but found no evidence of receiving the initial response.

40. Whilst we cannot explain why she did not receive the email, the evidence available to us shows the Practice did respond to her on 6 September. We think it is likely it did respond on this date.

41. We acknowledge the Practice was two days over its 28-day complaint response policy. Within the original response email, it apologised for the delay and explained this was due to staff being on annual leave. The Practice’s response was provided within the time period set out in the NHS Complaint Regulations.

42. We recognise not receiving the response within the timescale set out by the Practice has caused Mrs K frustration. As set out above, we have seen no indication of a failing in the Practice’s actions here. Because of this, we will not consider this part of Mrs K’s complaint further.

Blood tests

Cholesterol Test

43. Mrs K complains the Practice completed a cholesterol test, but she had not agreed to this.

44. In its response, the Practice explained it considered the cholesterol test was medically indicated which was why it requested this. It apologised for not fully discussing it with her beforehand and acknowledged the distress this caused her. It stated it has added a note to her medical records to ensure it discusses all blood tests with her in future and does not retest her cholesterol.

45. Our Principles say organisations should be open and accountable, put things right and seek continuous improvement. In being open and accountable, our Principles say organisations should give people information and advice that is clear, accurate, relevant and timely.

46. In order to be open and accountable, we think the Practice should have explained to Mrs K prior to undertaking the test about why it wanted to request this. We think there is an indication of a failing regarding the Practice not obtaining Mrs K’s consent to perform a cholesterol test.

47. We are satisfied this had no clinical impact on Mrs K. However, we acknowledge the matter has contributed to Mrs K losing faith in the Practice.

48. Our Principles say when mistakes happen, organisations should acknowledge them, apologise, explain what went wrong and quickly put things right.

49. We can see the Practice has apologised for this, acknowledging the impact Mrs K has explained and has taken actions to try and prevent this issue occurring again in the future.

50. We recognise how distressing this would have been for Mrs K, and why it has impacted on Mrs K’s faith in the Practice. We consider the Practice has acted in line with our Principles. While there is an indication of a failing here, we think the Practice has done enough to put things right. We have therefore decided not to progress this further.

Coeliac Test

51. Mrs K complains that although the Practice took blood samples, it did not complete the agreed coeliac test. She says to have the test she needed to follow a gluten rich diet for a period of six weeks after she had previously cut gluten out. She explains that reintroducing it caused her to experience daily pain and discomfort including severe bloating and flatulence. She complains that she would have to endure this again if she wanted to have the coeliac test in future.

52. In its complaint response, the Practice explained the nurse taking the blood samples did not see the coeliac test request and this is why the test was not completed. It apologised for this error and acknowledged the impact of the change Mrs K had made to her diet to have the test. It said it had reiterated to staff the importance of including all requests when taking blood samples to try and prevent similar issues happening again.

53. Section 1.1.5 of the NICE guideline states that if people who have restricted their gluten intake or excluded gluten from their diet are reluctant or unable to re-introduce gluten into their diet before testing, clinicians should: • refer the person to a gastrointestinal specialist and • explain that it may be difficult to confirm their diagnosis by intestinal biopsy

54. We consider this was a really unfortunate mistake, and we understand why Mrs K feels so let down. We acknowledge that Mrs K has concerns regarding reintroducing gluten to her diet again if she wants the Practice to complete a coeliac test. Fortunately, there is an alternative way by which she may be able to be tested as per the NICE Guideline.

55. We have discussed this outcome with the Practice, highlighting the NICE guideline and it has agreed to refer Mrs K directly to gastroenterology without the need for further testing. We think this is a reasonable way to resolve this matter for her as it should alleviate her concerns regarding reintroducing gluten into her diet.

56. In summary, we think there are indications of failings regarding the blood tests, which has caused Mrs K concerns and to lose faith in the Practice. We think the steps the Practice has taken to acknowledge these matters and acknowledge the impact to Mrs K are enough to put things right. We are also satisfied the Practice has taken learnings from her complaint and has made service improvements to avoid these same issues occurring again.

Data breaches

57. We considered whether there is an organisation that is better placed to deal with these concerns. Some complaints can be looked at by us, and by other organisations.

58. Mrs K complains the Practice has contacted her husband on numerous occasions providing him with information regarding her healthcare without her knowledge or consent.

59. In its response, the Practice explained it had contacted Mrs K’s husband as it had his telephone number listed as the main contact number for her. It also stated there was a note on her records stating to contact him as she is deaf. It apologised for storing contact information incorrectly on its records and for any distress the matter had caused both her and her husband.

60. We acknowledge Mrs K remains dissatisfied with the situation following the Practice’s response and she considers it should have referred itself to the relevant authoritative body.

61. It is our view that the Information Commissioner’s Office (ICO) would be the most appropriate organisation to investigate this element of her complaint. This is because it is an independent body responsible for making sure that organisations comply with the Data Protection Act 2018 and UK General Data Protection Regulation (GDPR).

62. Therefore, we consider it is best placed to provide Mrs K with the outcome she is hoping to achieve regarding this element of her complaint. The ICO can review the actions taken by the Practice and determine whether it should have referred itself for investigation.

63. We would like to thank Mrs K for providing us with the opportunity to review her concerns. We hope that our investigation has given her some reassurances that the Practice has taken her complaint seriously and has taken fair and proportionate actions to address it errors.

1. We have carefully considered Mrs K’s complaint about the Practice. We have, for the reasons we shall go on to detail, decided to take no further action.

2. We appreciate the cumulative nature of the incidents complained about have caused Mrs K to lose faith in the Practice. It is our view that the corrective actions it has already taken are fair and reasonable to put right the impact of what happened. We have also contacted the Practice negotiating a suitable remedy regarding the coeliac test issue.

3. We recognise these events, and losing faith in the Practice, have been distressing for her. Our decision is in no way meant to detract from the impact she has experienced.