A practice in the Buckinghamshire area

5. Mrs B complains about the following aspects of the treatment she and F received from the Practice in January 2025. She says the Practice:

• failed to inform her of F’s eye swab results in January 2025 • failed to refer her for investigations for a painful lymph node in her pelvic area on 20 January 2025 • did not prioritise her and F appropriately for appointments according to their symptoms and circumstances on 20 January 2025

6. Mrs B believes due to the poor care by the Practice, F experienced prolonged symptoms along with an additional three days of high fever. She also says F experienced further illness as the diagnosis of conjunctivitis was delayed, which led to it developing into an ear infection.

7. Mrs B states she herself experienced stress and loss of sleep along with pain and discomfort, causing her to miss out on four days of work and University. She also lost trust in her GP and felt she needed to seek private healthcare for investigations into her painful lymph node.

8. By bringing this complaint to PHSO, Mrs B seeks an acknowledgement of failings along with service improvements.

9. On 18 January 2025 Mrs B called 111 and got an appointment with an out-of-hours GP to see F on the same day. The GP diagnosed F with conjunctivitis (the inflammation or swelling of the conjunctiva - the thin, transparent layer covering the white part of the eye and inner eyelids) and the GP prescribed F medication for it.

10. On 20 January Mrs B rang the Practice and requested a face-to-face appointment for herself and F. The Practice booked a telephone consultation for Mrs B for the same day and booked F an in-person appointment on 30 January with a different clinician.

11. Mrs B reports during the telephone consultation the clinician failed to refer her for further investigations for her painful lymph node. She raised a formal complaint online to the Practice the same day.

12. Mrs B also states the Practice took an eye swab from F during the appointment on 30 January and they did not share the positive results with her until 12 February.

13. The Practice provided Mrs B with their detailed final response to her complaint on 12 February, and she raised her concerns to PHSO on 17 February.

Delay of communicating F’s eye swab results

17. To decide if we should conduct a detailed investigation into a complaint, we first consider whether there are any indications something went wrong with the service provided by the organisation. If so, we then explore the impact this had, and if the organisation has taken any steps to put things right.

18. Having done so, we have decided the Practice has already taken appropriate steps to put things right and we do not need to take any further action.

19. Mrs B complains about the care F received in January 2025 relating to an eye infection and the handling of her eye swab results. Mrs B states the Practice took an eye swab during the in-person appointment on 30 January, and they did not share the positive results in a timely manner with her. She says this delay caused further distress for her and especially F as her illness progressed. We understand how upsetting this was for Mrs B.

20. The Practice’s complaint response included their call logs showing they made multiple attempts to call Mrs B on 6 February to inform her about F’s swab results. Mrs B says she did not receive any calls from the Practice.

21. GMC guidance says the exchange of information between medical professionals and patients is central to good decision making. It says doctors should give patients information in a way they can understand and take steps to meet their language and communication needs, so they can engage in meaningful dialogue and make informed decisions about their care. It says the steps should be proportionate to the circumstances including the patient’s needs and seriousness of their condition, the urgency of the situation and the availability of resources.

22. The records provided by the Practice state the Practice received F’s eye swab results on 4 February. One of the doctors prescribed medication to treat F’s eye infection towards end of the day on 5 February. The Practice’s reception team then made four attempts to contact Mrs B on 6 February, to provide her with the results and inform her of the prescription. The Practice also included call logs of these attempts in the emails. On one of these emails, it also signposted Mrs B to link her online account on the Patient Online Access with F’s, so that she can access all relevant medical updates and information as soon as possible.

23. While the Practice did attempt to contact Mrs B, she did not answer the calls and the Practice did not try any other methods to contact her. The Practice acknowledged this and agreed it should have made further attempts to notify Mrs B about the eye swab results and the prescription.

24. The eye swab results and information about the prescription were important to Mrs B so she could collect the medicine F needed. Mrs B did not get this information until the Practice responded to her complaint on 12 February, seven days after the doctor prescribed the medication.

25. The Practice agreed to use this instance for staff training and provide feedback to the reception team.

26. Mrs B replied to the Practice thanking them for the information and updates. She also stated moving forward she would appreciate emails or text messages about updates. The Practice responded the next day acknowledging her feedback and promising to pass it on to the reception manager.

27. Our NHS Complaints Standards explain when things go wrong, we expect organisations to apologise and ‘see complaints as an opportunity to develop and improve its services.’ Further, it says we expect organisations to ‘take action to make sure any learning is identified and used to improve services. Finally, our standards say organisations should be ‘thorough and fair’ by ‘taking full accountability for mistakes identified’.

28. Taking all this into account, we can see the Practice have provided a meaningful apology, acknowledged its shortcomings, and put in place service improvements which Mrs B has also acknowledged. Because the Practice has already taken appropriate steps to put things right, we do not need to take any further action.

The Practice did not correctly refer Mrs B for her painful lymph node

29. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has done something wrong. We do this by comparing what should have happened with what did happen. We have done this and have found indications of a failing.

30. Mrs B says during the telephone consultation she had booked on 20 January, the Practice failed to correctly refer her for investigations into a painful lymph node in her pelvic area. Mrs B says due to this failure, the Practice missed an opportunity to diagnose her with a uterine polyp (generally benign, soft growths attached to the inner uterine wall).

31. The Practice’s records show the telephone consultation was mainly focused on Mrs B’s sore throat which the Paramedic was able to give detailed advice and guidance on. The paramedic asked her to send a photograph of her throat. When Mrs B did this, she said in her message she was very concerned about a swollen lymph node in her genital area and urinary tract infection (UTI). She asked if she should see a pharmacist about this.

32. The Paramedic replied they were not aware of these symptoms but agreed that Mrs B could seek support from a pharmacist as she suggested.

33. Our adviser stated there was limited information recorded about the swollen lymph node, and the paramedic did not explore key details such as how long it had been present, whether it was painful, or how Mrs B identified it as a lymph node. While a UTI can cause lymph nodes to enlarge, swollen lymph nodes, especially when painful, may require further assessment.

34. BMJ guidance and information on the NHS website indicates that clinicians should review swollen lymph nodes lasting two to four weeks, and that duration, size and characteristics help determine risk. In this case, the paramedic signposted Mrs B to a pharmacy for UTI symptoms but did not provide clear advice about when to seek further medical help or arrange follow‑up for the lymph node. Our adviser confirmed a swollen pelvic lymph node was not suitable for pharmacy assessment alone.

35. The HCPC Standards say paramedics must practise as independent practitioners, using their skills, knowledge, experience and the information available to them to make informed decisions. This includes knowing when a symptom may require further assessment or referral. In this situation, a more cautious approach such as arranging further review, or advising when to return to the GP, would have been more appropriate.

36. Mrs B told us the Practice’s lack of advice about her painful lymph node affected her physical and mental health, causing her to experience stress and loss of sleep, as well as prolonged pain and discomfort. This further led her to lose trust in the Practice, causing her to seek support through private healthcare. We are sorry to hear how distressing this was for her.

37. As an outcome to her complaint, Mrs B said she would like the Practice to acknowledge the failings she experienced and to confirm what service improvements it would make. We therefore contacted the Practice to ask whether it was willing to resolve this part of the complaint.

38. The Practice confirmed it is willing to write to Mrs B to acknowledge the issues identified. It said it will: • reinforce expectations around assessing and documenting new or complex symptoms, including lymphadenopathy • support clinicians to reflect on scope of practice and escalation pathways • improve the advice given to patients about when to seek further medical help • clarify how it responds to concerns raised through online or written communication.

39. Taking this into account, we are satisfied the Practice has acknowledged the issues raised and committed to meaningful service improvements. As it has agreed to take appropriate steps to address the concerns and prevent similar issues in future, we consider this part of the complaint resolved and will not take further action.

Prioritising Mrs B and F appropriately

40. Mrs B complains the Practice did not prioritise her and F appropriately for appointments based on their symptoms on 20 January 2025. Having looked at the evidence, we have not seen indications that anything has gone wrong.

41. Mrs B states the Practice should have seen her in-person instead of giving her a telephone consultation on 20 January 2025. She says the Practice should have seen F together with her under the same clinician, and earlier than 30 January. We understand how concerning this was for her.

42. Our principles of good administration say organisations should take reasonable decisions, respond to people’s needs flexibly, and ensure that decisions and actions are proportionate, appropriate and fair. From the evidence we have seen, we think the Practice’s actions were in line with these principles.

43. The Practice responded to Mrs B’s complaint in detail on 12 February 2025. They explained that due to the significant demand on NHS primary care services, there is a limit to how many Practice appointments can be allocated per day.

44. The Practice said it initially booked two telephone consultations for Mrs B when she called on 20 January 2025, one for her and one for F. The Practice said it called Mrs B back the same day to explain that a clinician wished to see F in-person. It apologised for not being able to offer the same for Mrs B.

45. The Practice had primarily booked Mrs B’s same day telephone consultation with a paramedic to discuss her tonsilitis (the inflammation of the tonsils, usually caused by viral or bacterial infections). The paramedic assessed Mrs B’s symptoms over the telephone and reviewed a photograph of her throat.

46. The paramedic assessed it was likely Mrs B’s symptoms were due to a viral infection. The gave advice about how she could treat her symptoms with home remedies and over the counter treatment such as salt water gargles, Difflam spray, simple pain relief and fluids. The paramedic did not identify any concerning symptoms which needed a GP appointment.

47. Sore throat is one of seven conditions covered by the NHS Pharmacy First Service (PFS). PFS allows patients to receive advice and NHS‑funded treatment (including prescription only medication) for minor illnesses directly from a pharmacy without needing a GP appointment. Patients with symptoms suitable for PFS are not prioritised for GP appointments unless there are signs of serious illness present.

48. We consider the Practice took proportionate and reasonable action in arranging for a paramedic to review Mrs B over the phone on the same day. The paramedic did not identify any need for a GP to review Mrs B and concluded she could manage her symptoms with treatments available at home or from the pharmacy.

49. For F, we understand the Practice initially offered a same day telephone consultation but then changed this to a face-to-face appointment with a GP later in the afternoon. The notes of the appointment show the GP examined F and measured her vital signs (pulse, temperature and oxygen levels). The GP assessed she seemed well and should continue with the treatment an out of hours doctor prescribed on 18 March.

50. We recognise how distressing this experience was for Mrs B, particularly the Practice not seeing her at the same time as F. It is understandable this caused confusion and concern. Given Mrs B’s symptoms were suitable for PFS we consider it was reasonable the Practice took a different approach than it took with F. The Practice has to make difficult decisions about who to prioritise for limited face to face appointments.

51. We appreciate the time and effort involved in raising these concerns, and we thank Mrs B for bringing them to our attention. We hope our explanation and the Practice’s actions to improve their services provides reassurance that the care provided to her and F was in line with the relevant standards.

1. We have carefully considered Mrs B’s complaint about the care and treatment she and her baby, F, received from the Practice.

2. We understand Mrs B is upset the Practice did not inform her of F’s eye swab results in a timely manner. Based on the evidence reviewed, we have decided the Practice has already done enough to put this right. We explain the reasons for our decision below.

3. Mrs B also complains about the Practice failing to appropriately refer her for investigations into a painful lymph node. We understand this has caused Mrs B to experience prolonged pain and discomfort. We are sorry to hear she was under a lot of distress. 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.

4. We are very sorry to hear that Mrs B feels the Practice did not prioritise appointments for her and F according to their symptoms and circumstances. We understand why this caused Mrs B concern. Our review has not identified any evidence that the Practice acted outside relevant policy. We explain this in more detail below.