A practice in the Uttlesford area

7. Miss L complains about aspects of care and treatment provided by the Practice in June 2025.

8. Specifically, Miss L said the Practice:

• did not contact her according to the agreed reasonable adjustment • pharmacist refused to prescribe her diazepam with no GP led clinical input • pharmacist incorrectly told her there was no rationale in her medical records in June 2024 for prescribing diazepam • pharmacist did not provide her any alternative pain relief • refused to provide a record of the telephone call with the pharmacist.

9. Miss L said withdrawal from diazepam and having no alternative pain relief options caused her distress and physical harm. Miss L said this affected her daily functioning. She further said she was forced to ration her pain medication as she feared she would not have any available when the pain became unbearable.

10. Miss L said this issue caused her to lose confidence in healthcare providers. She further said not having access to the call recording from June 2025 impacted her complaint as she could not verify the details.

11. Miss L seeks service improvements and an apology from the Practice.

12. Miss L also complains about the ICB’s complaint handling policy. Miss L said the ICB’s website suggested that she could escalate her unresolved GP complaint to its service.

13. Miss L tells us the complaint handling caused significant emotional distress. She further said the issue made navigating the complaints process extremely difficult and caused a loss of trust in the service.

14. She would like clarity on the ICB’s complaint handling process.

15. In April 2023, the Practice updated Miss L’s medical records to show diazepam is not helpful for her back spasms.

16. In May 2023, the Practice agreed it would put an alert on Miss L’s records that it should not make ad-hoc calls to her.

17. In June 2024, the Practice issued Miss L with a prescription of diazepam.

18. In June 2025, Miss L contacted the Practice via an online form (eConsult) to request a prescription of diazepam and an anti-inflammatory gel, for her back spasms.

19. The Practice sent Miss L a text message to say its Practice pharmacist would call her the same day.

20. Following this, Miss L completed an eConsult saying she did not want the Practice pharmacist to telephone her as scheduled.

21. Later the same day, the Practice pharmacist called Miss L. They said they would not prescribe diazepam. They told her, her medical records showed this was not an appropriate form of pain management.

22. Seven days later, a locum doctor at the Practice prescribed Miss L diazepam.

The Practice did not contact Miss L according to the agreed reasonable adjustment, in June 2025

25. Miss L said the Practice did not follow her reasonable adjustment request when it contacted her in June 2025. She said the Practice called her instead of sending her a text or email. She said this added unnecessary stress to her and worsened her anxiety. She further said she lost confidence in healthcare providers as a result of the error.

26. Miss L told us, in May 2023 the Practice agreed to update her profile with a reasonable adjustment request. This request was for communication to be by text or email. She said this was due to her neurodivergence (people whose brains function, learn, and process information differently from what is considered typical) and post-traumatic stress disorder (a mental health condition triggered by experiencing or witnessing terrifying events).

27. The Practice emailed Miss L in May 2023 to confirm it put an alert on her profile to showing it should not make ad-hoc phone calls to her.

28. Miss L responded to the Practice’s email in May. She asked for her medical profile to show the Practice should not make unannounced calls to her. She added if the Practice is unable to resolve queries by text or email it should send her an email or text message detailing the time it would be calling.

29. In June 2025, Miss L made an online request to the Practice asking for a prescription of diazepam (medication used to treat anxiety, muscle spasms, seizures or fits) and an anti-inflammatory gel.

30. The day after, the Practice sent Miss L a text to alert her the Practice pharmacist would be calling her that day for a medication review.

31. Miss L completed an eConsult shortly after the text, asking the Practice not to make the planned phone call it had scheduled.

32. The Practice made the scheduled call to Miss L to discuss her prescription request.

33. In its complaint response, the Practice said the pharmacist made the phone call to Miss L before it had the opportunity to triage the eConsult form Miss L had sent declining the upcoming telephone call.

34. To support us with our decision making we asked the Practice to provide its policy on triaging eConsults.

35. The Practice provided its Online Consultation (eConsult) Policy Version 2. In section 6 it says non-urgent eConsult requests are triaged within twenty-four hours. The Practice confirmed it updated its policy in October 2025, but the policy was the same in June 2025.

36. We have seen evidence to show Miss L had an alert on her profile ‘patient does not wish to receive ad-hoc calls, if you need to speak to patient, please send a text advising that you will be calling and rough time for call. This is because ad-hoc triggers anxiety’.

37. Based on the evidence we have seen, we consider the Practice had twenty-four hours to review Miss L’s eConsult request asking the Practice pharmacist not to call her.

38. We consider it is realistic for the Practice not to have seen Miss L’s request before making the scheduled call.

39. Our principles of good administration say public bodies should do what they say they are going to do. If they make a commitment to do something, they should keep to it or explain why they cannot.

40. Based on the evidence we have seen, we are satisfied the Practice acted in line with Miss L’s current communication request. We believe this was in line with Practice policy. The Practice made Miss L aware it was going to call her in line with the reasonable adjustment request.

41. We understand neurodivergence means communication methods may need altering to ensure people do not experience barriers when accessing information. We are sorry Miss L experienced distress on this occasion. We thank Miss L for bringing this complaint to us and hope communication with the Practice will be better for her in the future.

The Practice pharmacist refused to prescribe Miss L diazepam in June 2025 with no GP led clinical input and the Practice pharmacist incorrectly told Miss L there was no rationale in her medical records for prescribing diazepam in June 2024

42. Miss L told us the Practice pharmacist called her in June 2025 to discuss her prescription request for diazepam. She said during this call, the Practice pharmacist made the decision not to prescribe her diazepam without undertaking a clinical assessment.

43. Miss L said the Practice pharmacist’s decision not to prescribe her diazepam affected her daily functioning. She further said she was forced to ration her pain medication due to fear of not having any available when the pain becomes unbearable.

44. The Practice said it stopped Miss L’s diazepam prescription in April 2023. It said this was the reason the Practice pharmacist declined the prescription request in June 2025.

45. Miss L said during the telephone call she asked them to check her medical records from June 2024. She said the Practice prescribed diazepam in June 2024, and she did not understand why the Practice would not provide diazepam on this occasion.

46. She further said the Practice pharmacist told her there was no explanation in her medical records for prescribing diazepam in June 2024.

47. The Practice explained it recognised it had prescribed diazepam to Miss L after April 2023. It apologised for the confusion this caused.

48. Miss L’s medical records show the pharmacist left an entry in her medical records in June which said, ‘as outlined by previous clinicians, diazepam was not issued as not suitable for her pain relief’.

49. Miss L’s medical records show she discussed diazepam in April 2023 with a GP at the Practice. The Practice GP explained diazepam was not helpful for her back spasms.

50. We acknowledge Miss L believes she should have had a consultation with a Practice GP, before the Practice pharmacist declined to prescribe diazepam.

51. We got advice from a pharmacist (our adviser) who has 13 years’ experience. Our adviser said in their opinion, the Practice pharmacist acted in accordance with current national guidance and accepted standards of practice.

52. NICE clinical guideline NG59 advises against offering benzodiazepines (prescription drugs that have a sedative effect, used for anxiety and insomnia) for low back pain or sciatica. This is because there is a lack of clinical benefit and risks associated with addiction.

53. Our adviser said prescribing diazepam for back spasms is not consistent with evidence-based guidance and does not represent good practice.

54. We asked our adviser if the Practice pharmacist should have consulted with a GP at the Practice before making the decision to decline the diazepam request. Our adviser said professional judgement is a core requirement of the GPC standards.

55. GPC standards set out pharmacists must use their judgement to make clinical and professional decisions with the person or others.

56. Based on the evidence we have seen, we have not identified any indications of failings by the Practice. We are satisfied the Practice acted in line with NICE clinical guideline NG59 and GPC standards.

57. In addition, GPC standards show us the Practice pharmacist had the authority to make the clinical decision. We are satisfied the actions were appropriate.

58. We recognise the Practice provided Miss L diazepam in June 2024 which is after a GP at the Practice recorded diazepam is not suitable in April 2023. This understandably caused confusion to Miss L. We recognise this confusion may have caused her distress.

The Practice refused to provide a record of the telephone call with the Pharmacist in June 2025

59. Miss L told us the Practice refused to provide her with a copy of the telephone conversation between her and the Practice pharmacist in June 2025.

60. Miss L has told us that not having this evidence had been detrimental to her complaint as she cannot verify her dispute that the Pharmacist told her there was no reason to provide her with diazepam in June 2024.

61. The Practice said in its complaint response it was unable to provide the recording as the Practice pharmacist worked remotely on this occasion in June. It said the recordings were not available.

62. As the Practice did not have a recording policy, we asked the Information Commissioners Office (ICO) for advice on call recordings. We asked if the Practice had a duty to record the call between Miss L and the Practice pharmacist.

63. The ICO told us, data protection law does not dictate whether or not telephone calls should be recorded.

64. We have looked at the ICO’s general data protection regulation guidance, ‘what are the conditions for processing’. This is to help us understand if the Practice had a duty to record the call.

65. It sets out you must be able to justify why processing of this specific data is necessary. It must be reasonable and proportionate, and you must not have more data than you need.

66. GMC guidance ‘making and using visual and audio recordings of patients’ says when making or using recordings you must respect patients’ privacy and dignity, and their right to make or participate in decisions that affect them. This means you must make recordings only where you have appropriate consent or other valid authority for doing so.

67. Having considered the evidence, we are satisfied the Practice acted in line with ICO data protection guidance. There was no reason for the Practice to record the call. For this reason, we believe the Practice acted appropriately when it told Miss L there was no call recording to provide.

The Practice did not provide Miss L any alternative pain relief in June 2025 when the diazepam was refused

68. Miss L told us when the Practice pharmacist declined her diazepam prescription in June 2025, they did not offer her any alternative pain relief. She said this resulted in her being in pain and experiencing worry, as she was not sure when she would be able to get access to alternative pain relief. She also told us she had to ration her existing pain relief which caused further anxiety.

69. In the Practice response it said Miss L needed to arrange an appointment with a clinician at the Practice to discuss alternative pain medication, using the eConsult online system.

70. Miss L’s medical records show the Practice did not provide this advice during the telephone call. Her medical records show the Practice pharmacist issued Voltarol gel (an anti-inflammatory gel) to Miss L on this date.

71. Our adviser told us pharmacists should offer appropriate alternative treatment within their scope of competence or, where this was not possible, clearly outline suitable management options and proactively arrange a review with an appropriate clinician.

72. GPC standards say pharmacy professionals must work with others to make sure there is a continuity of care for the person concerned.

73. They also say pharmacy professionals must recognise and work within the limits of their knowledge and skills and refer to others when needed.

74. The Practice pharmacist issued Miss L an anti-inflammatory gel to help her with her back pain. We have not seen any evidence to show the Practice pharmacist referred Miss L’s care to an appropriate clinician to discuss further pain relief.

75. The Practice did prescribe alternative pain relief for Miss L seven days later.

76. Based on what we have seen, we believe the Practice should have referred Miss L to an appropriate clinician after refusing to prescribe diazepam. This is an indication of a failing.

77. We recognise the Practice did not prescribe Miss L the medication she believed was suitable for her pain management in June. We understand the upset this must have caused. We also appreciate she would have worried she may have to ration her existing supply of diazepam.

78. We use our Principles for Remedy to determine our approach for considering the remedy and outcomes the complainant seeks. Our Principes for Remedy say organisations should apologise about the injustice or hardship stemming from what went wrong. In many cases, an apology is a sufficient and appropriate response.

79. Level one on our Severity of Injustice scale, sets out emotional impact as distress, worry, annoyance and similar emotional impacts, for a period of up to two weeks. As the Practice provided Miss L with an alternative pain relief seven days later, we believe this is a level one injustice.

80. We generally consider an apology to be an appropriate remedy for a level one injustice.

81. We asked the Practice to apologise to Miss L for the distress caused by not referring her care to an appropriate clinician within the Practice. The Practice agreed to write to Miss L with its apology.

82. We appreciate Miss L is also looking for service improvements. When considering this, we noted the Practice corrected its error seven days later and prescribed Miss L pain relief. On this basis and given severity of injustice scale says an apology can be a sufficient response, we consider the Practice has done enough to put things right on this matter.

Miss L also complains about Essex Integrated Care Board’s (the ICB) complaint handling policy. Miss L said the ICB’s website suggested she could escalate her unresolved GP complaint to its service in error.

83. In July 2025, Miss L referred her complaint about the Practice to the ICB. She said in her email to the ICB, the Practice had failed to adequately address the serious concerns she raised.

84. The ICB responded to Miss L saying her only escalation route would be the Parliamentary and Health Service Ombudsman.

85. Miss L responded to the ICB on the same date saying its website stated, ‘if a complaint cannot be resolved directly with the GP practice, patients may escalate their concerns to the ICB for a review.’

86. The ICB responded to Miss L further apologising for the escalation information on its website being incorrect. It said its communication team had updated the wording on its website to reflect the correct process. It confirmed the ICB cannot reinvestigate a complaint that had already been responded to by a provider. The ICB thanked Miss L for raising the oversight.

87. Miss L said the complaint handling by the ICB caused her significant emotional distress. She further said the issue made navigating the complaints process extremely difficult and caused a loss of trust in the service.

88. We can see the ICB’s website sets out, ‘if you want to raise a concern about a GP practice, dental practice, community pharmacy or optician you should contact the service in the first instance. They can quickly access your medical records and the staff involved and may be able to resolve the matter quickly. If you cannot resolve your concerns informally with the service, you can either raise a complaint directly with the GP, dentist, pharmacist or optician, or raise a complaint with the Hertfordshire and West Essex Integrated Care Board, as we oversee these primary care services on behalf of patients locally. Complaints can only be investigated once, by either the provider of the service or the commissioner.’

89. We have been unable to identify the information the ICB detailed on its website when Miss L first raised her concerns about the complaints process information being incorrect. It is possible there was an indication of a failing.

90. NHS Complaint Standards says wherever possible, staff should explain why things went wrong and identify suitable ways to put things right for people. Staff give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.

91. We use our Principles for Remedy to determine our approach for considering the remedy and outcomes the complainant seeks. Our Principes for Remedy say organisations should apologise about the injustice or hardship stemming from what went wrong. In many cases, an apology is a sufficient and appropriate response.

92. Miss L told us she experienced emotional distress due to the incorrect information being shown on the ICB website.

93. Level one on our Severity of Injustice scale, sets out emotional impact as distress, worry, annoyance and similar emotional impacts, for a period of up to two weeks. As the ICB updated the wording on its website to reflect the correct process, we are satisfied it has done enough to put things right.

94. We are satisfied the ICB recognised the issue Miss L raised, apologised and corrected the error in a timely manner. We will not investigate this further.

Conclusion

95. We would like to thank Miss L for taking the time to bring her complaint to us. We do not underestimate how difficult it has been for her to share her concerns with us. We hope our findings help to clarify any information she was unsure about.

1. We have carefully considered Miss L’s complaint about how the practice managed her request for pain relief, and its contact with her in June 2025. We were sorry to her of the distress these issues cause her, at this time.

2. We have agreed some action with the Practice to resolve Miss L’s complaint. We have asked the Practice to apologise to Miss L for the distress caused. The Practice has agreed to do this.

3. We are satisfied that it is appropriate to ask the Practice to acknowledge Miss L’s experience and apologise for the distress caused to her.

4. We are satisfied the Practice contacted Miss L in line with the agreed communication alert on Miss L’s records.

5. We have carefully considered Miss L’s complaint about the ICB’s handling of her complaint. We were sorry to learn this element of Miss L’s complaint added additional stress at the time of her concerns with the Practice.

6. We are satisfied the ICB took appropriate action to resolve Miss L’s complaint locally.