An independent provider in the Liverpool area

6. Mr B complains about the care he received from Spectrum Community Health at the prison (Spectrum) in December 2023 and April 2024.

7. He complains Spectrum failed to provide him with his HIV medication in December 2023 and again in April 2024.

8. He also complains about Spectrum’s complaint handling, and that he had to repeatedly complain before receiving a response.

9. He says as a result of missing his HIV medication, he developed an anal fistula, requiring surgery to remove this. He says it was painful and leaked discharge which made his everyday life very uncomfortable.  He also says without his medication, his immune system weakened, and his HIV developed.

10. Mr B says this experience impacted his mental health significantly. He tells us he had no one to help him in prison and was scared he was going to die in prison. He says he felt suicidal at the time, and he has experienced ongoing worry and distress about his HIV.

11. He says Spectrum caused additional distress in how it handled his complaint.

12. He would like Spectrum to make service improvements and to provide him with a financial remedy.

13. In December 2023, Mr B’s HIV medication, Dovato, was not supplied by Spectrum. He waited six days before his medication was supplied.

14. In April 2024, for 10 days, Spectrum did not supply Mr B with his HIV medication. Spectrum said his antiviral medication was delivered by a different hospital, who were responsible for the delay in delivery.

15. In April 2024, Mr B noticed he had an anal cyst. His GP suspected this as a pilonidal cyst (a sac-like pocket in the skin near the tailbone, often containing hair and skin debris, which can become painful if infected).

16. After leaving Spectrum, he was referred for an MRI which confirmed he had an anal fistula which needed surgery to be removed.

20. Mr B complains Spectrum failed to provide his HIV medication on two occasions in December 2023 and in April 2024.

21. Mr B was prescribed Dovato, which is a daily medication he had to take to treat his HIV.

22. The BHIVA guidelines says stopping antiretroviral treatment (ART), or not taking it every day as prescribed, will mean that the HIV will start to reproduce again and the viral load will no longer be undetectable. It says a patient might develop resistance to the HIV drugs used, which limits treatment options.

23. Spectrum’s critical medicines policy lists antivirals (HIV/hepatitis treatment) as a critical medicine. It says critical medicines should never be omitted or delayed without being assessed by a clinician. It says if the critical medicine has not arrived for the patient, and there is no medicine stock onsite to:

• obtain a FP10 prescription and arrange collection of medicine from a local pharmacy promptly • supply medicine to patient promptly as it arrives in the establishment and monitor compliance • send a task to order a prescription for prompt dispensing • request a review of contents of the onsite critical medicine list and adjust stock levels with considerations of adding additional item.

24. It also says if any medicines are omitted or unable to be obtained for a patient this should be Datix submitted (an incident reporting system) and investigated, and an action plan will be put in place.

25. In December 2023, Spectrum did not supply Mr B with his HIV medication for six days.

26. Spectrum has supplied evidence of admin tasks chasing this prescription up from the hospital. It also completed a Datix report confirming it has put a longer timeline to re-order this medication to anticipate any delays and prevent this from happening again.

27. In April 2024, Spectrum did not provide Mr B’s HIV medication for ten days. Spectrum’s admin tasks show this was reported to be an issue with delivery from the hospital. Spectrum did not complete an incident report after this period of omitted medication.

28. In line with Spectrum’s critical medicines policy, Mr B’s HIV medication was a critical one, and should not have been omitted. Spectrum should have obtained a FP10 prescription (an NHS prescription) and got Mr B’s medication from a local pharmacy. Spectrum did not do this on either occasion, and instead, waited for his medication to be delivered. We consider this a failing by Spectrum.

29. Spectrum did not complete a Datix report in April 2024, which is not in line with its critical medicines policy.

30. We have found a failing by Spectrum to supply Mr B’s medication in line with its own policy. As outlined by the BHIV guidelines, antiviral medications should not be missed as it does risk a patient’s HIV developing.

31. As we have found a failing, we need to assess whether we can link this to Mr B’s claimed impact.

32. Mr B claims his HIV developed in the time he was not taking his HIV medication.

33. The NICE CKS says to monitor a patient’s viral load, which reflects the rate of viral replication. It says viral load ranges from undetectable (less than 20-50 copies of viral load/mL) to over a million copies/ML.

34. Spectrum took blood tests to check Mr B’s viral load in December 2023, after his first period of missed medication. His viral load was reported as less than 50 copies/ml. In line with the NICE CKS, his HIV viral load was undetectable, meaning his HIV had not been impacted by missing his medication.

35. Mr B did not attend his appointment with the HIV nurse in April 2024. The nurse requested Spectrum to take Mr B’s HIV viral load in April 2024, after his second period of omitted medication, and to repeat this in a four weeks’ time. Mr B signed a healthcare refusal form in April 2024 declining this and requested an appointment with the HIV nurse.

36. Mr B did not attend his appointment with the HIV nurse as scheduled in May 2024, when it was planned to take his blood tests to test his HIV viral load.

37. As Mr B declined his viral load being checked after he missed his medication April 2024, we do not have test results to assess whether his viral load changed during this time.

38. However, Mr B was transferred to a different prison in June 2024 where is HIV is noted to be undetectable. In a clinic letter from July 2025, his surgeon noted ‘Mr B’s HIV is well controlled on ART Dovato.’

39. Our adviser said as Mr B’s HIV was well controlled on his HIV medication before the period of missed medication, its effect would still work during the time of missed medication. They said if there was a low-level of virus, it would quickly be reversed once restarting the HIV medication.

40. They said the clinic letter in July 2025 states Mr B’s HIV is well controlled, suggesting the period of missed medications has had no lasting impact on his HIV viral load.

41. We recognise why Mr B has concerns about his HIV medication developing due to the importance of taking HIV medication every day. We have not found Mr B’s HIV developed after missing his medication. We have seen evidence that his HIV viral load was undetectable in blood tests taken after missing his medication December 2023, and in July 2025 his HIV was noted to be well controlled. As such, we have found it likely there has been no lasting impact to Mr B’s HIV after missing his medication.

42. Mr B also claims he developed an anal fistula as a result of missing his medication.

43. The NHS website for anal fistula says most anal fistulas develop after an anal abscess does not heal properly. It says a less common cause for a fistula is HIV.

44. As seen in his records, Mr B reported his anal fistula developed around the start of March 2024, before his second period of omitted medication in April 2024.

45. As Mr B’s viral load after missing his medication in December 2023 was undetectable, our adviser said it is unlikely Mr B’s anal fistula was caused by his HIV.

46. We are sorry Mr B thinks his anal fistula developed due to his time without HIV medication. As Mr B’s HIV viral load was undetectable after missing his medication in December 2023, we consider it unlikely that he developed an anal fistula because of this. We are unable to say this was an impact of missing his medication.

47. Mr B says missing his HIV medication impacted his mental health significantly. He told us he was scared his HIV would develop and that he could die. He says at the time, he was asking for his medication and felt helpless as he could not do anything else, and he says he felt suicidal.

48. In Mr B’s medical records in December 2023, he told the nurse he has had anxiety and poor sleep due to his concerns about his medication and possible decline in his health. It is noted he firmly denied any thoughts of suicide and self-harm. A staff member chasing this medication noted Mr B was really stressed without his critical medication. He was also chasing his medication with Spectrum’s staff members.

49. In April 2024, he asked to see the nurse, where he raised concerns about his missing HIV medication. It was noted he appeared settled.

50. On both occasions, Mr B promptly raised complaints with Spectrum about his missing medication, showing his concern and worry. After the period of missing medication in April 2024, Mr B requested a transfer to a different prison due to his ongoing concerns about this happening again.

51. From Mr B’s medical notes and complaint file during the periods of missed medication, it is clear that he was distressed and worried about his missing medication. We recognise the importance of HIV medication and how worrying it must have been for him to not have this.

52. We also recognise how helpless Mr B felt, being in a prison setting, where he could not do anything else to get his prescription and had to rely on Spectrum. We found Mr B’s distress, worry and poor mental health is an impact caused by Spectrum’s failing to supply him with his HIV medication.

53. Spectrum has not yet apologised for this failing and has not taken any steps to remedy Mr B’s impact. Therefore, we have made recommendations for this, which we have detailed later in our report.

Complaint handling

54. Mr B complains about Spectrum’s complaint handling. He says Spectrum did not respond to his complaint in an appropriate timeframe or uphold his complaint. He says it was difficult to escalate the complaint due to the lack of response.

55. After Mr B did not receive his medication at the start of December 2023, he complained to Spectrum.

56. This was logged as a ‘concern’ in Spectrum’s complaint history. Spectrum’s complaints policy says a concern should be resolved by early resolution. It says if the patient is happy with the action taken during early resolution, the concern can then be closed. Spectrum closed Mr B’s concern, but we have not seen evidence of Mr B being asked if he was happy with the resolution.

57. Mr B has told us he completed eight ‘Better Health’ complaint forms about his concerns. Spectrum has not provided copies of his complaint forms in December 2023.

58. Mr B has provided some copies of his complaints to the Independent Monitoring Boards (IMB). In his complaint to the IMB on 9 December 2023, he raised his concerns about his medication not being supplied. In this form he said he has put in a complaint to Better Health and had not received a response yet.

59. On 15 December 2023, the IMB responded to his complaint explaining it would discuss the issue with the Healthcare team. He did not receive a response.

60. In April 2024, after his second period of missed medication, Mr B raised five complaints using the Better Health complaint form. This was logged as an ‘informal complaint’ in Spectrum’s complaint history.

61. In April 2024, Spectrum wrote to Mr B confirming he had raised a complaint about his medications. It said it was unsure why his medication was not available for him to collect. This was not a formal complaint response.

62. Spectrum’s outcome for this complaint was ‘withdrawn and closed’ due to Mr B transferring to another prison in June 2024. It did not provide a formal response to Mr B.

63. In April 2024, Mr B called us and explained he had not received responses to his complaints. We advised him to raise his complaint with HM Prison and Probation Service using its complaint form.

64. Mr B raised a formal complaint with HM Prison and Probation Service in May 2024. He also complained to NHS England.

65. NHS England responded to Mr B in May 2024 advising him it had contacted Spectrum to contact him about this.

66. Mr B contacted NHS England in October 2024 raising his complaint again. NHS England passed this complaint letter to Spectrum in November 2024. Spectrum provided a formal response to his complaint in December 2024.

67. Spectrum’s complaints policy says formal complaints may be submitted from patients if they are unhappy with the resolution following a local informal complaint. It says complains received from other external organisations such as NHS England are logged as formal complaints.

68. Due to Mr B raising over five complaints in April and May due to the lack of response, it would have been reasonable for Spectrum to assume he was unhappy with the informal response he had received. In line with Spectrum’s complaints policy, this should have been escalated to a formal complaint.

69. NHS England advised Mr B it wrote to Spectrum with Mr B’s concerns. In line with Spectrum’s complaint policy, due to NHS England forwarding the complaint, it should have been logged and treated as a formal complaint in May 2024.

70. Our NHS Complaint Standards says an effective complaint system goes out of its way to create a positive environment in which complaints are welcomed and resolved at the earliest opportunity. It says to ensure people are confident that their complaint will be taken seriously, looked at with empathy and be answered as quickly as possible.

71. We do not think Spectrum handled Mr B’s complaint in line with our NHS Complaint Standards. Mr B made several complaints, yet these were not treated as a formal complaint. Mr B had to take his complaints to other organisations to try and get a complaint response. We understand why Mr B feels ignored by Spectrum, as it was not answering his concerns in line with its own complaint policy and our NHS Complaint standards.

72. Our NHS Complaint Standards say organisations should give people fair and open answers to their questions based on the facts and take full accountability for mistakes identified.

73. In December 2024, Spectrum responded to Mr B. In this response, it concluded Spectrum acted in line with policy and guidance. As we have found failings by Spectrum to act in line with its critical medicine policy, we do not consider Spectrum answered the complaint openly or took accountability in line with our NHS Complaint standards.

74. We have found failings in Spectrum’s complaint handling. We found Spectrum did not handle Mr B’s complaint in line with its own complaints policy and our NHS Complaint Standards.

75. As a result of this, Mr B felt ignored by Spectrum, and felt he was being prevented from pursuing his complaint.

76. We recognise this must have been frustrating and distressing for Mr B as he had to continuously make complaints to Spectrum and other organisations. We have found Spectrum’s poor complaint handling caused Mr B unnecessary distress and frustration. To remedy this impact, we have made recommendations which we have detailed below.

1. We are sorry to hear about Mr B’s complaint about Spectrum Community Health at the prison (Spectrum). Mr B told us he thinks Spectrum failed to provide him with HIV medication on two occasions. He also complains about Spectrum’s complaint handling.

2. We are especially sorry to hear this experience caused Mr B serious distress on each occasion, and he has told us how he felt helpless. Mr B told us he has experienced ongoing anxiety as he thinks missing his medication led to his HIV developing, and to him developing an anal fistula. He has told us how he felt ignored by Spectrum when trying to raise a complaint which caused him further distress.

3. We found Spectrum failed to supply Mr B’s medication in line with its critical medicines policy. We have not found this impacted Mr B’s HIV or caused him to develop an anal fistula. We found this failing impacted Mr B’s mental health and caused him serious distress.

4. We have also found Spectrum failed to act in line with our NHS Complaint Standards, which caused Mr B further distress. Therefore, we partly uphold Mr B’s complaint.

5. We consider Spectrum needs to take further steps to put this complaint right. We recommend Spectrum make service improvements and pay Mr B a financial remedy of £650.