A practice in the Lincoln area

5. Mr A complains about the care and treatment he received from the Practice between 8 November 2024 and 25 February 2025. Specifically, he complains that the Practice:

• failed to document or act on three disclosures of suicidal ideation during an appointment on 8 November 2024, including by not arranging a referral, safeguarding action, or follow-up support • denied him permission to record his consultations during appointments on 28 November 2024 (Advanced Nurse Practitioner - ANP) and 16 January 2025 (GP) • failed to provide reasonable adjustments linked to his autism, despite his explanation that recording helps him understand, remember and process consultations • mishandled his complaint, including delays and inadequate investigation, and did not follow its own complaints policy • treated him differently after he raised a complaint, including by allegedly referencing his earlier complaint during the 16 January 2025 appointment and telling him future appointments would primarily be with a nurse practitioner.

6. Mr A says the events above caused him significant emotional harm and deterioration in his mental health, and he says he later self-harmed because he felt invalidated, unsafe and dismissed.

7. Mr A says refusing his request to record consultations made him feel intimidated and unsafe, and made it harder for him to participate with his healthcare. He describes feeling a loss of trust in healthcare providers and now finds it very difficult to access or engage with services.

8. Mr A is seeking service improvements in relation to how the Practice supports patients after suicidal disclosures, makes reasonable adjustments, and handles complaints so that raising concerns does not affect healthcare. He would also like a financial remedy of £5,500.

9. Mr A has a recorded medical history including autism, anxiety and depression, insomnia, irritable bowel syndrome (IBS), and a severe sight impairment.

10. Mr A attended a GP appointment on 8 November 2024 in which he disclosed suicidal ideation (thoughts about ending one’s life) on three occasions. He additionally recorded this consultation without making the GP aware of this. Mr A states this was required as a reasonable adjustment for his autism.

11. Mr A says the GP did not make crisis referrals or record the disclosures and instead offered antidepressants which Mr A said were not suitable for him. Mr A also says he was offered a follow-up appointment which was not arranged.

12. The Practice says the consultation involved multiple issues, including physical health concerns and requests for support relating to autism.

13. Following the consultation, the Practice records show that the GP sent Mr A information about local autism support services and a urology referral was arranged for unrelated physical symptoms.

14. On 25 November 2024, Mr A emailed the Practice stating that he was experiencing a mental health crisis and felt he had not received adequate support.

15. The Practice arranged a further appointment with an ANP on 28 November 2024, and an appointment with the Practice’s in-house mental health nurse on 11 December 2024.

16. During the appointment on 28 November 2024, Mr A informed the ANP that he intended to record the consultation. The ANP asked him not to record as they did not feel comfortable and Mr A left the appointment shortly afterwards.

17. Mr A submitted a complaint to the Practice on 28 November 2024 regarding the issues with the GP and ANP appointments.

18. Mr A attended the appointment with the mental health nurse on 11 December 2024 in which support was provided, and the clinician agreed to be recorded.

19. On 16 January 2025, Mr A attended a further appointment with the same GP and felt it was inappropriate when his complaint was raised. He again requested to record the consultation, which the GP refused and the appointment was terminated.

20. Mr A received complaint responses dated 30 January 2025 and 25 February 2025.

21. Mr A remained dissatisfied and brought the complaint to us on 17 July 2025.

26. 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. We have done this and have not found any indications that something has gone seriously wrong.

Issue 1 - failure to document or act on disclosures of suicidal ideation (8 November 2024)

27. Mr A says he disclosed suicidal ideation three times during the appointment on 8 November 2024 and that the GP failed to document this or take appropriate action, such as crisis referrals, safeguarding action or follow-up support.

28. We recognise that any disclosure of suicidal thoughts is serious and should be carefully assessed by clinicians. We have therefore considered this issue particularly carefully.

29. The Practice’s position is that the appointment covered multiple issues and that the GP did not consider Mr A to be at immediate risk at the time. The Practice also says that when Mr A later made contact raising mental health concerns, it arranged further support, including an appointment with the ANP and an appointment with the in-house mental health nurse.

30. Our clinical adviser considered Mr A’s medical records as well as the recording that Mr A submitted to us of that appointment. They explained it is difficult to fully compare the recording with the medical record because the recording appears to have started part way through the consultation. However, the adviser noted the recording includes statements said by Mr A such as “I really don’t want to live anymore” and “I’m done”.

31. The adviser explained that, in context, these statements appeared to reflect frustration and distress about the support available rather than clear evidence of active suicidal intent, such as making plans to end one’s life. The adviser noted the GP may have been able to assess this more fully during the face-to-face consultation.

32. We consider the GP discussed appropriate options that primary care can offer, including medication and referral for talking therapies, and that Mr A was seeking broader life support which the GP could not provide. We also note the GP texted Mr A details of local autism support groups afterwards.

33. We next considered the quality of the clinical record. The adviser explained that while it is good practice to document relevant information discussed during a consultation, it can be difficult to document everything when several issues are raised. In this case the GP record was very brief (“Autism support”), and the adviser noted there were other points discussed that were not recorded.

34. The GMC’s Good Medical Practice sets out that clinicians should keep clear, accurate records of relevant clinical findings, decisions and actions.

35. In our view, while it would have been best practice for the GP to record a more detailed note of the discussion, we understand that several issues were raised during the consultation. As the GP did not consider there to be any immediate risk at the time, a brief summary was recorded to capture the main concerns discussed.

36. Taking the clinical advice into account, we did not see evidence that the brevity of the note meant the GP failed to take appropriate action, or that further urgent action (such as A&E admission, mental health referral, or safeguarding) was required on the information available.

37. Overall, we therefore found no indications of failings in the GP’s actions following what was disclosed during the 8 November 2024 appointment.

Issue 2 – refusal to allow recording and reasonable adjustments (28 November 2024 and 16 January 2025)

38. Mr A says he was denied the legal right to record his consultations on 28 November 2024 (ANP) and 16 January 2025 (GP). He says recording is a reasonable adjustment linked to his autism because it helps him understand and process the consultation.

39. Mr A submitted a recording of the 8 November 2024 GP appointment in which the GP was unaware they were being recorded at the time. In the complaint correspondence following this, the GP stated that they were surprised and concerned to learn they had been recorded without prior consent or knowledge.

40. The Practice’s position is that staff were uncomfortable with recording and that it is important to seek consent or at least acknowledge a recording to maintain a positive clinician-patient relationship.

41. The Practice records show that during the appointment on 28 November 2024, Mr A informed the ANP that he intended to record the consultation. The ANP asked him not to record as they felt uncomfortable, when Mr A persisted the ANP stated they would like it stating the recording was against their will. The Practice records state the consultation ended shortly afterwards.

42. Similarly, during the appointment on 16 January 2025, Mr A stated that he intended to record the consultation. The GP explained that they were not comfortable with this and declined to be recorded. The GP also reminded Mr A that on a previous occasion he had been recorded without his consent, to which Mr A responded that he did not need to inform the GP if he was recording. The GP maintained their position that they did not consent to being recorded and offered Mr A an alternative appointment.

43. The British Medical Association (BMA) guidance on patients recording consultations explains that patients are generally entitled to record consultations for their own personal use and clinicians should not normally prevent this. However, the guidance also recognises that clinicians may feel uncomfortable being recorded and should discuss concerns with the patient or consider alternative arrangements where necessary.

44. Based on this, we consider Mr A should have been allowed to record consultations for personal use. We recognise in some instances clinicians can find this uncomfortable and our adviser informed us that requests to record are not common, so staff may be unaware of the detailed guidance.

45. The adviser explained that where a clinician is not comfortable being recorded, the patient should be offered another appointment in a timely manner.

46. The evidence shows that following the 28 November and 16 January consultations, Mr A was offered further alternative appointments and support, including an appointment with the Practice’s mental health nurse in which he was able to record the appointment.

47. Taking the above into account, while we recognise Mr A experienced this as unfair and discriminatory, the evidence does not indicate that the Practice’s approach resulted in a loss of access to care or that it caused a clinical detriment.

48. When the clinicians were informed of Mr A’s intent to record, they were within their right, as outlined in the BMA guidance, to decline this if they felt uncomfortable and offer an alternative appointment with another clinician.

49. We therefore did not see indications that this issue meets our threshold for a detailed investigation.

Issue 3 – perceived bias or different treatment after Mr A raised a complaint

50. Mr A says information from his earlier complaint about recording consultations was used against him during the 16 January 2025 appointment and that the GP became biased, leading to unnecessary delays and decisions such as future appointments being mainly with a nurse practitioner.

51. The Practice’s position is that Mr A was not treated differently because he made a complaint. The Practice’s complaints policy states that the Practice will ensure that patients, relatives, and their carer are not treated differently because of raising a complaint.

52. Our clinical adviser explained that, in general, it can be relevant to refer to a complaint to try to address concerns and clarify expectations. It was also noted that in the documents Mr A submitted to us that he himself raised concerns regarding awaiting responses to his complaint during the 16 January appointment.

53. We considered the records and found Mr A continued to receive appointments and support following his complaint, including referral to support services and involvement from the neighbourhood team. We understand there is no evidence in the GP notes that the complaint was raised in a way that affected clinical care.

54. We also considered that, as mentioned in the previous issue, appointments with other clinicians have been selected to aid Mr A in being able to record his consultations with a member of staff that was comfortable with this as detailed in the complaint correspondence.

55. Taking into all account all the evidence available, we did not find indications of failings in relation to this concern.

Issue 4 – complaint handling

56. Mr A says the Practice mishandled his complaint which he submitted on 28 November 2024, including delays, lack of agreement to extensions, and not addressing the core issues he raised.

57. We can see from the records that the Practice sent an acknowledgement letter on 2 December 2024, including a brief summary “inadequate care and support from the practice during a mental health crisis”.

58. Mr A stated that this summary did not fully encompass what his complaint detailed.

59. Mr A states he did not receive an update for 30 days following the acknowledgement letter and had to chase for progress which is not in line with the Practice’s complaints policy. Mr A sent a chasing email on 18 January 2025.

60. The Practice responded on 21 January 2025 apologising for the delay and explaining that it was still investigating the complaint. It additionally sent a holding letter.

61. Mr A stated this was frustrating and distressing as he had been waiting longer than 30 days for a response to his complaint and that an extension had been made without his agreement, which is again against the Practice’s policy. He sent another email detailing this on 22 January 2025.

62. The Practice responded on the 23 January 2025 reiterating why the complaints response was late and that a full response will be sent by the end of the month.

63. Mr A received the final response on 30 January 2025, he described it as vague, omitting key issues and included unrelated matters. He detailed this in an email back to the Practice.

64. The Practice provided a final response 25 February 2025, which Mr A remained dissatisfied with.

65. We considered the Practice’s complaint responses in line with the PHSO NHS Complaint Standards, which set expectations that complaint handling should be patient-focused, timely, open and transparent, and provide clear explanations.

66. We recognise that whilst the response to the complaint was late, the Practice responded to correspondence and updated Mr A with the reasons for this and new timeframes. Additionally, we reviewed the content of the complaint responses and found it addressed Mr A’s concerns and provided proportionate explanations.

67. While Mr A remained dissatisfied with the responses, and while there were aspects of the process he experienced as unclear and frustrating, we have not seen evidence that the Practice failed to engage with the complaint altogether or that the complaint handling issues identified indicate a serious failure requiring investigation.

Conclusion

68. We recognise how upsetting this experience has been for Mr A, particularly given his vulnerabilities and the reasons he gave for wanting to record consultations.

69. We hope this explanation reassures Mr A that we have carefully considered his concerns, the Practice’s account, the medical records, and independent clinical advice.

70. Taking all of this into account, we have not found any indications that anything went seriously wrong with the care and treatment the Practice provided. For this reason, we will not investigate the complaint further.

1. We have carefully considered Mr A’s complaint about the care and treatment he received from the Practice between 8 November 2024 and 25 February 2025. Mr A says the Practice failed to document and act on disclosures of suicidal ideation, refused him permission to record consultations (which he says was a reasonable adjustment linked to his autism), mishandled his complaint, and treated him differently after he raised concerns.

2. We are sorry to learn of Mr A’s concerns and recognise how difficult and distressing this experience has been for him.

3. We want to reassure Mr A that we have looked carefully at all the available information. We have seen no indication that anything went seriously wrong with the care and treatment the Practice provided, and we consider the actions taken were broadly in line with relevant clinical guidance, professional standards, and the Practice’s own policies.

4. We hope our explanation below helps Mr A understand how we reached our view.