A practice in the City of Brighton and Hove area

3. Mr B complains about the care and treatment provided by the Practice between 6 and 28 May 2025 in relation to a change in the appearance of his scalp. Specifically, he says the Practice:

• refused to prescribe tretinoin (a treatment used for skin conditions) or make an urgent referral to dermatology services • gave him conflicting information about the referral.

4. Mr B also complains on 24 September the Practice unfairly and incorrectly removed him from its register.

5. Finally, he complains the Practice failed to meet with him to discuss his complaint.

6. Mr B says the changes to his scalp remain untreated and this is affecting his ability to live a normal life. He also says he has been emotionally affected by the Practice’s actions and its complaint handling, and his removal from its register has affected the continuity of his medical care.

7. Mr B wants an independent investigation into his concerns, an acknowledgement of failings, and an apology.

8. On 6 May, Mr B reported the appearance of linear indentations (line shaped marks or grooves) across his scalp, which he believed could be conditions such as scarring alopecia (a condition where hair follicles become scarred), connective tissue disorders, or cutaneous atrophy (an inflammatory condition causing skin changes).

9. Mr B reported that these marks appeared over the past week without any history of trauma or external pressure.

10. Mr B also reported a broader skin health concern, saying he has been experiencing signs of chronic photoaging (premature skin aging), including fine wrinkling, uneven pigmentation (colouring), and textural changes, which Mr B said could suggest early actinic damage (pre-cancerous skin changes caused by sun exposure).

11. Mr B said these skin changes, combined with his scalp issue, have significantly affected his mental well-being, particularly as he has been experiencing severe work-related stress and recent incidents of workplace discrimination. Mr B says as part of his job, he must go into people’s homes, and they will not let him in due to Mr B’s skin marks.

12. Mr B therefore asked his doctor for tretinoin for his condition. We were very sorry to hear about how Mr B’s health was affecting him at that time.

13. Mr B was told by the Practice that these marks were not suggestive of a serious condition and only represented some fat loss in the area of concern. Mr B was then told by the Practice there is no clinical need to prescribe the requested medication. It suggested he can wear caps to cover his scalp when working.

14. On 8 May, Mr B asked again for topical tretinoin for his condition. The Practice told Mr B this is only prescribed for acne and not licenced for skin changes on the scalp. The Practice then offered to ask for a dermatologist’s advice which Mr B agreed to.

15. On 21 May, the dermatologist reviewed photographs of Mr B’s skin. They reported the images showed expected changes in normal aging. The dermatologist told the Practice there is no prescription medicine that can be offered within NHS dermatology services.

16. The Practice discussed the dermatologist’s advice with Mr B on 22 May 2025. Mr B again requested tretinoin which the Practice denied.

17. On 22 September Mr B contacted the Practice. He said the doctor had promised an urgent medical referral to dermatology and complained the Practice had not done this.

18. The Practice told Mr B he was not promised a dermatology referral, instead the doctor had got advice from the dermatology department, which the doctor had already shared with him.

19. Mr B then came into the Practice on 23 September. Mr B says he experienced inappropriate, dismissive, and intimidating behaviour at the Practice resulting in his removal from the surgery. Mr B says his request for a formal meeting with the Practice managers was ignored.

20. The Practice said in its complaint response that on 23 September, Mr B came into reception and spent around 40 minutes creating a disturbance at the reception desk. The Practice said Mr B demanded to speak to staff who were not available.

21. The Practice said Mr B then made threats about legal action and complained about the surgery not fulfilling his needs.

22. It said one doctor came out of their room to speak to Mr B and requested that he come back the next day. The Practice said another doctor then came into the reception to call another patient and Mr B confronted them. That resulted in the doctor interrupting his surgery list to speak to Mr B in his room.

23. The Practice said the meeting ended with the doctor stating that the doctor-patient relationship had broken down, and the doctor did not feel able to continue to look after Mr B.

24. The Practice also stated in their letter detailing that Mr B was being removed from the Practice that since May, Mr B has: • written numerous complaint emails and letters and made numerous phone calls about the same thing • his behaviour has been unacceptable, and he has made continuous false allegations about discrimination and prejudice • tried to manipulate staff by misrepresenting the truth.

25. The Practice also stated it has received several complaints from staff about the way Mr B has spoken to them, refusing to listen to them, and talking over them.

26. The Practice told Mr B it was removing Mr B from the Practice as it is not able to meet his needs and the Practice’s relationship with Mr B has broken down beyond repair.

30. 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 carefully considered this in Mr B’s complaint.

Refusal of tretinoin 31. Mr B complains the Practice refused to prescribe tretinoin and did not make an urgent referral to dermatology services.

32. The Practice explained to Mr B that tretinoin is only prescribed for acne and not licenced for skin changes on the scalp. It then sought advice from a dermatologist who reviewed Mr B’s medical photographs and reiterated there was no prescribable medication for his condition under NHS provisions.

33. GMC guidance states that when providing good clinical care, the investigation or treatment doctors propose, provide or arrange must be based on assessment, and on your clinical judgement about the likely effectiveness of the treatment options. It also says doctors should consult with colleagues and seek advice as required.

34. We asked our adviser if the Practice’s actions were what we would expect to see based on Mr B’s clinical presentation.

35. Our adviser explained when a doctor has a consultation concerning a dermatological condition, the patient must send a photograph to their doctor of their dermatological condition first.

36. Mr B’s medical records show on the same day the Practice spoke to Mr B saying his condition did not look serious and he did not need a prescription for tretinoin.

37. The doctor then sent the pictures to a dermatologist for further advice. Our adviser says these actions were in keeping with what they would usually expect to see.

38. Our adviser explained BNF guidance details that one variant of tretinoin is only prescribed for acne, and another variant is prescribed for acute promyelocytic leukaemia (a blood condition). Mr B did not appear to have these conditions.

39. Based on the information we have seen in Mr B’s records, our adviser’s view and considering the relevant guidance, we have seen the Practice assessed Mr B as we would expect. The Practice sought advice from a relevant specialist and relayed that information back to Mr B.

40. Overall, we are satisfied the doctor’s decision to refuse to prescribe Mr B tretinoin was in line with GMC and BNF guidance.

41. We have seen no indications of failings regarding the Practice’s refusal to prescribe Mr B tretinoin. For this reason, we will not be taking any further action on this part of the complaint.

Conflicting information about a dermatology referral 42. Mr B complains the Practice gave him conflicting information. He says the Practice promised an urgent referral to dermatology, but it had not done this.

43. GMC guidance says doctors should manage resources effectively and sustainably. It also says doctors must make sure they give patients the information they want or need in a way they can understand.

44. Records show on 6 May, the Practice offered to ask for a dermatologist’s advice which Mr B agreed to. It did this promptly.

45. The Practice discussed the dermatologist’s advice with Mr B on 22 May.

46. We cannot see any evidence the Practice offered to refer Mr B for a face-to-face appointment. We can see a referral was made in the sense that it referred Mr B’s images for specialist consideration and input. As we have identified above, this was in keeping with what we would expect to see.

47. We do not dispute Mr B’s account of events, and we recognise he was left with the impression he would be seen directly be a dermatologist. We can see this caused him avoidable distress.

48. Both accounts from the Practice and the Trust show it was clear Mr B knew a dermatologist would consider his skin condition and advise on the next steps. This is what happened.

49. Whilst there was a misunderstanding about how that process would take place, we would not consider this amounted to a failing in the Practice’s communication or a conflict of information. For this reason, we are satisfied the Trust has acted in GMC guidance when communicating with Mr B.

50. As there are no indications anything went wrong, we will not be taking any further action on this part of the complaint.

Removing Mr B from the Practice’s register 51. Mr B complains on 23 September he experienced inappropriate, dismissive, and intimidating behaviour at the Practice resulting in his unfair and incorrect removal from the Practice register on 24 September.

52. The Practice said in its complaint response Mr B’s behaviour on 23 September was unacceptable. He created a disturbance, made threats of legal action, complained about the Practice and interrupted a doctor’s surgery list. It said the doctor felt the doctor-patient relationship had broken down and they felt able to continue to look after Mr B.

53. The Practice also said it has received a number of complaints from staff about the way Mr B has spoken to them, refusing to listen to them, and talking over them.

54. GMC guidelines states that the breakdown of trust between a doctor and a patient means the doctor cannot continue to provide the patient with good clinical care. Examples of this include when a patient us persistent and unreasonable or they have been violent, abusive, or made threats to you or a colleague.

55. Mr B’s medical records show that he was informed on 23 September that there was a breakdown in the doctor-patient relationship.

56. We asked our adviser if the decision was reasonable given Mr B’s presentation. Our adviser explained Mr B’s records show the situation had come to a point where he was clearly unhappy at the Practice.

57. It is also clear form the complaint response the staff were also unhappy overseeing Mr B’s care. On this basis it was reasonable to direct Mr B to a different practice.

58. Considering the guidance, records, and the information we received from our adviser, we are satisfied the Practice acted in line with the GMC guideline when it deregistered Mr B.

59. WE have seen there was a clear breakdown in the relationship, and we consider it was not unreasonable for the Practice to refuse to continue to provide his care. We have seen no indications of failings regarding the Practice’s decision. For this reason, we will not be taking any further action on this part of the complaint.

60. We recognise it was upsetting for Mr B. We hope this explanation gives him reassurances about the Practice’s actions.

Failure to meet with Mr B to discuss his complaint 61. Mr B says when he went to the Practice on 23 September he was raising a verbal complaint about his clinical care. He says he specifically asked to discuss his complaint with the Practice manager, and this was refused.

62. The NHS complaint regulations say, ‘At the time it acknowledges the complaint, the responsible body must offer to discuss with the complainant’. There is no specific guidance that says this should be a face-to-face meeting at the time the complaint is made.

63. The complaint records show the Practice did not offer to meet with Mr B about his complaint. However, we also recognise Mr B had already spoke with a doctor by the point the Practice was formally addressing his complaint. Additionally, the relationship had broken down, and Mr B was clearly very upset.

64. In this case we can see why the Practice may have felt it was not appropriate or necessary to offer a face-to-face meeting in order to address the concerns.

65. We asked our adviser if the Practice’s actions were in keeping with what we would expect to see in this situation, where a relationship has broken down. Our adviser confirmed given Mr B’s recent contact with the Practice at that time, it was not unreasonable that the Practice did not offer a face-to-face meeting about his complaint.

66. Taking account of the guidance, Mr B’s account and the experience of our adviser, we have seen signs the Practice did not act entirely in line with guidance, as it did not offer him a face-to-face appointment. Given the circumstances, we do not consider this unreasonable.

67. Overall, we are satisfied the Practice’s actions in relation to Mr B’s request do not fall so far short of expectations that we would say there is a failing. For this reason, we will not be taking any further action on this part of the complaint.

Conclusion

68. As we have not identified any indications of service failure in Mr B’s complaint, we will not consider it further. We appreciate how disappointing this will be for Mr B. We thank him for bringing his complaint to us and hope our explanation helps reassure him of the Practice’s actions and the care he received.

1. We have carefully considered Mr B’s complaint about the Practice. We are sorry to hear about the very difficult time Mr B experienced when trying to treat the change in appearance on his scalp.

2. We have not seen any indications that things went seriously wrong with the Practice’s assessment. This means we will not be taking any further action at this time.