A practice in the East Staffordshire area

6. Mr L complains staff at All Saints Surgery (the Practice) did not assess his son, P, properly and did not prescribe the right medication for him on 1 November. He is also concerned staff delayed providing an adequate response to him when he complained about this. He also told us the Practice did not give reasons for missing a scheduled meeting to discuss Mr L’s complaint.

7. Mr L told us he felt disregarded by the staff member who misdiagnosed his son and had to visit a walk-in centre to get him adequate treatment for his chest infection. Mr L says he was forced to chase information from the Practice for a prolonged period of time which has caused him distress and inconvenience. This has impacted his work and daily life as he has had to spend time chasing emails, making calls and feels emotionally exhausted for trying to advocate for his child’s health. He says he was also affected because he now lacks trust in staff at Practice. He feels if staff handling his complaint had acted professionally and treated his issue with the seriousness it deserved, all this distress could have been avoided.

8. Mr L seeks a formal written apology from the Practice for the complaint handling, delays in responding to him and a lack of transparency. Mr L also seeks service improvements and compensation of £1200 for the distress, time and inconvenience caused to him over a prolonged period.

9. On 1 November P attended an appointment at the Practice. He had a cough and a high temperature. The clinician assessing him advised him to take over the counter medication to treat his symptoms and advised he should return for a further checkup if there were any changes. Mr L said he later visited a different clinician who diagnosed P with a chest infection.

10. Mr L complained to the Practice about this consultation on 4 November. The Practice did not see his complaint as the email went to their spam folder, so there was a delay in acknowledging his complaint. The subsequent communications between Mr L and the Practice continued until June 2025.

15. 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.

16. If we identify an indication something went wrong, we look at the impact this had on the complainant. We then consider whether the Practice has already taken steps to put matters right, and if this goes far enough to address the impact felt by the complainant.

Assessment of P’s clinical condition on 1 November

17. P’s mother took him to the Practice because he had suffered with a cough for two weeks and had a fever. The clinician advised the family to continue to monitor P’s condition and give over the counter medication to him. He also advised that if there were any new changes or concerns, they should call back for further support.

18. Mr L is concerned the clinician performing the assessment had not assessed his son properly because he was later diagnosed with a chest infection by a different clinician.

19. To investigate this element of Mr L’s complaint, we obtained the consultation record of P’s appointment. We then got advice from an independent clinician who reviewed this consultation record. We compared what happened with what should have happened by considering clinical guidance.

20. Our adviser explained P had throat pain, a dry cough and slightly inflamed lymph nodes but his temperature and oxygen levels were normal during the assessment. This showed P had a localised illness, most likely an upper respiratory tract infection (normally known as cold or sinus infection).

21. Our advisor said, from the medical records provided, there were no signs P had a chest infection (a lower respiratory tract infection) at the time of the assessment. Signs of a chest infection include producing mucus in his cough, a high temperature, shortness of breath and chest pain. P did not have these symptoms at the time of the assessment.

22. Our advisor said because P’s condition did not indicate he had a chest infection there was no need for further medication to be prescribed at the time of the assessment. It is also documented the member of staff performing the consultation advised P’s mother to call back if there were any changes or concerns.

23. Our advisor also considered whether the member of staff assessing P followed the correct guidelines and pathways recommended for assessing children aged under 5. Our advisor said clinicians can refer to the NICE traffic light tool in cases like these.

24. This NICE traffic light tool indicates if a child is at low (green), intermediate (amber) or high (red) risk of serious illness. Symptoms which would be deemed ‘low’ risk (in the green category) include responding normally to cues, normal colour of their skin, lips and tongue, moist mucus membranes, stable breathing and no evidence of a high temperature.

25. This NICE traffic light tool outlines the signs to look for if a child is at ‘intermediate’ risk and be in the ‘amber’ category. These signs would include a fever which had lasted over 5 days, not responding to cues normally, having a respiratory rate of over 40 breaths per minute, hearing crackles in the chest or wheezing, dry mucus membranes and reduced urine output.

26. The clinician who assessed P noted in the records that P seemed happy and content in the appointment. They noted the P’s respiratory rate was 28 breaths per minute and observed a ‘good rise and fall’ of P’s chest, with good air entry. The clinician heard no signs of wheezing or crackling in the chest. It is also noted P was passing urine as normal and had normal moist oral ‘mucosa’ (the mucus membrane).

27. Mr L’s son showed symptoms that were categorically all ‘green’ on this clinical tool, so it was appropriate for them to recommend care at home with over-the-counter medication to manage his discomfort.

28. Mr L was also concerned the member of staff who assessed his son should have asked for a second opinion. Our advisor said, according to the NICE guidance and the NICE traffic light tool, the right decision had been made. This was because there were no indications of symptoms which would come under the ‘amber’ column on the traffic light tool, so there was no requirement to ask for a second opinion.

29. Our advisor stated, had there been a mix of green and amber symptoms present at the time of the consultation, it would have been a sign the clinician could consider asking for a second opinion. However, P was showing a localised and non-severe illness so there were no concerns which would raise any amber flags during the assessment.

30. On consideration of the medical evidence and clinical advice provided to us, the clinician assessed P in line with how we would have expected. As there was no indication P had a chest infection, the clinician appropriately did not prescribe treatment for this. We have also seen no indication that the clinician should have referred P for a second opinion.

31. We were sorry to hear Mr L’s son was unwell and appreciate the concern he had for his family’s wellbeing. We understand he raised this part of the complaint with us because he worried staff at the Practice may go on to misdiagnose other patients. We hope we have reassured him that the clinician assessed P appropriately.

Delays in providing an adequate response to his complaint

32. Mr L complained to the Practice on 4 November, raising concerns his son had been misdiagnosed. He sent an email to the Practice and requested a response within 7 days. The Practice acknowledged his complaint 10 days later with an apology, saying his email had gone to the spam folder.

33. The Practice then issued a full complaint response to Mr L by email on 21 November.

34. On 25 November, Mr L complained to the Practice raising further concerns with the response he had received, stating he was unhappy staff would not provide him with a clear timeframe regarding the investigation.

35. On 9 December, he emailed the Practice again expressing similar frustrations and requesting a meeting with the Practice Manager. He warned the Practice he would escalate his complaints to the Clinical Commissioning Group (CCG) and the Health and Care Professions Council (HCPC) and other public forums if he did not get a response within 7 days.

36. We can see records of Mr L, in later months, contacting the Practice with follow-up emails requesting responses to questions about how the Practice ran its daily operations, enquiring about Subject Access Requests (SAR), or updates on timeframes for a response to his queries. He had also raised concerns about access to recordings of a meeting held with an NHS England Manager and recordings of a phone call made by a CQC inspector to the Practice.

37. We reviewed records of correspondence between Mr L and the Practice between 4 November and 18 June 2025. We also reviewed correspondence between a CQC complaints caseworker and Mr L. We could see Mr L had been in frequent contact with the Practice Manager and the CQC regarding complaints handling at the Practice.

38. We know there was a meeting held, at Mr L’s request, to discuss his concerns at the Practice. Further concerns were then raised by Mr L between 14 February and 9 May. Within this timeframe, Mr L contacted the Practice by email 17 times.

39. In considering this aspect of Mr L’s complaint we reviewed the time it took the Practice to provide him with a response when he complained, and the quality of the response.

The time it took to respond to Mr L

40. We can see the Practice did take 10 days to acknowledge Mr L’s first complaint. This is longer than we would generally expect, as the NHS England guidance states ‘you should expect an acknowledgement and the offer of a discussion about the handling of your complaint within 3 working days of receiving your complaint’.

41. The Practice apologised in its acknowledgement email to Mr L for the delay in responding to his complaint. It explained the email had been sent to a spam folder by mistake. The Practice issued a full response on 21 November 2024, which was 7 days after it acknowledged Mr L’s complaint. In this it, again, apologised for the delay and said it had reviewed its email monitoring systems to stop it from happening again in the future.

42. Our Principles of Good Administration say ‘when mistakes happen, public bodies should acknowledge them, apologise, explain what went wrong and put things right quickly and effectively… public bodies should review their policies and procedures regularly to ensure they are effective’.

43. We consider the Practice complied with these principles by acknowledging their mistakes, apologising twice, and updating their policies to increase effectiveness.

44. We have already outlined the scale of responses Mr L required. We can see the Practice acknowledged Mr L’s emails within 3 working days each time, after the initial mistake where Mr L waited 10 days. On 10 December, the Practice responded to one of Mr L’s complaints and explained why a strict 7-day deadline for a lengthier response was not always possible:

‘While we acknowledge your request for a strict seven-day response timeline, we must reiterate that our ability to respond is influenced by our ongoing commitment to prioritizing patient care and access. As previously mentioned, this remains our primary responsibility as a healthcare provider. We understand that this may not align with your expectations, and we appreciate your patience as we work within these constraints’.

45. Importantly, we must also consider NHS England only gives organisations a strict timeline for issuing an acknowledgement email. For full complaint responses, the NHS England guidance states ‘there is no set timeframe for responding, and this will depend on the nature of your complaint’.

46. Our Principles of Good Administration says organisations should: ‘behave helpfully, dealing with people promptly, within reasonable timescales and within any published time limits. They should tell people if things take longer than the public body has stated, or than people can reasonably expect them to take’.

47. We recognise the Practice should have provided an acknowledgement of Mr L’s complaint within 3 working days, according to NHS England guidelines. We can see the Practice did apologise for this delay and this was not a regular occurrence on the other occasions Mr L contacted the Practice. When there was a longer gap, formal responses were being written. When the complaints manager was on leave, staff ensured they continued to provide acknowledgements to Mr L’s emails.

48. The Practice apologised for the error which occurred and ensured it did not happen again. We consider staff have already taken steps to put matters right and we find these steps appropriate and in line with our Principles of Good Administration. We would not expect the Practice to do more in this situation.

49. We understand the frustration and worry the delay in receiving a response caused Mr L. We appreciate he was working hard to advocate for his child whom he was concerned about.

The quality of complaint responses

50. We have considered whether the Practice’s response is in line with our expected standards. The NHS England guidelines state a complainant can expect the following from a Practice: ‘once your complaint has been investigated, you’ll receive a written response. The response should set out the findings and, where appropriate, provide apologies and information about what’s being done as a result of your complaint’.

51. When Mr L submitted a formal complaint, he was provided with a formal written response which addressed key points in his complaint. The response apologised for the delay he had experienced and aimed to address the majority of points Mr L had raised in his written complaint and in phone calls to the Practice.

52. Many of the remaining responses provided by the Practice were giving acknowledgements or receipt of Mr L’s emails or reiterating their stance on an issue. These points of contact were in line with the NHS England guidelines.

53. We can see the Practice was aware the relationship between Mr L and its staff was breaking down and they advised he register his family at a different Practice. Mr L was unhappy with this suggestion.

54. We have reviewed the Practice’s complaint files which reflect on the handling of Mr L’s complaint. We can see the Practice, in an effort to address the fractured relationship, worked with an independent NHS manager to facilitate a meeting which had been requested by Mr L. In this meeting staff reviewed the decision made by the clinician who treated his son and addressed further concerns raised about the Practice in general.

55. Our NHS complaints standards advise organisations to:

‘Identify when issues raised in a complaint should be addressed…via another route at the earliest opportunity, so a co-ordinated approach can be taken…Staff know when and how to seek guidance and support from colleagues on such matters so they can give people information on the relevant process and explain where they can get support’.

56. We consider the Practice’s choice to bring in an independent NHS manager shows it was considering alternative routes to resolve Mr L’s complaints, and that it was aiming to remain impartial in light of its relationship with Mr L breaking down.

57. We can see Mr L was frustrated with the complaints process and the responses he was receiving. It is evident he was seeking answers to rebuild the confidence he had in the Practice’s care for his son.

58. We must be impartial and look at the evidence we have available to us. It is clear the Practice complied with the CQC’s investigation into their complaints procedures and took on their recommendations. We have also seen evidence the Practice has acted accordingly after this complaint and that the steps it took to improve its practise after Mr L’s complaint have been carried out.

59. Taking all of this into account, it appears the Practice has acted in line with our Principles of Good Administration, our NHS complaints standards and the NHS England guidelines.

The Practice did not give reasons for missing a scheduled meeting

60. Mr L and the Practice arranged an in-person meeting to discuss his complaint and concerns. Unfortunately, on the day the member of staff who was due to conduct the meeting was ill and could not attend. The Practice did not make Mr L aware of this cancellation.

61. Mr L was unhappy about this and felt it showed the Practice was not considerate of his time. He told us the Practice never provided reasons for missing this scheduled meeting. After this point, the Practice rescheduled for a different date and organised for the independent NHS manager to be in attendance to conduct the meeting.

62. Our role is to consider the key issues which may have led to the most serious impact. This means we must take a proportionate approach and focus on the issues that have had the biggest consequences for individuals raising concerns.

63. We consider the issue about the Practice failing to give reasons for missing a scheduled meeting would fall into this category. We do not consider it is one of the key issues of Mr L’s complaint which has had a significant impact on him. We can see that while it was clearly inconvenient, he was still able to hold the meeting later with the Practice. Therefore, we will not be considering this point further at this stage.

64. By doing this, we do not intend this to diminish or minimise these concerns, and we recognise that these also formed part of Mr L’s experience and contributed to how he feels

65. We hope our explanation goes some way in reassuring Mr L we have thoroughly considered his complaint. We would like to thank Mr L for giving us an opportunity to consider his concerns and we hope our consideration helps provide some reassurance his son received appropriate care and treatment.

1. We have carefully considered Mr L’s complaint about the Practice. We are sorry to hear about the events Mr L has complained about and recognise he has found his time communicating with the Practice frustrating and time consuming.

2. We considered if staff at the Practice assessed Mr L’s son properly and if the right medication and advice was given on 1 November 2024. In this instance, we found no indications anything went wrong in the treatment and care Mr L’s son received.

3. We also considered Mr L’s complaint about the delay in providing an adequate response to him. We can see he spent a lot of time and energy following this up with the Practice, and with the CQC. In this instance, we have decided the organisation has already done enough to put right the frustration caused by the delay in responding to his complaint.

4. Finally, we considered Mr L’s complaint the Practice did not give reasons for missing a scheduled meeting to discuss his concerns. We know this was frustrating for him. In this instance, we do not think it is proportionate to investigate this matter further.

5. We understand this decision will be disappointing to Mr L. We know he has expressed frustrations with the Practice and has been seeking answers. We do not wish to diminish the impact that Mr L’s experience with the Practice has had on him. We hope the reasoning set out below goes some way in explaining how we have come to this decision.