A practice in the Medway area

4. Miss B complains the GP made errors on its consultation notes. Specifically, she says her records incorrectly state she refused to give a sputum sample. Miss B says she was physically unable to provide the sample. Miss B also says her records state her cough was dry when in fact it was persistent and productive.

5. Miss B explains she has written to the Practice several times to have the error corrected but it has refused to do so.

6. As a result, Miss B says she has had to contact several organisations to try and get this error corrected causing her distress and impacting her mental and physical health. She has concerns this could cause other clinicians to perceive her as a difficult patient, impacting the care and treatment she may require in the future.

7. Miss B would like an apology, service improvements, and a financial remedy.

8. Miss B attended a GP appointment in February 2025. She says, she saw a GP for a persistent, and productive cough. Miss B says the GP incorrectly recorded Miss B refused to give the sputum sample and that she presented with a dry cough.

9. Miss B says she did not refuse but that she was physically unable to bring up the sputum/phlegm.

11. When we receive a complaint, we must consider whether we can and should undertake a detailed investigation into that complaint. In doing so, we must consider several factors. These include whether we can reach a robust conclusion about the matters raised and whether another organisation is better suited to consider the matters raised.

Errors on the consultation note

12. Miss B visited the Practice in February 2025. She gave us her account of what happened during her GP appointment.

13. The records from the appointment show the GP recorded Miss B ‘did not do sputum culture’, ‘said she cannot do it’ and ‘she refused’. The GP also recorded her cough as ‘dry’.

14. In its response, the Practice explained the GP’s documentation accurately reflects the discussion that took place during the consultation. The Practice says the clinical notes indicate Miss B explained to the GP she was unable to produce a sputum sample due to a dry cough. The Practice says the GP explained why a sputum sample was clinically important and gave advice on how to collect one. It says Miss B declined to proceed after this explanation and that this reflects Miss B's stated inability to provide a sample, rather than a simple refusal without reason.

15. It is important to explain our role is to make independent final decisions about NHS complaints in England. We make decisions by weighing up and considering all the available evidence. We then consider the likelihood that something has gone wrong with the service provided. As we are impartial, we must make robust decisions based on facts and evidence.

16. We have carefully considered the Practice’s response to Miss B’s complaint. We can see Miss B feels strongly about the events she complains about and that they will have affected her as she says. As an independent organisation, we are unable to reach a view without evidence to support what happened. We do not doubt Miss B’s account of events or how it made her feel. His interaction with the GP is a matter of perception which is subjective, and we cannot come to a conclusion on this.

17. We recognise this may cause Miss B further frustration. We are sorry we have not been able to investigate her complaint further or provide her with closure for her concerns. We would like to thank her for her time and effort in bringing this complaint to our attention.

Medical records

18. Miss B also raises concerns about the Practice’ decision not to amend her medical records to reflect her account.

19. Concerns about data matters fall within the remit of the ICO.

20. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there is an organisation that is better placed to deal with the concerns. Some complaints can be looked at by us, and also by other organisations. We have considered whether another organisation is better suited to giving an answer to the complaint and whether it can provide the outcome Miss B seeks, and we have determined that the ICO is more appropriately placed to handle this concern than the PHSO.

21. We understand Miss B says she has approached the ICO and it has declined to take this matter further. We appreciate Miss B has been unable to achieve the outcome she is seeking through complaining to the ICO.

22. If Miss B is unhappy with the ICO’s decision, she must follow its complaints process to raise her concerns.

23. Miss B may wish to approach the Information Commissioner’s Office (ICO). The ICO upholds information rights in the public interest, promoting openness by public bodies and data privacy for individuals.

24. Miss B can contact the ICO by:

• Email: If all supporting evidence is available electronically, Miss B can send her form via email by taking the following steps. The ICO uses Transport Layer Security (TLS) to encrypt and protect email traffic. If Miss B’s mail server does not support TLS, she should be aware that any emails she sends to the ICO may not be protected in transit.1. Complete and save the form to computer.2. Open a new email, with 'Complain to the ICO' in the subject line.3. Attach this form and any other documents to send the ICO. Please ensure combined email attachments do not exceed 10 MB in a single email. Miss B may send attachments over multiple emails, but please indicate this in the subject line.  4. Send to icocasework@ico.org.uk

• Post: If supporting evidence is in hard copy, Miss B can print out the form and post it to the ICO with supporting evidence.Send to:Public Advice and Data Protection Complaints ServiceInformation Commissioner's OfficeWycliffe HouseWater LaneWilmslowSK9 5AF

25. We would like to make Miss B aware, should she want to make a complaint about the ICO, then she should do so within three months of receiving its decision. Waiting longer than that could affect its ability to look into her complaint. In some cases, a long delay will mean that it will not consider the matter at all.

26. We appreciate this matter is important to Miss B, and we appreciate she has gone to some lengths to seek a resolution. We are sorry we are unable to help her in the way she would have liked, and appreciate this decision may be disappointing. We hope we have explained the careful consideration given to our decision and clearly outlined the reasons for it.

1. We have carefully considered Miss B’s complaint about the Practice. We are sorry to hear about the circumstances which led Miss B to make a complaint and the frustration and stress she suffered.

2. On balance, we sadly cannot reach a view on the care Miss B received. This is because, Miss B and her GP have a different recollection of what symptoms she presented with during the appointment. We do not have sufficient evidence available to us to determine what most likely happened or what was discussed during the appointment. For this reason, we have decided not to consider this complaint further.

3. We will explain our reasons for our decision in this decision statement. Complaints give us valuable insight into the organisations we investigate, so we would like to thank Miss B for sharing her experience with us.