A practice in the Torridge area

5. Mrs M complains about the care and treatment her late husband, Mr M, received from the Practice since he joined the Practice in June 2012 up until his death in November 2022. She also complains about the Practice’s lack of timely responses to her complaint queries.

6. Mrs M says she has gone through intense grief due to her late husband’s poor care by the Practice. She also says she could have provided better support to Mr M had the Practice communicated with her proactively.

7. Mrs M states she experienced significant stress and anxiety, due to the Practice delaying responding to her complaint queries for over 10 months.

8. As an outcome to her complaint, Mrs M is seeking:

• a personal written apology for what she considers poor care provided by the Practice in monitoring Mr M and in handling the complaint.

• a written commitment from the Practice to improve its processes, specifically to ensure follow-up contact is made with patients who miss appointments.

9. Mr M registered with the Practice in July 2012.

10. In 2014 the Practice prescribed Mr M medication to help lower his cholesterol levels. After a few months, Mr M informed the Practice he did not want to take this medication due to the side effects of the medication. The Practice said it would continue to monitor his cardiovascular health on a routine basis.

11. In 2021 Mr M had a stroke. Following this, hospital staff diagnosed Mr M with some heart abnormalities in 2021 and 2022.

12. Mr M died in November 2022.

13. in May 2023, Mrs M raised concerns to the Practice in regards of the care and treatment provided to Mr M since 2012.

14. Mrs M brought her complaint to us in October 2024 and we decided the complaint was not ready for us. The Practice provided a further response in April 2025 and Mrs M brought her complaint back to us in July 2025.

17. 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.

18. When we see indications something has gone wrong, we consider the impact this had and the actions the organisation has taken to put things right. If we are satisfied the organisation has already done enough to put things right, we will not take further action.

Regular monitoring of Mr M’s heart and follow-up call after missed appointment

19. We have considered these parts of the complaint together as our analysis and decision is the same.

20. Mrs M says the Practice did not monitor Mr M’s heart condition regularly since he joined them in June 2012. She says due to this she was not able to support Mr M properly in his care throughout the years. We are sorry Mrs M feels this way.

21. Mrs M complains the Practice did not make follow-up calls with Mr M after he missed an appointment in February 2015. She states the Practice was lacking in their duty of care to a patient with cardiac issues and they should have done better to check why Mr M missed the appointment.

22. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so. We have discussed this with Mrs M to understand when she became aware of her concerns.

23. Mrs M said she first became aware of Mr M’s overall cardiac issues in November 2002. She later confirmed by email that the next time the Practice initiated a cardiac test for Mr M was in November 2022, despite the Practice referring to a cardiac issue in a GP letter from March 2014.

24. From the records provided by the Practice, we can see after Mr M registered with the Practice in 2012, it carried out regular general age-related health checks. In response to the results of these checks, from September 2014 the Practice prescribed statin mediation to Mr M to reduce his cholesterol and lower the risk of heart and circulatory problems.

25. On 19 February 2015 Mr M notified the Practice that he no longer wished to continue taking the prescribed statins. He asked the Practice to note on his records that this is an informed decision by himself due to the side effects he experienced from the drug. When the Practice replied to Mr M on 27 February 2015, it said it would continue to monitor his cardiovascular system.

26. During our initial phone call with Mrs M, she stated the Practice did not monitor Mr M’s condition properly since he stopped taking statins. She also stated the Practice should have prescribed more effective medication to address Mr M’s health concerns. Based on this, we consider Mrs M was aware of her concerns about the monitoring of Mr M’s heart in February 2016, by which point she says Mr M had been off statins for a year without further checks of his risk of heart problems.

27. For Mrs M’s complaint to be in time, she would have needed to approach our office no later than February 2017. She first brought this complaint to us on November 2024. This means her complaint about this issue is approximately seven years and nine months out of time.

28. Now turning to Mrs M’s concerns about the lack of follow up when Mr M missed a health check appointment on 27 February 2015. She told us the Practice sent a follow-up letter after the missed appointment, but there are no records of any calls attempted to Mr M. Mrs M stated the Practice should have made more of an effort to get Mr M to attend his appointments. Based on this, we are satisfied Mrs M was aware of her concerns in February 2015, when the Practice did not call Mr M after he failed to attend his appointment.

29. For Mrs M’s complaint to be in time, she would have needed to approach our office no later than February 2016. She contacted us in November 2024, which means her complaint about this issue is approximately eight years and nine months out of time.

30. During our initial phone call with Mrs M, we asked her the reasons why she did not bring her complaint to us within the one year time limit, so that we could consider if there were grounds to put the time limit aside.

31. Mrs M explained that Mr M did not want to make a complaint about this matter and she also did not want to raise a complaint on his behalf while he was alive, as he was unwilling to do so. Mrs M further said that Mr M was not always forthcoming with his concerns to the Practice, so she wants to raise the complaint now as she believes the Practice needs to improve their duty of care to their patients.

32. We understand why Mrs M respected her husband’s wishes and did not complain while he was alive. If Mr M did not want to complain while he was alive, this does not mean we should accept a complaint from Mrs M several years after the date she became aware of her concerns.

33. Mr M sadly died in November 2022. Mrs M said until February 2023 she was coming to terms with his death and dealing with urgent and important legal and financial issues. She also told us she was dealing with health problems brought about as a result of the stress she had experienced. Mrs M said from March to May 2023 she was taking time to think and get advice on her physical and mental health.

34. We recognise Mrs M needed time after her husband’s death to grieve, deal with important legal and financial matters, and focus on her own health. We are satisfied that from November 2022 to May 2023 there is a good reason why Mrs M did not pursue her complaint.

35. In May 2023 Mrs M requested a copy of Mr M’s medical records, which she received in July 2023. She told us many of these were copied in an illegible way so she had to request new copies. Mrs M explained it was tough and very time consuming to review Mr M’s healthcare records for the last 20 years off his life across a variety of healthcare providers. Mrs M said the time it took to review the records meant she could not complain to the Practice until February 2024.

36. We do not consider Mrs M needed to review 20 years of medical records from a variety of providers before making a complaint to the Practice. If she was unsure what actions the Practice had taken to monitor Mr M’s heart health after he came off statins in February 2015, she could have asked the Practice for just this information. We do not consider it was necessary for Mrs M to spend seven months reading all of Mr M’s medical records before making a complaint.

37. Mrs M complained to the Practice in February 2024. She contacted us in November 2024 as she had not received a response from the Practice. We contacted the Practice and asked it to respond to Mrs M’s complaint. The Practice response is dated 3 December 2024, but Mrs M did not receive it until 24 January 2025. On 27 January Mrs M informed the Practice and us she was unhappy with the response. The Practice responded in April 2025 to confirm it had nothing further to add. Mrs M says she did not receive this response, so we sent her a copy in August 2025.

38. We recognise the Practice took a very long time to respond to Mrs M’s complaint. This was outside Mrs M’s control. We consider Mrs M came to us within a reasonable timeframe of realising the Practice was taking longer than expected to respond.

39. Overall we do not think there are strong enough reasons to put our time limit aside to consider the failure to monitor Mr M’s heart and contact him when he missed an appointment. It seems Mr and Mrs M made a deliberate decision not to complain while Mr M was alive. Once Mrs M felt able to pursue her concerns after Mr M’s death, she then took seven months reviewing 20 years of medical records. We do not consider Mrs M had to do this, and so we have decided this is not a strong enough reason to put the time limit aside.

40. Unfortunately, the timeline and Mrs M’s actions suggest she had both the awareness and capacity to escalate her complaint to us within the required timeframe. As we have not seen a good reason to set aside our time limit, we have decided that this complaint is out of time and we will not investigate it. We know this will be disappointing for Mrs M.

Timely responses to complaint queries

41. Mrs M complains the Practice did not respond to her queries in a timely manner, and she had to reach out to different organisations to ask for support to get the Practice to respond. In May 2023 Mrs M requested full disclosure of Mr M’s medical information. Over the following months she received his medical records.

42. Mrs M complained to the Practice in February 2024. In April 2024, she wrote to the Practice with further questions and requests for updates. After Mrs M received no response, she contacted the CQC in May 2024. The CQC advised her to approach Devon ICB or us. Mrs M later raised the issue with the ICB, who confirmed the Practice had sent an acknowledgement letter in February but had not yet responded substantively.

43. Mrs M contacted us in November 2024 and we asked the Practice to respond to her complaint. The Practice response is dated 3 December 2024, but Mrs M says she did not receive it until we sent her a copy on 24 January 2025.

44. Mrs M raised further concerns with the Practice on 27 January 2025. The Practice’s final response is dated April 2025 but Mrs M says she did not receive this until we sent her a copy in August 2025.

45. Both the Practice’s Complaints Policy and our NHS Complaint Standards state that the Practice must provide information and updates on timeframes during which the complainant might expect a full response. The NHS complaint regulations also state the Practice must communicate if it required more time than the relevant period of six months since the complaint was made, as it is their responsibility to keep complainants reasonably informed.

46. From the timeline provided, we can see the Practice responded on 3 December 2024 to Mrs M’s complaint which she raised on 5 February 2024, which is over 10 months. Though some complaints do take longer than six months for the organisation to investigate, we have seen no reasons why this case took so long, nor that the Practice communicated with Mrs M about the reasons for the delay. This indicates service failure as the Practice did not do what it should have done.

47. As a result of the Practice’s delays and lack of updates, Mrs M then contacted other organisations including the CQC, Devon ICB, and us to try and get an answer to her concerns. This was a source of stress and anxiety Mrs M should not have had to experience.

48. Mrs M told us as an outcome for this issue, she would like the Practice to provide a personal apology for its poor handling of her complaint and a written commitment from the Practice to improve its processes. We asked the Practice if it would provide these outcomes to Mrs M.

49. The Practice agreed to meet Mrs M’s requests and sent her a letter on 17 September 2025 apologising for the delays in responding to her complaint and for not communicating with her in the way it should have done. The Practice explained it had made service improvements. These improvements include reminding staff of the statutory and internal requirements for complaint handling, monitoring complaints to ensure they are handled properly while complainants are informed of delays and their reasons, and the periodic auditing of compliance with complaints handling procedures.

50. Given the Practice has now taken full accountability for the mistakes it made we are satisfied these improvements will prevent a similar situation occurring. As the Practice has now provided the apology and assurance of service improvements Mrs M said she was looking for, this component has now been resolved, and we do not need to take any further action.

50. We know it will be disappointing for Mrs M that we are not considering her complaints about the care her husband received from the Practice. We hope she is reassured by the actions the Practice has taken to improve its complaints handling and its apologies for the delays in responding to her complaint and the poor communication.

1. We have carefully considered Mrs M’s complaint about the Practice. We are sorry to hear Mrs M feels the Practice did not monitor or care for Mr M regularly. We understand she is also upset at the lack of communication by the Practice when Mr M missed an appointment, and when she raised issues to them.

2. Mrs M complains the Practice did not monitor Mr M’s heart regularly since he joined them. We appreciate Mrs M has found this upsetting. We have decided this complaint falls outside of our one-year time limit. We have not seen a good enough reason to set our time limit to one side, so we cannot consider it further. We understand this decision will be disappointing to Mrs M. We explain the reasons for this in more detail below.

3. We recognise how important this complaint is to Mrs M and acknowledge the difficulties she experienced with Mr M’s death. We are sorry to hear she feels the Practice did not uphold their duty of care for Mr M with attempting follow-ups for missed appointments. We have decided this complaint also falls outside of our one-year time limit, and we have not seen a good reason to set it aside. Therefore, we cannot consider it further. We explain the reasons for our decision below.

4. Mrs M also complains about the Practice’s lack of timely responses to her complaint queries. We understand this has caused Mrs M to experience significant stress. The Practice has agreed to take action to put this right. We are satisfied with these proposed actions and explain them more in detail below.