A practice in the Southwark area

3. Miss J complains about aspects of care provided by the Surgery. She specifically complains that:

• staff failed to action an urgent psychiatric assessment as requested by a hospital consultant • staff uploaded untrue, hurtful and damaging information onto the NHS app (a codeine overdose was uploaded as a cocaine overdose) • staff did not issue her with the medication she needed (Miss J states that she had to go and request them personally each time) • staff made negative, upsetting and untrue comments to Miss J via telephone calls.

4. Miss J also complains about the conduct of the manager at the Surgery. She states they have been unprofessional during this time and has never taken her concerns seriously.

5. Miss J says that her mental health has been damaged by the ongoing difficulties and that they are currently housebound. She states that she no longer takes her health complaints to the Surgery and her anxiety can become extreme when having to request medication due to prior difficulties. Miss J also states that the errors in her NHS record (a codeine overdose being recorded as a cocaine overdose) has caused her emotional distress, primarily due to humiliation, anxiety and exhaustion. Miss J also claims that this has caused her reputational damage and impacted her relationships with care workers and healthcare providers.

6. Miss J would like to achieve a sincere apology from the Surgery and the current manager. She would like them to take accountability for their actions and acknowledge the harm caused to her. She would like a full, independent investigation to take place into the conduct of the surgery and further training to be given based around patient care and dealing with complaints effectively. Miss J is also seeking a financial payment of between £10,000 and £12,000.

7. What follows is a summary of the complaint components we have not included all the details as both parties to the complaint are aware of them.

8. Miss J joined the Surgery as a patient in 2022.

9. New medication (mirtazapine) was issued by the surgery on 21 May 2024. This occurred after the current prescription had finished, Miss J was unable to get anymore.

10. The Surgery explained they had never prescribed it to Miss J.

11. Miss J makes an initial written complaint to the Surgery on 13 February 2025.

12. Miss J also raised the same issues to the complained to the South East London Integrated Care Board on 13 February 2025 (not part of this investigation)

13. A complaint response from the Surgery was provided to Miss J.

14. The South East London Integrated Care Board responded to the complaints brought by Miss J on 29 September 2025.

15. There was a five-day period in which the Surgery needed to reply, although that reply was never received by Miss J.

16. Miss J formally write to the Parliamentary and Health Service Ombudsman on 1 October 2025, expressing her wish to make a complaint.

17. Miss J makes her complaint to the Parliamentary and Health Service Ombudsman on 28 October 2025. Further notes relating to the case were sent on 4 November 2025.

20. For any complaint the Ombudsman receives, the HSCA states the Ombudsman must first consider if there is a legal route to achieving the remedy sought.

21. This is contained within section 4(1)b of the act which states the Ombudsman shall not investigate if there is a remedy by proceeding the complaint through any court of law.

22. Further to this, the HSCA states that the Ombudsman must be satisfied that in considering the personal circumstances of a complainant it is not reasonable to expect the complaint to legal proceedings.

23. This translates into our own policy referred to as a ‘two stage legal test’ that we must look at before any consideration of a complaint. The two stages being is there a legal route and is it reasonable for the complainant to pursue?

Is there a legal route?

24. From talking to Miss J, we recognise the strength of feeling that she considers negligence has occurred and is seeking a significant amount of financial redress up to and around £12,000 as well as mixed outcomes. Miss J states that her mental health has been impacted greatly by these events, and she constantly feels that The Surgery are not taking any care of her.

25. We recognise on occasions through the determination of a court explanations and apologies can be a byproduct.

26. We considered the other outcomes Miss J seeks. We note under the NHS Complaint Guidance of 2013 and the Complaint Standards of 2021 a senior person will be responsible for handling a complaint and the NHS does not operate providing personal apologies form specific named people. Therefore, we would not pursue that aspect as a remedy point.

27. In reaching our view, we consider if a complaint has an alternative legal remedy in reaction to their complaint, based on the remedy they are seeking, one that a court could reach determination on.

28. We consider Miss J does have a legal route (though we are not reaching a view on the success of a claim). This is because financial redress is significant and wide-ranging amounts can be made as a binding determination through the courts if negligence is found and upheld. We also recognise that as a biproduct of court, a recognition of harm and apologies can sometimes be provided. An improvement of standards can also be achieved.

Is it reasonable to pursue a legal claim?

29. Next, after establishing there is a legal route, we have gone onto explore with Miss J if it is reasonable for her to pursue.

30. When considering reasonableness, the factors we take into account are based on the individual circumstances of a complaint such as (though not an exhaustive list of considerations): if the costs are proportionate to the legal claim; if financial means to pursue a claim are in place; how long legal proceedings may take; the age and health circumstances of the complainant; if there are any other circumstances which may impact on this.

31. On 3 June 2026, we spoke to Miss J to understand the complaint, the injustices she says she has faced resulting from her experiences and whether legal action would be reasonable for him to pursue.

32. Miss J made it clear during this call that she does not really want to go down the legal route, but she is prepared to if necessary. From the call we note there is a sense of willingness from Miss J to explore this avenue.

33. Miss J stated that a friend has given her the number of a clinical negligence lawyer, although Miss J has not contacted a lawyer yet.

34. During these discussions, we were not made aware of any other surrounding circumstances or reasons which leads us to consider it unreasonable to pursue a legal route.

35. In summary, we consider it is reasonable for Miss J to pursue a legal route as we have not been made aware of any other present factors that may cause us to doubt this reasonableness.

In summary

36. The law says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider this is (or was) unreasonable in the circumstances. We have engaged with Miss J to understand her outcomes and if reasonable to pursue a legal route.

37. In do so, we recognise Miss J’s claimed injustice is clinical negligence and her impact is a significant deterioration in her mental health. She has told us she is seeking between £10,000 and £12,000 in compensation and we recognise her other remedies, an investigation and apology, may also be achieved as a biproduct of a court. Therefore, we consider there may be a legal route.

38. We recognise the claimed impact this has had on Miss J, not just her care but the claimed impact on her mental health as a result of incorrect information being attached to her NHS profile and the issues with obtaining her medication. We note (informed by our own policy section 2.298) that Miss J can return to us with any outcomes not achieved through the courts afterwards, that in doing so, we strongly advise Miss J pursues matters as there are time limits to the Ombudsman considering complaints (details can be found here https://www.ombudsman.org.uk/making-complaint/what-we-can-and-cant-help)

39. For the reasons we have provided, we shall take no further action on the complaint as an alternative legal route exists and it is reasonable to pursue.

1. We have carefully considered Miss J’s complaint about the Surgery. We are sorry to learn of her concerns regarding her issues obtaining assessments and medications, as well as the difficulties of incorrect information being placed on her NHS record and staff being unprofessional towards her.

2. We recognise the emotional and mental pain Miss J told us she battles with every day and how this has affected herself and those she cares for. In speaking with Miss J, we consider she could take legal action on the matter she has brought to us, and it is reasonable for her to do so.