A practice in the Leeds area

5. Miss S complains on behalf of her daughter (P) who has ADHD and autism, about her experience at the Practice. Specifically, she says:

• the Practice processed P’s referral incorrectly and booked her into an adult service even though she is a child • the clinician disregarded P’s time and needs as they took ear moulds even though they could not provide her the service she needed

6. Miss S says the failings caused:

• a significant impact on P’s ability to cope at school. She was scared to start school without the ear moulds, which caused a spike in her anxiety and caused further stress for the family • P to go through an unnecessary procedure which resulted in upset and anxiety, as well as further adding to her difficulties in coping with medical settings • unnecessary travel to the appointment which incurred unnecessary costs.

7. Miss S wants:

• the Practice to formally acknowledge the service failures and provide a meaningful apology • the Practice to inform families from the outset if it cannot provide a service • a financial remedy.

8. P is a 14-year-old girl with diagnoses of ADHD and autism. Her GP referred her to the Practice for noise-cancelling ear inserts, to help manage her sensory issues. P attended the Practice on 19 August 2025. Miss S told us at the appointment the clinician took ear moulds unnecessarily. She said the Practice told her after the appointment that the service could not meet P’s needs and the NHS does not provide noise-cancelling ear inserts.

9. Miss S complained to the Practice on 22 August 2025. The Practice provided a final response on 28 August 2025. Miss S brought the complaint to PHSO on 3 September 2025.

The Practice processed P’s referral incorrectly

12. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have found the Practice has already done enough to put right the impact of the events.

13. Miss S complains the Practice processed P’s referral incorrectly and booked her into an adult audiology clinic even though she is a child.

14. In the Practice’s response it apologises for the distress and inconvenience caused and acknowledges the error. It says a new member of staff processed the referral and accidently booked P into a routine adult audiology clinic. It says it has addressed this with the administration team and made service improvements. An experienced member of staff now triages all referrals and discusses each one with the lead audiologist before they make a booking.

15. We asked the Practice to comment further. It says all administrative staff have received further training on checking service eligibility and appointment appropriateness at the point of booking, and on clear communication protocols for informing families if it cannot provide a requested service.

16. It says it has documented the measures, and as a Practice it will continue periodic refresher sessions and monitoring to ensure consistent adherence.

17. We are sorry to hear this incorrect booking caused P and Miss S distress and inconvenience. We recognise that Miss S does not feel the Practice’s response is enough.

18. Miss S described the impact of the fitting procedure caused P upset and anxiety particularly given her existing anxiety around medical settings. It also resulted in unnecessary travel to the appointment which incurred unnecessary costs of around £13.

19. We use PHSO’s ‘guidance on financial remedy’ to decide whether the impact of any potential injustice meets our threshold for financial remedy. We think this part of Miss S’s complaint falls into level one, in that it represented a one-off administrative failure which caused P and Miss S minor distress and inconvenience. We generally consider an apology to be an appropriate remedy for a level one injustice.

20. Our ‘NHS Complaint Standards’ say organisations should provide meaningful apologies and transparent explanations. The evidence shows the Practice apologised for the distress and inconvenience caused by the acceptance of P’s referral into a service designated for adults only. It recognises this should not have occurred and provided a transparent explanation. It has made service improvements to ensure this does not happen again.

21. We consider the Practice has taken appropriate steps to address this matter and it has provided appropriate remedies in line with our NHS complaint standards. We will not consider this issue further.

The clinician disregarded P’s time and needs

22. Miss S complains the clinician at the audiology appointment disregarded P’s time and needs by taking the ear moulds despite being aware the Practice could not provide the service. She says this caused P unnecessary upset and anxiety, adding to her existing difficulties in coping with medical settings.

23. In its responses, the Practice apologises for any distress and inconvenience caused. It explains that the clinician did not want to waste P’s time, so they attempted to help by taking an impression of P’s ear in preparation for ordering the appropriate device. It says it was only after the clinician sought advice from the manufacturer they became aware the moulds they had taken would not work as they needed a longer ear canal impression.

24. The Practice says the lead audiologist advised a referral to the paediatric audiology department for specialist care at LTHT. The lead audiologist contacted LTHT who advised that the NHS does not offer noise-cancelling ear inserts as part of its service.

25. We are satisfied that P would not have been provided with the moulds, for the reasons provided by LTHT. We appreciate P was scared to attend school without the ear moulds and we are satisfied that her not receiving the moulds was not due to the Practice’s failings. We understand how much P wanted the ear inserts and that not receiving them when she expected to was distressing and disappointing.

26. We reached this decision by considering the advice provided to the Practice by LTHT. They say the NHS does not provide noise-cancelling ear inserts for children with sensory issues as part of its service. It says patients seeking this service would need to go private. This means the injustice claimed did not happen because of the failings. P would never have received the ear inserts as the NHS does not provide this service.

27. We recognise one of the outcomes Miss S wants is for the Practice to inform families from the outset if it cannot provide a service. We asked the Practice to reflect on this and provide us with any learning taken.

28. It reiterates and acknowledges the clinician took the ear moulds despite the service being unavailable and apologises again for the unnecessary distress this caused.

29. It says the clinician has reflected on this and recognises the importance of confirming service eligibility and capacity before progressing with any clinical procedures.

30. It says the clinician has received additional one-to-one training focused on pre-procedure checks, patient communication, and sensitivity when working with children with autism and ADHD.

31. It says it has documented the measures, and as a Practice it will continue periodic refresher sessions and monitoring to ensure consistent adherence.

32. We use PHSO’s ‘guidance on financial remedy’ to decide whether the impact of any potential injustice meets our threshold for financial remedy. We think this part of Miss S’s complaint falls into level one, in that it represented a one-off service failure which caused minor distress and annoyance.

33. Our ‘NHS Complaints Standards’ state that organisations should explain why things went wrong and identify suitable ways to put things right for people. They also state that staff should give meaningful and sincere apologies and explanations the openly reflect on the impact on the people concerned.

34. We believe the Practice has provided a sincere apology and acknowledged the service failures. They provided transparent explanations and made reasonable efforts to improve the service to ensure the failings do not happen again.

35. We appreciate the distress Miss S and P have experienced and we appreciate the time Miss S has taken to bring the complaint to us.

1. We have carefully considered Miss S’s complaint about her daughter’s (P) experience at the Practice.

2. Miss S told us the Practice incorrectly booked her daughter in to an adult audiology clinic, despite her being a child. She said the clinician disregarded her daughter’s time and needs by going ahead and taking ear moulds, despite knowing they could not provide the service.

3. We have decided we cannot link the events complained about to the impact on P’s ability to cope at school. We have decided the Practice has already done enough to put right the other impacts of these events on P.

4. We fully acknowledge P’s experience and do not wish to minimise this. We hope our explanation below reassures Miss S the Practice has taken appropriate actions to improve its service and responded to her complaint in line with guidance.