A practice in the Somerset area

4. Miss T complains the Practice:

• refused - on multiple occasions from late 2024 - to carry out blood tests required by her consultants before scheduled hospital appointments • refused to send her for iron transfusions between 2023 to 2025 • in line with National Institute for Health and Care Excellence (NICE) guidelines, failed to carry out blood tests while she was taking Levothyroxine medication • refused to add her as a patient to the Practice’s Complex Medical Care Team (CMCT) • denied some repeat prescriptions • failed to respond to her complaint.

5. Miss T says the Practice’s refusal to carry out necessary blood tests prevented her various specialists in secondary care from having up to date blood test results, which delayed them in providing advice. She says she was therefore unaware of her up to date kidney and heart performance, causing her to fear she may have a heart attack and die if she tried to do too much to improve her mobility.

6. She explains there has been a serious decline in her kidney function since 2025, which she believes could have been prevented with regular blood testing. The lack of testing and a two-year delay in receiving iron transfusions caused worsening anaemia, severe fatigue, heart issues, frequent falls, and a leg injury that took two years to heal. These falls left her bruised, scared to stand, and lacking confidence in mobility. To manage, Miss T says she had to purchase an expensive chair to help her get up after falls.

7. Denying her some repeat prescriptions caused her inconvenience and distress in having to contact the Practice when this happens and concerns if it does not prescribe the required medication.

8. Being denied access to the Practice’s CMCT delayed essential specialist care, including a late transient ischemic attack (TIA) referral that prevented tests for temporary vision loss. She says this left her fearful, believing she might have had a stroke or could experience another, which she found distressing.

9. Miss T believes the Practice’s actions resulted in her lifespan being lessened by a considerable number of years.

10. As an outcome, Miss T would like the Practice to acknowledge what went wrong and why, make service improvements to minimise the risk of this happening again and to review its decision of refusing to add her to it CMCT, as well as pay her a financial remedy.

Blood tests

15. Miss T complains the Practice:

• refused - on multiple occasions from late 2024 - to carry out blood tests required by her consultants before scheduled hospital appointments • in line with the NICE guidelines, failed to carry out blood tests while taking Levothyroxine medication (thyroid hormone).

16. We have carefully considered the information provided to us by Miss T and the Practice. Although we consider Miss T had opportunity to do so, there is no evidence she raised any of these complaints with the Practice.

17. In health cases, section 4(4) and (5) of the HSC Act 1993 prevents us from conducting an investigation unless we are satisfied the complaints process has been used and exhausted, or it was not reasonable to expect the complainant to have done so.

18. In line with the HSC Act, we cannot investigate this aspect of Miss T’s complaint. This is because there is no evidence she raised this with the Practice and gave it opportunity to respond. Her complaint is not yet ready for us.

19. The HSC Act 1993 (Section 9(4)) also says we cannot accept a complaint if it is made more than a year after the day on which the person aggrieved first had notice of the matters in the complaint, unless we consider it reasonable to do so.

20. Even if Miss T raised this with the Practice now and brought her complaint to us, it is more than likely we could not investigate. This is because the complaint is outside of the statutory time limit time for us to investigate, in line with the HSC Act 1993.

Iron Transfusion

21. Miss T complains the Practice refused to send her for iron transfusions between 2023 and 2025.

22. Miss T refers to a letter and an online message she sent to the Practice in early and mid-November 2023 regarding an overdue iron transfusion. She says this transfusion was denied time and time again by the GP over many years (2023 to 2025). She explains the GP said this was because she did not meet the required criteria, despite her having received transfusions annually prior to him becoming her GP. She says this formed part of her continuing complaint made to the Practice in early February 2025.

23. The HSC Act 1993 (Section 9(4)), says we cannot accept a complaint if it is made more than a year after the day on which the person aggrieved first had notice of the matters in the complaint, unless we consider it reasonable to do so.

24. We have carefully considered Miss T’s date of knowledge – that is, when she became aware she had reason to complain.

25. Miss T explains she first wrote a letter to the Practice in early November 2023 about being misled into believing the Practice had made a referral for her to have an iron transfusion. In mid-November, she says she sent a message via the Practice’s online GP system as further proof. She says there are numerous requests for iron transfusions during this time. She says she never received a response to this complaint from the Practice.

26. Miss T sent us a letter she sent to the Practice dated early November 2023. Within this letter she complains about the Practice not making a referral for an iron transfusion to the haematology team.

27. We are of the view Miss T’s date of knowledge is early November 2023.

28. The available evidence from Miss T and the Practice shows she raised a further complaint to the Practice in early February 2025, via its online form. However, there is no reference to her complaint about the Practice’s refusal to refer her for iron transfusions.

29. Miss T did not raise this complaint within her complaint form to us in mid-April 2025 nor during our introductory call in early February 2026.

30. The first time Miss T raised this as a complaint was within an email to us in late February. We consider it has taken Miss T two years and three months to bring her complaint to us - one year and three months outside of the statutory time frame.

31. For us to move the time limit to one side we must be satisfied the explanation given for the delay is reasonable.

32. We asked Miss T why there was a delay in raising this complaint with us.

• Miss T says in approximately 2021, after being discharged from hospital, she says she had to learn to walk again and spent many months learning to speak coherently and form sentences again. She says making a complaint to us was not at the top of her list at this point in her life.

• Miss T explains that as the Practice was new, she believed it was only fair and reasonable to allow the new staff time to familiarise themselves with her medical complexities and the new systems being introduced.

• She says she did call and report this matter to us, and that we advised her to continue to liaise with the Practice at this time.

• Miss T explains she tried complaining regarding the same matters to the Practice in August 2024. She says the Practice advised her it would send her a complaint form for completion.

• She says she been promised on multiple occasions by the Practice that her complaints made would be addressed and that its Practice Manager (PM) would contact her to discuss. The PM did not call or write.

• Miss T says she discovered on the Practice’s website in January 2025 there was an online complaint form and a dedicated complaints manager. She says she thought it only fair and reasonable to contact them about her complaint which she then did in early February 2025.

• Despite writing to the Practice, Miss T got no response. She then wrote to the local integrated care board (ICB), but the ICB was unable to get a response from the Practice and so she brought her complaint to us.

33. The onus is on the complainant to make enquiries (with the organisation – in this case the Practice) when they are unhappy with the care and treatment they receive or think they should be receiving. Raising this as a complaint brings it to the attention of the organisation and allows it the opportunity to address the issue and if appropriate offer a suitable resolution.

34. We note Miss T raised a complaint with the Practice in November 2023. On receiving no response from the Practice, we consider she had the ability and opportunity to bring the complaint to us.

35. The evidence shows she raised formal complaints with the Practice in August 2024 and February 2025 but did not raise again her complaint about iron transfusions.

36. Miss T first contacted us in mid-April 2025, sending us her completed complaint form. However, this did not refer to her complaint about iron transfusion, but about another matter.

37. The first time Miss T asked us to look into the complaint about iron transfusion was late February 2026.

38. The Practice’s Complaint Procedure explains that if the complaint cannot be resolved, the person has the right to bring their complaint to us. Our website explains there is a 12-month time limit for making a complaint to us.

39. Miss T brought another complaint to us, about an unrelated matter, in 2021. She therefore knew about our services and more than likely knows about our time limits.

40. We are not persuaded there was any significant barrier during the majority of the time between the date of knowledge and the point she came to us. We recognise the Practice did not respond to her February 2025 complaint and has been unresponsive in the past, which might have contributed to some of the delay. Although we acknowledge the experiences she was going through may cause some delay, we are not satisfied the total length of time taken in bringing the complaint to us is reasonable for us to move the statutory time limit to one side. We cannot investigate this complaint any further.

Complex Medical Care Team (CMCT)

41. Miss T complains the Practice refused to add her to the Practice’s CMCT, saying she is too young. The Practice never responded to this specific complaint.

42. During our primary investigation, we asked the Practice for a copy of its policy. It explained that it does not have a policy relating to complex care. This is a Practice initiative and is not a contractual requirement. It provided us with some general criteria, for example that a patient must be 70 years or above, frail/palliative care, multimorbidity.

43. Our adviser said it is for the Practice to decide if it adds a patient to the CMCT. There are no standards or guidance applicable as it is a practice-level initiative.

44. We are sorry to learn of Miss T’s complaint and the impact she says this caused. The CMCT is the Practice’s initiative. As there are no relevant standards or guidelines, we cannot say the Practice should have placed her on its CMCT. The Practice could have placed her on CMCT, but there was no requirement for it to do so. We therefore cannot say there is a failing.

45. Miss T says being denied access to the Practice’s CMCT delayed essential specialist care, including a late TIA referral that prevented tests for temporary vision loss. She says this left her fearful, believing she might have had a stroke or could experience another, which she found distressing. Miss T believes the Practice’s actions resulted in her lifespan being lessened by a considerable number of years.

46. Even if the Practice should have placed Miss T on its CMCT, our adviser said we cannot reasonably link this to Miss T’s claimed impact. The Practice needs to provide essential medical care to all its patients as per its NHS contract. Being added to the CMCT would not affect Miss T’s ability to receive essential medical care such as being referred to a TIA clinic if she had symptoms of a TIA.

47. The records show the optician made the referral to the TIA clinic. Because of this the Practice did not need to make the referral. Even if the Practice should have placed her on the CMCT there is no evidence this would have delayed a referral to the TIA clinic.

Repeat prescriptions

48. Miss T complains the Practice denied some repeat prescriptions – from late 2024, for example clotrimazole (antifungal medicine).

49. Miss T feels it is a constant battle to get the medications she requires on repeat prescription. She refers to the first letter she sent to the Practice Manager (PM) about this in late August 2024, followed by a further letter sent the following day, and an email chain with the Practice which she said ended abruptly with no outcome. The Practice did not respond to this complaint.

50. The medical records show that in late August 2024 the Practice sent Miss T a message advising it would no longer prescribe clotrimazole and so she would have to purchase this over the counter.

51. Our adviser said this is a treatment for thrush which Miss T had recurrently, she was previously treated with fluconazole by mouth, and this was stopped in early August due to concerns about interactions with other medication she was taking. Thrush can affect different areas of the body. Our adviser cannot tell from the records provided which area was affected for Miss T for certain, but it is most likely to have been vaginal thrush.

52. The relevant guidance is NHS: Policy guidance: conditions for which over the counter items should not be routinely prescribed in primary care. This provides details of conditions for which items available over the counter should not be routinely prescribed in primary care. Our adviser said oral thrush is included, however thrush elsewhere, such as vaginal thrush is not.

53. Miss T had type 1 diabetes, which predisposes her to thrush infections.

54. Our adviser said it was not in-line with NHS policy guidance for the Practice to decline Miss T prescriptions for thrush, as she was predisposed to it due to her diabetes, and she had it recurrently.

55. However, despite the Practice’s message in late August, the Practice did email Miss T a few days later explaining it had prescribed clotrimazole five days before. This is corroborated in the prescription history, which indicates the Practice continued to prescribe this medication.

56. Our adviser said the prescription history shows the Practice did continue issuing clotrimazole, but they cannot tell if it issued it every time Miss T requested it, as requests do not show in the medical records.

57. We recognise Miss T’s complaint that the Practice denied her clotrimazole prescriptions. We have carefully considered Miss T’s account, the communication between her and the Practice, the medical records and clinical advice. Although the Practice initially refused to prescribe clotrimazole (SMS message in late August), the evidence indicates it did prescribe the medication on the same day and did continue issuing clotrimazole when requested. We cannot say there is an indication of a failing nor can we say Miss T’s care was adversely affected because of this.

Complaint handling

58. Miss T complains the Practice failed to respond to her complaint. She explains that all her complaints made by her in writing, email, telephone or hand delivered have never been fully responded to. She says despite having a policy for complaints, it shows how little regard the Practice has for its own policies.

59. The relevant guidance is Regulations 2009. This explains the responsible organisation must acknowledge the complaint within three working days of receipt, and during the investigation must keep the complainant updated.

60. Regulations 2009 goes onto to say that the responsible organisation must send the complainant a written response within six months of the date the complaint was received.

61. Miss T made a complaint to the Practice in February 2025. Despite communication from her and escalation from us between February to September, there is no evidence the Practice responded to her complaints, in line with Regulations 2009. This is an indication of a failing.

62. Having seen an indication of a failing, we next looked at whether this had a negative impact on Miss T, and, if so, whether the Practice has put things right. We do not normally progress a complaint to detailed investigation where we consider appropriate action has been taken to put things right or if we cannot link the impact to the failing.

63. We recognise this lack of response caused Miss T distress at an already difficult time.

64. Our Principles explain that where there have been failings leading to an injustice, the public organisation should offer a remedy that returns the complainant to the position they would have been in, if the failings had not happened.

65. During our investigation, the Quality Improvement Lead at the Practice provided details about its complaint process. They explained that prior to late 2025, complaints were generally received via email and correspondence may have been exchanged across several different mailboxes.

66. Prior to the above, towards the end of 2024, the Practice introduced a new website that allowed patients to submit complaints online. The Quality Improvement Lead said that unfortunately, this function was not configured correctly by the website supplier, which resulted in several complaints remaining unacknowledged. They have since reviewed these cases personally and have made contact with patients who submitted complaints through this route.

67. The Quality Improvement Lead took over responsibility for patient contact in August 2025. They acknowledge the complaints process prior to this was not as robust as it should have been. They explained that in November 2025, they restructured the way the Practice processes patient communication, particularly complaints. These are now logged and managed through a portal, which enables them to record incoming correspondence, assign actions, track and monitor progress of complaints on a case-by-case basis.

68. The Practice has acknowledged that complaints have not been as robust as they should have been and have carried out suitable service improvements in line with our Principles.

69. Miss T has requested a financial remedy. This relates to the complaint as a whole, which includes the more serious claimed impact regarding clinical matters. If we look at complaint handling in isolation, we consider the actions the Practice has carried out to date do meet our Principles, and so we are not going to take any further action.

70. We are sorry to learn of Mr T’s complaint about the Practice. Our primary investigation decision is not made without recognition of the impact her concerns have had, and we are sorry if our decision causes any further upset. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it.

1. We are sorry to learn of Miss T’s experiences with the Practice. We acknowledge the difficult circumstances around this complaint, and the impact this is having. We acknowledge this was and continues to be a difficult time for Miss T.

2. We have carefully considered the complaint about the Practice. Having done so, and for the reasons set out in this statement, we have decided not to investigate this complaint further.

3. Our decision is not made without recognition of the distressing circumstances around the events.