A practice in the Hammersmith and Fulham area

6. Mr P complains the Practice mismanaged his referral for an ADHD assessment between March and June 2024. He also complains the Practice did not handle his complaint appropriately and its responses contain factually incorrect information.

7. He says the Practice’s actions meant that his ADHD assessment, diagnosis, and treatment was delayed. He told us this caused him issues at work as he was not able to access support for one year, and this caused him significant stress which impacted his quality of life. He told us the poor complaint handling caused him a great deal of distress and impacted his mental health.

8. He says that due to this experience, he now has a heightened sense of anxiety surrounding medical processes and he has lost faith in the Practice. Mr P wants service improvements and a financial remedy to resolve his complaint.

9. This very brief background is only intended to place the key events in context, not to provide a full, chronological account of everything that happened.

10. Mr P had a consultation with the Practice at the beginning of March 2024 and discussed the possibility of an ADHD diagnosis. ADHD is a neurodevelopmental disorder where the brain works differently to other people. Mr P completed an ADHD questionnaire following this appointment. The Practice told him it had referred him to an ADHD assessment provider eight days after his consultation.

11. At the beginning of June, Mr P contacted the Practice as the ADHD assessment provider had not received his referral. The Practice sent it 10 days later. The ADHD assessment provider diagnosed Mr P with ADHD in January 2025.

ADHD referral 14. Mr P complains the Practice mismanaged his referral for an ADHD assessment between March and June 2024. He says it failed to send his referral to the ADHD assessment provider in March and caused a further delay when it took 10 days to send the referral in June, when it recognised the initial error.

15. He complains the Practice did not help him resolve the issues with his referral as it did not consider referring him to another provider. He told us it did not liaise with the original ADHD assessment provider to expedite his referral when it realised its delay in sending it.

16. Mr P told us these delays impacted his ability to get support in his workplace in a timely manner which caused him distress. We were sorry to hear about his experience at the Practice and how its actions impacted his work. It is clear from our conversations that this was a difficult time for him.

17. Mr P attended the Practice at the beginning of March to discuss his concerns about his symptoms and the possibility of being assessed for ADHD. The Practice asked him to complete an ADHD questionnaire and return this to it. Mr P completed the questionnaire. Eight days after his original appointment, the Practice told him it had referred him for an ADHD assessment. It gave him the details of the assessment provider it referred him to and asked him to contact the provider directly for information about his referral.

18. At the beginning of June (three months later), Mr P contacted the Practice as the ADHD assessment provider told him it had not received his referral. The Practice sent the referral 10 days later. He had an ADHD assessment with the provider in January 2025, and it diagnosed him with ADHD.

19. In its responses to the complaint, the Practice acknowledged the initial three-month delay in it sending the referral. It explained it had documented that it made the referral, but it did not send in March 2024 due to human error. It said the referral process in place at that time increased the risk of human error and it apologised for this. The Practice apologised for the 10-day delay in it sending the referral in June when the initial error was recognised. It explained it should have prioritised the referral, but it did not.

20. From the information we have seen, it appears something went wrong with the referral as the Practice acknowledged it did not send it when it said it would. Therefore, we have gone on to consider how this impacted Mr P.

21. Mr P told us that when he asked the Practice to refer him for an ADHD assessment in March, he understood the waiting list to be seen was between eight and 12 weeks. Therefore, he thought he would have a diagnosis by May and be able to seek support in the workplace from his employer before summer when it would allocate his workload for the following year. He explained he specifically sought support from the Practice at the time he did, to ensure he had a diagnosis before summer.

22. He told us that when the Practice did not send his referral when it said it did, this delayed his assessment for ADHD and therefore his ability to get support at work. He explained that he did not get his assessment until January 2025 which meant he missed the deadline to get support in the workplace from his employer and he had to wait an additional year until October to receive this. We were sorry to hear that Mr P was not able to get support from his employer before the summer deadline.

23. We contacted the ADHD assessment provider, and it explained its wait times for an ADHD assessment in 2024 was approximately six months. This means if the Practice had sent the referral when it said it would in March 2024, it was highly unlikely that Mr P would have been reviewed in May as he suspects.

24. It is more than likely the ADHD assessment provider would have carried out its assessment around September at the earliest and this would mean Mr P would still miss the deadline to apply for workplace support.

25. Although we can acknowledge the ADHD assessment provider may have diagnosed Mr P with ADHD earlier than January 2025 if the Practice had sent the referral in March 2024, we cannot say it would have diagnosed him before the summer deadline. Therefore, we cannot say with any certainty that the Practice’s delay in sending the referral led to the full impact Mr P claims. It is understandable that Mr P may find this disappointing.

26. We also considered if the Practice should have contacted the ADHD assessment provider to try and expedite Mr P’s referral when it realised its error, or if it should have considered referring him to another provider to ensure an earlier assessment. We are not aware of any guidance that says the Practice should have done this. Therefore, we cannot say its choice to not do this was wrong.

27. We reviewed the information from the ADHD assessment provider and considered the national context of ADHD assessments and its increased demand. Based on this, it is difficult for us to say with any certainty if a referral to another provider or an expedite letter to the original ADHD assessment provider would have impacted Mr P’s wait for an ADHD assessment. This is because we do not know what would have happened had the Practice taken this action. It is understandable that Mr P thinks the Practice should have taken further action to speed up his wait for an assessment and we are sorry we cannot provide any further clarity on this matter for him.

28. Based on the evidence we have seen, it appears the Practice delayed sending Mr P’s ADHD referral on two occasions. Unfortunately, we cannot say this delay led to the main impact Mr P told us about (that he was unable to gain support from work for one year due to the Practice’s actions). This is because we consider the waiting time for an assessment was at least six months and not the two months Mr P believed it to be. This means it was highly unlikely he would have been assessed in May as he hoped.

29. Mr P told us this experience caused him significant distress, and we recognise from what happened, the delay is likely to have caused him some level of additional stress. Unfortunately, modern day living presents people with multiple stressors, and it would be difficult for us to say how much distress in particular this delay for an assessment had on Mr P. We are not dismissing what Mr P told us about the impact the delay had on him, and it is clear the delay was frustrating for him.

30. Our Principles of Remedy say that to put things right, organisations should provide an apology, explanation, and an acknowledgement of responsibility. The remedy should be appropriate and proportionate to the injustice sustained and consider the wishes and needs of the complainant in deciding an appropriate remedy.

31. In its responses to the complaint, the Practice acknowledged and apologised for the delay in it sending Mr P’s initial referral and the 10-day delay in resolving this when it realised this error. It also recognised the difficulties Mr P faced in getting support from his workplace.

32. It explained it can now send referrals electronically to minimise the risk of them being lost or delayed and this also means the clinician can complete the referral themselves, without passing it onto another team (which can cause a delay). It recognised it would have been reasonable for it to contact the ADHD assessment provider and highlight that Mr P had already been waiting for three months when it sent his referral in June 2024. It acknowledged it does not know if this would have impacted his wait time, however, it apologised it did not do this and will ensure this is done for similar cases in the future if needed.

33. Mr P told us he wants service improvements and a financial remedy to resolve his complaint, so we have considered these outcomes alongside our Severity of Injustice scale. The impact of failings we found relating to the ADHD referral, appears to fall into the lower levels of our Severity of Injustice scale. We would expect an apology to remedy the impact that flowed from the failings, which in this case, appears to be distress and frustration. It does not appear the Practice’s actions caused Mr P an ongoing wider impact as we cannot say what appears to have gone wrong led to his main injustice, that he missed the deadline for workplace support because of the delayed referral.

34. Based on the information we have seen, we are satisfied that the Practice has apologised for and acknowledged what went wrong and implemented service improvements to prevent the same thing from happening again, which is in line with our Principles. It appears its actions here remedy the impact on Mr P. For this reason, we will take no further action on this aspect of the complaint.

Complaint Handling 35. Mr P complains about the way the Practice handled his complaint. He says it took too long to respond to his concerns, did not answer all of his questions, and gave him factually incorrect information about what happened with his ADHD referral in its complaint responses. He is also concerned the Practice has not improved its service despite it saying it has.

36. We were sorry to hear Mr P’s concerns about the Practice’s complaint handling. From what he kindly shared with us, it is clear he found his experience and the complaints process very frustrating and time consuming.

37. The NHS complaints standards say organisations should give people a clear, balanced account of what happened based on established facts and be open and honest when things have gone wrong and take accountability for this. The NHS Complaints Regulations say that organisations must provide a response within six months from the day the official complaint was made.

38. Mr P raised a formal complaint to the Practice in July 2024, and the Practice acknowledged receipt of his concerns the following day. In January 2025, he contacted our office for support in getting a response. We contacted the Practice on his behalf in January, February, and June.

39. Following our intervention and 11 months after Mr P raised his formal complaint to the Practice, it provided a response to his concerns in June. He escalated his complaint to the Practice’s second stage complaints process the same month as he was unhappy with its response. The Practice provided a second and final response in July, one month later.

40. It appears the Practice promptly responded to Mr P when he escalated his concerns to its second stage complaints process. However, it took 11 months to respond to his initial complaint. This falls outside of the six-month timeframe in the NHS Regulations. Therefore, it appears that something may have gone wrong here and we will consider the impact of this later in our statement.

41. Mr P complains the Practice did not answer his questions and gave him incorrect information about the timeline of his referral for an ADHD assessment during the complaints process.

42. From the information we have seen, it appears the Practice provided Mr P with the information he requested about his referral in its two complaint responses. It does not appear it missed any questions about this, although we acknowledge the conclusions the Practice reached may not have been those he was hoping to receive.

43. It also appears the information the Practice gave him about timeline of his referral is the same as the information recorded in his medical records. Mr P is concerned the Practice did not send his referral in June 2024 like it said it did. We have seen evidence to suggest that it did email the ADHD assessment provider in June and July. However, we cannot say with any certainty if the referral was included in the email in June or if the ADHD assessment provider received this. We are sorry we cannot provide Mr P with any further clarity about this or reach a decision about what happened here.

44. Based on the evidence we have considered, we are satisfied the Trust followed the NHS complaint standards when it responded to Mr P’s complaint as it gave a clear account of what happened based on established facts, acknowledged it got something wrong when it delayed sending his referral and did not respond to his complaint promptly, and took accountability for this like the standards say it must. Therefore, we have not seen any indication it got something wrong here.

45. Although it appears the Practice followed the NHS complaint standards when it responded to Mr P’s complaint, it appears it did not follow the NHS Regulations when it took 11 months to provide this response. Therefore, we have gone on to consider how this impacted Mr P.

46. Mr P told us the complaints process caused him a great deal of distress and impacted his mental health. He explained that he spent a lot of time chasing his complaint with the Practice. He told us he does not feel reassured by the reasons the Practice gave him to explain why its response to his complaint was delayed, or that it has put service improvements in place to prevent the same thing from happening again.

47. We were sorry to hear Mr P’s concerns about how the Practice handled his complaint and that he does not feel reassured by its service improvements. From our conversations with him, it is clear he found the complaints process very frustrating.

48. Our Principles of Remedy say that to put things right, organisations should provide an apology, explanation, and an acknowledgement of responsibility.

49. We can see the Practice apologised for the delay in responding to Mr P’s complaint. It acknowledged he had to chase the team on numerous occasions and escalate it to our office before receiving a response. It explained this is not the standard it wants to achieve and apologised for his experience.

50. It went on to explain that since Mr P’s complaint, it has undertaken a full review and re-organised its governance team to ensure it consistently meets its deadlines for responding to complaints in the future.

51. The Practice also provided our office with an update on its service improvements. It explained the previous system in place for referrals at the time and how this carried an increased risk of administrative oversight. It told us it has since strengthened its referral tracking and escalation safeguards to reduce the risk of the same thing happening again. Based on our conversations with the Practice, we are satisfied it has implemented the service improvements it told Mr P about, and we hope this information goes some way to reassure him of its actions and commitment to prevent the same thing from happening again.

52. As we explain above, modern day living presents people with multiple stressors and it would be difficult for us to say how much distress the delay in complaint handling in particular, impacted Mr P’s mental health in the way he described. However, we recognise the delay in the Practice responding to his complaint despite his efforts to encourage it to engage with him, would be extremely frustrating for Mr P.

53. Mr P wants service improvements and a financial remedy to resolve his complaint, so we have considered these outcomes alongside our Severity of Injustice scale. The impact of failings we found relating to complaint handling, appears to fall into the lower levels of our Severity of Injustice scale. We would expect an apology to remedy the impact that flowed from the failings, which in this case, appears to be distress and frustration. It does not appear the Practice’s actions relating to its complaint handling, caused Mr P an ongoing, wider impact as it appears it resolved his injustice when it responded to his complaint and provided him with the information he requested.

54. Based on the information we have seen, we are satisfied that the Practice has acknowledged what went wrong, apologised for this and made improvements to prevent the same thing from happening again, which is in line with our Principles. It appears its actions here remedy the impact on Mr P. For this reason, we will take no further action on this aspect of the complaint.

Conclusion 55. Overall, we have seen indications the Practice may have got something wrong when it delayed sending Mr P’s referral for an ADHD assessment on two occasions and when took longer than the six months in the NHS Regulations to respond to his complaint.

56. Although we have seen indications that something went wrong, and the Practice did not consistently follow relevant guidelines when it responded to Mr P’s complaint, we consider it has remedied the impact this caused by apologising, acknowledging what went wrong, and implementing service improvements. We will take no further action on this complaint for this reason.

57. From our conversations with Mr P, it is clear that his experience at the Practice was significantly frustrating for him. We hope our report helps to clarify any information he was unsure about and reassures him of the service improvements the Practice has made following his complaint.

1. We have carefully considered Mr P’s complaint about a GP Practice in the Fulham area (the Practice). We were sorry to hear his concerns about how the Practice managed his referral for an attention deficit hyperactivity disorder (ADHD) assessment between March and June 2024. From what he told us, this has clearly been a significantly frustrating time for him, and his concerns about the Practice’s actions continue to worry him.

2. From the information we have considered, it appears there are indications the Practice got something wrong when it managed Mr P’s referral for an ADHD assessment. Although it appears the Practice delayed sending Mr P’s referral, we have decided that we cannot link this to the full impact he told us about.

3. We have also considered the action the Practice has taken to remedy this part of the complaint. We are satisfied it has acknowledged what happened, apologised for what went wrong, and improved its service to prevent the same thing from happening again. Therefore, we have decided to take no further action on this part of the complaint for this reason.

4. Mr P also complains the Practice handled his complaint poorly. We have considered his concerns, and it appears the Practice did not consistently follow relevant guidelines when it managed his complaint. We considered the action the Practice has taken to remedy this part of the complaint, and we are satisfied it has acknowledged and apologised for what went wrong. Based on this, we have decided to take no further action on this complaint.

5. We recognise how important this complaint is to Mr P, and we would like to take this opportunity to thank him for bringing his complaint to our attention. We hope our explanations below show how we have considered this complaint and reassure him of the actions the Practice has taken in response to his concerns.