A practice in the East Riding of Yorkshire area
The Practice improperly removed her from the patient list without proper guidance or communication and dismissed her personal safety concerns despite her vulnerability.
Outcome
The complaint
5. Miss B raises concerns about aspects of the care and service provided by the Practice.
6. Specifically, Miss B complains the Practice:
• removed her from the patient list without following proper guidance or providing appropriate communication in respect of this decision • dismissed her concerns and failed to take appropriate action when she reported a personal safety risk, despite being aware of her vulnerability.
7. Miss B reports that these events caused her significant distress. Most significantly, she says these events led to a worsening of her previous diagnosis of PTSD which is a mental health condition that can develop after someone experiences or witnesses a traumatic event.
8. Miss B also notes that attempting to resolve the concerns around her removal has consumed substantial time. She remains concerned that her incorrect removal remains included in her medical records.
9. Miss B is seeking an apology from the Practice for the distress and inconvenience caused and that her medical record is updated to reflect the situation.
10. Miss B is concerned for others accessing the Practice experiencing a mental health crisis and believes the staff at the Practice would benefit from additional training in respect of communication and safeguarding at times of increased vulnerability
Background
11. Miss B has a number of long-standing mental health conditions, including:
• borderline personality disorder (BPD) - a complex mental health condition that affects how a person thinks, feels, and relates to others.
• anxiety - a feeling of stress, panic or fear that can affect a person’s everyday life physically and psychologically • depression - a low mood that can last a long time or keep returning, affecting a person’s everyday life • PTSD – a mental health condition caused by very stressful, frightening, or distressing events
12. During periods of severe distress, Miss B experiences self-harm episodes, suicidal ideation, and prolonged low mood. In these times, she says she struggles to make sound decisions and often feels overwhelmed.
13. Miss B is under the care of her local community mental health team (CMHT), a psychologist, and her GP.
14. Miss B has a diagnosis of endometriosis. This is an often-painful condition in which tissue that is similar to the inner lining of the uterus grows outside the uterus. At the time of this complaint and for a number of years prior, Miss B has been receiving treatment for this and had regular injections at the Practice.
15. Due to the chronic mental health episodes affecting Miss B, a plan was developed with the CMHT and the Practice which was put in place in January 2023. This noted Miss B was to be offered a monthly appointment to discuss, review and treat the chronic issues she was experiencing. This theory behind this plan was a long term one to assist Miss B in developing tolerance for some of the anxieties she was experiencing.
16. There was a further discussion with Miss B in June 2023 as she was not following the plan, and a Practice meeting also took place to discuss the demands Miss B was placing on the Practice. A plan was then made to offer Miss B monthly appointments to help address her chronic issues and encourage personal resilience.
17. Miss B reports that her relationship with the Practice deteriorated over time. She felt pressured to accept terms of engagement that prioritised the Practice’s interests over her own. She also believes that communication from the Practice was dismissive and challenging, which she says exacerbated her PTSD symptoms.
18. On 20 March 2024, Miss B was informed in writing by the Practice, that due to the breakdown in the relationship she was required to register with another practice and was given eight days to do so.
19. Miss B made a complaint about the Practice’s handling of the removal on 6 February 2025. The Practice responded in writing to this on 4 March 2025. Miss B brought her complaint to us on 10 March 2025.
Our decision
1. We have carefully considered Miss B’s complaint about her removal from the Practice’s list.
2. We have found evidence of failings on the part of the Practice in the process it followed when making the decision to remove Miss B from its patient list, and when communicating this decision. Whilst we have not been able to say this led to a worsening of Miss B’s post-traumatic stress disorder (PTSD), we consider these failings caused her considerable distress. Our final decision is to partly uphold this complaint.
3. We have set out our recommendations at the end of this report. We recommend the Practice writes to Miss B to acknowledge what it got wrong and apologise to her and that it develops an action plan to take learning from the failings identified in this report.
4. We recognise the significant emotional distress Miss B has experienced, and hope this report provides her assurance and fully explains our findings.
Recommendations
69. We make recommendations in line with our Principles for Remedy. These say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services.
70. Our Principles for Remedy are reflected in the NHS Complaints Standards UK which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.
What we found
71. Through investigating Miss B’s complaint, we found:
• The process of removal of Miss B from the Practice was not in line with GMC guidance as we cannot see evidence that the criteria for unreasonable behaviour was met.
• Communication of the decision from the Practice to Miss B does not adhere to GMC guidance as the warning given was not appropriately recorded and Miss B was not provided with a suitable explanation of the potential impact.
• The Practice failed to accommodate Miss B’s well documented vulnerabilities when making and communicating the decision to remove contradicting GMC guidance.
72. What our investigation has informed us is that the failings identified had a cumulative impact on Miss B increasing the risk of self-harm linked to chronic mental health issues. We feel that this would have been better mitigated if the Practice had managed this situation more appropriately in light of its extensive knowledge of Miss B’s medical history.
What the organisation should do
73. Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship.
74. The Practice should write to Miss B to:
• acknowledge and apologise for the impact of the failings we have identified • send a copy of this letter to us within one month of the date of our final report.
75. Our Principles for Remedy also say organisations should look for continuous improvement and learn lessons from complaints to make sure poor service is not repeated.
76. We recommend the Practice: • produces an action plan to address the failings relating to the removal from the Practice, the communication of the decision to remove, and the failure to accommodate Miss B’s vulnerabilities • identify the reason(s) for the failing (where possible) • explain the learning taken and set out what it will do differently in the future (or does differently now) • for each action it should state who is responsible, timescale for completion, and how it will be monitored • share the action plan with us, Miss B, the local clinical commissioning body, and NHS England within three months of the date of our final report.
Other decisions about A practice in the East Riding of Yorkshire area
Decision details
- Reference
- P-005389
- Decision type
- Report
- Jurisdiction
- NHS in England
- Decision date
- 14 May 2026
- Outcome
- Partly Upheld
Complaint summary
- Summary
- The Practice improperly removed her from the patient list without proper guidance or communication and dismissed her personal safety concerns despite her vulnerability.
Source links
- PHSO portal
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Data from PHSO.
Contains public sector information licensed under the Open Government Licence v3.0.