A practice in the Wakefield area

6. Mr S complains about the care received from the Practice in February 2025. Specifically, he claims the GP deemed him unfit to drive and attempted to reduce his medication without valid clinical reasons.

7. Mr S also complains about the Practice’s record keeping. Specifically, he claims the GP inappropriately included information provided by family members in his medical records and the GP did not accurately reflect consultations in medical notes including cause of symptoms, medication dosages, and conversations had.

8. Finally, Mr S complains the Practice shared his medical information. Specifically, contacting his psychiatrist without patient permission or a valid clinical reason, and discussing his medical issues with two of his family members.

9. Mr S claims the impacts that follow the care he received are having his driving licence revoked, loss of job and income, and exacerbation of his mental health (stress, anxiety and derealisation symptoms).

10. For the record keeping and the data breaches the impact was further stress, exacerbation of his derealisation symptoms, as well as damaged familial relations.

11. Mr S would like an acknowledgement of what the GP did wrong and the impact this had on him. He would also like service improvements on privacy and clinical thresholds.

12. Mr S had been suffering from anxiety and derealisation symptoms and sought support from a private psychiatrist. The private psychiatrist prescribed him medication and Mr S established a shared care agreement for this medication with the Practice in February 2025.

13. In February 2025, Mr S was involved in a car accident where he fell asleep at the wheel and drove into a pole at 60mph. Two days after this, he sought medical help at a local hospital. His medical records state he had neurology to his left hand. Following further tests coming back as normal, Mr S was discharged to his GP.

14. Mr S’s mother contacted the Practice to share her concerns about her son’s medication and the side effects he was experiencing. The Practice added these concerns to Mr S’s medical records.

15. Mr S’s sister also contacted the Practice to inform it she was taking him back to hospital. At the Accident and Emergency Department (A & E) staff diagnosed him with pneumonia and excessive sleepiness. In the discharge letter sent to Mr S’s GP, A & E staff recommended he does not drive and that his GP informed the Driver and Vehicle Licensing Agency (DVLA) of his accident and medication.

16. Two days following his last visit to A & E, he returned as he experienced abdominal pain and black stools. He was admitted to hospital for upper gastrointestinal bleeding.

17. Mr S was seen by his GP on 24 February 2025 for the above issues following the letter sent by the hospital. In this appointment, the GP discussed reducing Mr S’s pregabalin dosage and encouraged him to contact the DVLA to inform them of the incident and of the side effects he was experiencing. Pregabalin is a medicine doctors can use to manage anxiety.

18. Mr S explained he did not believe he is unfit to drive and since his psychiatrist has stated as much, he would not contact the DVLA nor reduce his dosage.

19. Because Mr S made it clear he would not be contacting the DVLA, the GP decided to contact the DVLA to inform them Mr S was not fit to drive. The GP also contacted Mr S’s psychiatrist to discuss his dosage and side effects.

20. Mr S’s driver’s licence was revoked by the DVLA shortly after, which led him to lose his job. In a consultation on 14 April 2025, the GP agreed to provide a letter for the DVLA recommending it gave Mr S his license back. Despite the letter, Mr S has not regained his licence.

The GP deemed Mr S unfit to drive

24. Mr S says the GP deemed him as unfit to drive without good clinical reason. We appreciate having his driving licence revoked caused him a lot of stress as it had personal and professional consequences.

25. The Practice says the GP made the decision Mr S was unfit to drive in a lawful manner. It states the GP acted in the interest of public safety and in their duty as a medical professional.

26. The DVLA guidance on medication refers to section 4 of the Road Traffic Act 1988, which does not differentiate between illicit and prescribed drugs. It states any person driving or attempting to drive in a public place while unfit due to any drug is liable for prosecution. It states this is all drugs with an action on the central nervous system as this can impair alertness, concentration and driving performance.

27. Our GP adviser explains the medication Mr S was on did influence the central nervous system. We note the DVLA guidance on medication says this can be a reason someone should not drive.

28. In a consultation in February 2025, the GP told Mr S not to drive. They advised this because the information available to them was the car accident where he fell asleep at the wheel, his mother’s concerns around the medication making him more sleepy than normal and the discharge letter from A & E.

29. Based on the fact Mr S had already had an accident and was on medication which effected his central nervous system, we feel there was evidence to support the GP’s decision about his fitness to drive. On this basis, we saw they acted according to the above guidance in reaching this view. We therefore see no indications the Practice got things wrong and will not be taking this part of the complaint further.

30. We recognise Mr S will find our decision disappointing, and the loss of his driving license has made his life more difficult. We hope we have clearly explained our decision and our explanations assure Mr S we gave his concerns careful consideration.

The GP attempted to reduce his medication without valid clinical reasons

31. Mr S says in February 2025 the GP tried to reduce his medication that had been prescribed by his private psychiatrist. He says the GP did not have valid clinical reason to do this.

32. In its letter to us in September 2025, the Practice say the medication was prescribed by them as part of the Shared Care Agreement with his private psychiatrist. A Shared Care Agreement (SCA) is a formal (verbal or written agreement) between a specialist, a patient and the GP. It states the GP was able to prescribe the medication as part of this agreement.

33. GMC Good Medical Practice states that for a doctor to prescribe medication, including repeat prescriptions, they can only do so when they have adequate knowledge of the patient’s health and are satisfied the drugs or treatment service the patient’s needs.

34. We consider the GP suggested a reduction in Mr S’s anxiety medication in line with relevant standards.

35. Our GP adviser said whilst the GP did not prescribe the drugs to Mr S, they were competent to provide clinical advice. This was because they were assessing him during the consultation as experiencing side effects from the medication. Our GP adviser also referred to the above GMC guidance stating the GP was providing good standard of practice and care.

36. The hospital discharge summary from February 2025, states the increase in medication dose of pregabalin was likely the cause of Mr S’s sleepiness and therefore the crash. It suggests a medication review with Mr S’s psychiatrist and discharged Mr S back to his GP. The GP wrote to the private psychiatrist asking them to review the dose as a matter of urgency.

37. We appreciate the discussion around reducing the dose of Mr S’s medication caused him stress and anxiety.

38. We feel the Practice has acted in line with guidance in its suggestion as the GP has acted on their knowledge of Mr S as the patient and of the drugs. There was evidence, which we explained in paragraph 36, to support considering a reduction in his dose. We also feel the Practice has been proactive in seeking the right medical review for Mr S following his car accident.

39. We feel the GP and therefore the Practice have acted in line with the guidance above. This means we do not see any indications of failings and will not be taking this part of the complaint further.

The Practice contacted Mr S’s private psychiatrist without his permission

40. Mr S says the Practice contacted his private psychiatrist without his permission. He says the reason for the contact did not meet the grounds of serious risk or public interest. We are sorry to hear Mr S was distressed when the Practice contacted his private psychiatrist.

41. The Practice says it prescribed Mr S’s medication as part of his SCA with his private psychiatrist. It says this is a formal agreement between the specialist, the patient and the GP. As part of the SCA, the Practice explain a two-way communication with the private psychiatrist was implicit. Following its meeting with Mr S, it has now written an alert entry on his records stating his consent is needed before approaching his private psychiatrist. It also adds there are exceptions to this when contact is needed for public interest.

42. We note the GMC’s Good Medical Practice, specifically the Continuity and Coordination of Care section. This states a doctor must share all relevant information with others involved in the patient’s care, within and across teams, as required. In the circumstances, our GP adviser said they would expect the Practice’s GP to share the information about the car crash and the side effects Mr S was experiencing with his medication with his private psychiatrist.

43. We can see the Practice has explained its reasoning for this contact We can also see the Practice have acted in line with GMC guidance when sharing information about the car crash and the side effects Mr S experienced from his medication.

44. We understand Mr S was distressed to learn the Practice had contacted his private psychiatrist and we do not wish to undermine his feelings this experience has had on him.

45. We hope we have clearly explained why we have not seen indications that the Practice did anything wrong and so we will not be taking this part of the complaint further.

The Practice included inaccurate information from family members in his records and shared his medical information with his mother

46. Mr S says the GP has potentially breached his GDPR in disclosing information to his mother on the phone. Mr S says his mother’s concerns were then put into his medical records. He says the information his mother gave was not factual and should not have been added to his records.

47. In its final response, the Practice explain it listened to the phone recordings and confirmed the GP stated to Mr S’s mother they could not disclose any information and could only listen to her concerns. The Practice also explains its job as medical professionals is to listen to concerns of relatives and neighbours whilst maintaining confidentiality.

48. As part of our investigation, we also listened to the phone calls and can confirm the Practice did not share any of Mr S’s medical records. It only listened to his mother’s concerns.

49. We appreciate Mr S found it distressing to learn the Practice had spoken with his mother. GMC confidentiality guidance states if someone close to the patient wants to discuss their concerns, it should not refuse to listen on the grounds of confidentiality. This is because the information provided could give the Practice helpful insight into caring for the patient.

50. After reviewing the evidence and the above guidance, we can see no indication the Practice shared Mr S’s medical records with his mother. In line with the GMC confidentiality guidance, it listened to his mother’s concerns. This means we will not be considering this part of the complaint further.

The GP did not accurately reflect Mr S’s consultations in his medical notes

51. Mr S says the GP did not accurately reflect the consultations they had in his medical notes. He says following a subject access request (SAR), he found several instances where the consultations were misrepresented or made up.

52. Mr S says he told the GP he believed the car accident caused the gastrointestinal (GI) issues but the GP has written Mr S believed his GI issues may be related. Mr S feels this is a significant difference. He also says there was a difference in the dose of pregabalin he said he had taken that day to what the GP had recorded.

53. The Practice says in its response it had listened to both Mr S’s description of events and the GP’s description of events. It says it cannot comment on what actually happened in the consultations as both versions of the events differ.

54. We understand how frustrating and upsetting this situation was for Mr S, especially given the importance of accurate communication during medical consultations.

55. As only Mr S and the GP were in the consultation, and there is no independent record of the conversation, we do not have sufficient evidence to help us determine exactly what was said. As we do not consider we can reach a robust conclusion on what happened, we have decided not to consider this matter further.

56. Overall, besides the issue we cannot reach conclusions on, we have found no indications of failings and we have decided not to consider Mr S’s complaint further.

57. We thank Mr S for taking the time in bringing his complaint to our attention. We hope our explanation offers reassurance that the Practice has provided care in accordance with established guidelines and did not breach his GDPR in disclosing information to relatives.

1. We have carefully considered Mr S’s complaint about the Practice. We are sorry to hear Mr S’s concerns about his care and treatment and the impact this had on him. We appreciate his concerns around his fitness to drive is still ongoing.

2. Mr S complains the GP attempted to reduce his medication without valid clinical reasons. We appreciate Mr S felt frustrated and that the GP had no clinical reason to suggest a reduction in medication. We have seen no evidence to indicate any service failings and will not be taking this part of the complaint further.

3. Mr S also complains about the Practice’s record keeping. He says the GP should not have included his mother’s concerns in his medical records. We have seen no evidence to indicate any service failings and will not be taking this part of the complaint further.

4. He also says the GP recorded conversations in consultations inaccurately. We are sorry to hear Mr S felt distressed to see the consultation notes differed to his account. We have decided not to take this part of the complaint further. Without third-party evidence, we are unable to reconcile this part of the complaint.

5. Mr S also complains the GP shared his medical information with family members and contacted his private psychiatrist without valid reason. We appreciate Mr S experienced stress in this situation. In the work we have carried out, we have seen no indication the GP acted inappropriately or shared medical information about Mr S to his family. We will therefore not be taking this part of the complaint further.