A practice in the South Tyneside area

6. Mrs A complains about the care and treatment she received from the Practice between May 2024 and July 2025. She says the Practice:

• breached its own record keeping procedures by not retaining a letter it wrote for her in 2024 • wrote an incorrect diagnosis on a letter • refused to rectify her medical records to reflect the correct diagnosis • failed to review her records thoroughly before a consultation • communicated insensitively during a consultation.

7. Mrs A says the Practice’s failure to ensure the letter and her medical records were accurate affected her mental health, she felt like it wasn’t taking her mental health seriously which caused her to move to another Practice. She says the Practice’s failure to retain a letter it previously wrote also affected her mental health as she began to question her own memory. This caused distress. Mrs A says the Practice’s failure to thoroughly review her records meant she had to relive distressing life events during a consultation. She says the Practice’s failure to communicate sensitively meant she felt the Practice thought she was out to cause trouble. Mrs A says she felt dehumanised and made to feel issues with her mental health are her own fault.

8. Mrs A is looking for an apology and service improvements.

9. Mrs A attends university. In 2024, the Practice wrote a letter, detailing Mrs A’s medical conditions, to present to the university. It agreed to do this again, one year later.

10. In 2025 Mrs A wrote a letter to the Practice requesting a fertility referral. The Practice arranged a telephone consultation to discuss this.

11. The following month, Mrs A attended a telephone consultation to discuss her mental health.

Letters

14. Mrs A says the Practice failed to keep a letter on record it wrote for her in 2024. She says this letter informed her university of her diagnoses. She also says the Practice failed to write an accurate diagnosis on a letter it wrote for her in 2025. She says instead of writing mixed anxiety and depressive disorder it wrote that she has low mood.

15. The Practice apologised it did not follow its private work process in 2024.

16. BMA fee guidelines say the NHS does not fund all of the work GP’s do. They say any work GP’s do, outside of their NHS responsibilities is private work and must be funded by other means, such as charging the patient. It lists the certificates and reports funded by the NHS and which are part of a GP’s NHS responsibilities.

17. The law says we can only investigate NHS funded care in England.

18. We have reviewed the BMA’s list of certificates that come under a GP’s NHS responsibilities. We have not seen that a letter to a university is included within a GP’s NHS responsibilities. We therefore consider the letters written in 2024 and 2025 were completed on a private basis. Additionally, Mrs A has confirmed that she paid for the second letter.

19. The actions complained about are not in our jurisdiction so we cannot investigate them, or anything surrounding them. We hope our explanation helps to show Mrs A we have carefully considered her complaint in line with the law.

20. Before we decide if we should conduct a detailed investigation a complaint, we look at whether there are signs an organisation has got something wrong. We do this by comparing what should have happened with what did happen.

Medical records

21. Mrs A complains the Practice refused to rectify her medical records to reflect a correct diagnosis. She says the Practice documented she has low mood instead of mixed anxiety and depressive disorder on a letter it wrote to her university. She says she found that a GP recorded this diagnosis as a past problem. She says the Practice did not update her medical records to reflect she still has mixed anxiety and depressive disorder 22. The Practice said Mrs A’s previous Practice put this diagnosis into the past problems section of her records. It said it is important it only records information which is a true reflection of Mrs A’s medical records.

23. The NHS constitution says patients should provide accurate information about their health, condition and status.

24. We appreciate it must have been a shock for Mrs A to find out the other Practice moved the diagnosis to the past problem section of her records. We asked Mrs A if she booked a further consultation with the Practice so it could assess her for this condition and potentially record it as a current diagnosis. Mrs A told us she did not as she moved to another Practice.

25. We think if Mrs A had booked a further consultation she could have provided the Practice with accurate information about her health in line with the NHS constitution. This would have allowed the Practice to complete a full assessment of Mrs A and update her records accordingly.

26. GMC guidelines say clinicians must make sure formal records of their work (including patients’ records) are clear accurate, contemporaneous and legible.

27. Mr A’s previous Practice moved the diagnosis of mixed anxiety and depressive disorder to the past problems section of her medical records. This means the diagnosis was not listed as a current issue.

28. Based on this we have not seen any indication the Practice did anything wrong. The Practice’s decision to not record the diagnosis as current appears to be within guidelines which says clinicians must make sure formal records are accurate. It is understandable this issue caused Mrs A to experience distress as she was unaware the diagnosis had been moved. We hope our explanation reassures Mrs A the Practice appears to have acted within the relevant guidelines when making sure her records are accurate.

Record review

29. Mrs A complains the GP did not read her records thoroughly enough before a consultation. She says this led to the GP asking questions that forced her to relive distressing life events during the appointment. She says the GP should have been aware of this information as she had stated it on the referral form and it would have been on her medical records.

30. The Practice said it can assure Mrs A the GP completed a brief overview of her history before the consultation. It said it is not realistic for a GP to read every document prior to every appointment. It said it booked a consultation with Mrs A because it needed to discuss the issue in more detail. It said it needed to ask questions to make a plan going forward. It said following the consultation it made the necessary referral.

31. GMC Guidelines say clinicians must adequately assess a patient’s condition, taking account of their history. The guidelines also say clinicians must encourage an open dialogue with patients about their health, asking questions to allow them to express what matters to them.

32. We appreciate Mrs A is concerned the GP did not read her records before the consultation. We do not know the extent to which the GP did or did not review Miss A’s records. There is no guidance to mandate how long a GP spends reviewing records before a consultation or which ones they should review prior to the appointment.

33. We note the Practice did gather enough information to be able to make the referral to secondary care.

34. We acknowledge Mrs A felt significant distress when the GP raised difficult life events and asked her questions relating to sensitive matters. We do not think the GP did anything wrong here. The GP’s actions appear to be in line with GMC Guidelines which say clinicians must adequately assess a patient’s condition, taking their history into account.

35. It also appears the GP acted in line with GMC guidelines when it asked Mrs A questions about the issues she was seeking a referral for. The guidelines say clinicians must encourage an open dialogue and ask questions. As we have seen no indication of a failing, we will be taking no further action.

36. We do not wish to diminish the distress Mrs A felt during this consultation. It must have been extremely difficult to talk about events which have been very traumatic. We hope our explanation assures Mrs A the care she received during this consultation was within relevant guidelines.

Insensitive comments

37. Mrs A complains the Practice made insensitive comments to her during a telephone consultation. She says the GP told her if she does not attend her Psychology appointments she will not get better. She says this placed the burden of recovery on her and suggested she wasn’t trying hard enough to get better.

38. The Practice said the language the GP used during the consultation was appropriate. It said part of the role of a GP is to encourage patients to engage with services to improve their health.

39. The NHS constitution says patients can make a significant contribution to their own health and wellbeing by keeping appointments or cancelling within a reasonable time. It says patients should follow the course of treatment they have agreed to and talk to a clinician if they find this difficult.

40. We have reviewed the transcript of the conversation. The transcript shows the Practice informed Mrs A the records document she did not attend a planned psychology appointment. It then verified Miss A’s address and told her the department had sent a copy of the appointment to her address. It then said ‘if you don’t engage that will not help you to get better either. Do you want us to do another referral back to them?’

41. We recognise the Practice’s comment made Mrs A feel she wasn’t trying hard enough to get better. We have not seen the Practice said Mrs A wasn’t trying hard enough. We have seen it said that not attending appointment will not help her to get better.

42. We think what the GP said to Mrs A reflected what the NHS constitution says about patients engaging in their own care. It stated the importance of keeping to appointments and provided a reason why this is important.

43. As we have not seen any indications the Practice did anything wrong here, we will be taking no further action.

44. In summary, taking into account the evidence, we have not seen the Practice did anything wrong when it made this comment. This comment was in line with the NHS constitution which says patients should keep to appointments to improve their own wellbeing. We hope our explanation reassures Mrs A we have not seen any indications of failings in the care she received.

45. We would like to take this opportunity thank Mrs A for bringing her complaint to us. We hope our work helps to assure her about the care she received.

1. We have carefully considered Mrs A’s complaint about the care provided by the Practice. We are sorry to hear of the difficulties Mrs A has faced and recognise these have caused her anxiety about her care and to lose faith in the Practice.

2. Mrs A complains about a letter the Practice wrote for her university. As this was a private service we cannot investigate this. The Health Service Commissioner’s Act is clear that we can only investigate NHS Services in England.

3. We have seen no indication the Practice should have changed Mrs A’s medical records to say she has mixed anxiety and depressive disorder.

4. We have seen the Practice adequately reviewed Mrs A’s records before a consultation. We have also seen the Practice’s comments during a further consultation were in line with the relevant guidelines.

5. As we have seen no indications of failings we will not be taking further action.