A practice in the Blackpool area

5. Mr Y has several complaints about the care and treatment he received from the Practice between September 2023 and April 2024. He says it did not make adequate attempts to contact him regarding results from an ECG and ankle X-ray and lied about leaving messages on his answering machine regarding this. He also says the Practice reduced the frequency of his medications and did not tell him beforehand.

6. He also says the Practice inappropriately documented the word suicide in his notes and did not respond to emails he sent in April and May 2024. He also says the Practice contacted him via an online system despite being asked not to.

7. Mr Y says the impact of these events is he has been to make him feel belittled, humiliated and condescended. Mr Y says he has autism, and the change to medication has been unwelcome and problematic. He states that receiving unsolicited messages have disrupted his daily routine and caused him unease.

8. By bringing his complaint to us Mr Y is seeking: • financial compensation in recognition of the distress and inconvenience caused • a formal letter of apology that demonstrates empathy, acknowledges the distress caused and reflects genuine accountability • service improvements, particularly in the areas of transparency and communication.

9. In September 2023 Mr Y had an ECG. Two weeks later the Practice tried to contact him on the phone to discuss results but was unsuccessful. It sent a letter to Mr Y the same day asking him to contact the surgery to discuss his results. Mr Y received the results during a consultation in April 2024.

10. In February 2024 Mr Y visited the Practice in distress at the death of his mum and told staff he had lost the will to live. Five days later he spoke to a doctor at the Practice and said he had no suicide intent or plan but that he “did not want to be here”. He said he did not want any input from the mental health team or bereavement counsellor. The same day, the Practice signposted Mr Y to a therapy and counselling service to refer himself for counselling.

11. In February 2024, Mr Y collected his prescriptions and found them to have been limited to two weeks. Mr Y told the Practice this caused him distress as he is autistic and any change to his routines are unwelcome.

12. In early March 2024, the Practice sent Mr Y a message saying it thought a message had been sent to him via the Pharmacy team about the plan regarding two weekly prescriptions and apologised that it did not reach him.

13. In mid-March 2024 the Practice received a call from the funeral home to say Mr Y had collected his mother’s ashes and had been talking about suicide.

14. In late March 2024 Mr Y had an X-ray of his right ankle with results reported two days later. The results say Mr Y was to have a telephone appointment within one month. An appointment was booked for 23 April 2024, but Mr Y did not attend.

15. Two days later, Mr Y completed an eConsult asking to speak to a doctor about the results of his ECG and ankle X-ray. The same day the Practice tried to call Mr Y and left a message for him to make a routine appointment to discuss his results.

16. Following this Mr Y had an appointment to discuss the ECG and X-ray results. He had a follow up ECG in June 2025.

The Practice did not take appropriate steps to contact Mr Y with the results of an ECG and ankle X-ray The Practice said it left multiple messages for Mr Y

20. 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. We have done this and have not found any indications that something has gone wrong.

21. In early September 2023 Mr Y had an ECG. Two weeks later the Practice tried to contact Mr Y on the phone to discuss results but was unsuccessful. The Practice sent a letter to Mr Y the same day asking him to contact the Practice to discuss his results. Mr Y told us he received this letter but events in his life at that time put the subject to the back of his mind.

22. In March 2024, Mr Y had an ankle X-ray done which showed mild degenerative changes (expected wear and tear over time). Mr Y could not attend an appointment scheduled in April 2024 to discuss results. We have seen in Mr Y’s records the Practice left a message on his answerphone for him to contact the Practice to schedule an appointment.

23. Mr Y contacted the Practice via email to make an appointment to discuss the results and the Practice tried calling him to arrange this and left a voice message. Mr Y then went into the Practice to arrange this but ultimately made a complaint and did not arrange an appointment.

24. The GMC guidance says doctors must give patients the information they want or need in a way they can understand including information about their condition(s), likely progression, and any uncertainties about diagnosis and prognosis.

25. The guidance does not set out a specific number of times a Practice should contact somebody to try to give them results.

26. Our adviser said the Practice followed the normal channels for attempting to share results with Mr Y, including calling him, and then either leaving a message or writing to him asking him to make an appointment when they could not get hold of him. Our adviser said a patient also has the responsibility of their own health and should communicate and respond back to the Practice to discuss their results.

27. We have seen the Practice made attempts to contact Mr Y to discuss his results and when this was unsuccessful, it asked Mr Y to contact it to make an appointment at his convenience. We consider this is in line with the GMC guidance as the Practice attempted to give Mr Y the information he wanted/needed to know. Therefore, we have not seen any indication of failings for this aspect of the complaint.

28. Mr Y also complains that the Practice has lied about leaving messages on his answering machine during this time.

29. As above, in late September 2023, the Practice tried to call Mr Y with the results of his ECG but could not reach him so the Practice sent him a letter. In its complaint response to Mr Y, the Practice said it left messages for Mr Y on multiple occasions to ask him to return calls or arrange necessary appointments. This comment was in relation to several attempts to contact Mr Y over a period of time and not just regarding his ECG results.

30. Looking at his records in general, we have seen the Practice tried unsuccessfully to contact him by phone seven times between August 2023 and November 2024. Six out of the seven times, a message was left on Mr Y’s answer phone, and on one occasion a letter was sent to him instead. During the period referred to here, September 2023 to April 2024, the Practice have documented that it called Mr Y four times and left a message on three of those occasions and on one occasion a letter was sent to him instead.

31. The GMC guidance says staff should take steps to meet patient’s communication needs. Mr Y had stated a preference for contact by telephone, and we can see the Practice followed this as per the GMC guidance. When it was not possible to speak with Mr Y, it is documented in Mr Y’s records that the Practice left messages for him.

32. We have seen no reason to doubt the legitimacy of the Practice’s records. As such, we consider the Practice did leave messages on Mr Y’s answer phone. We are therefore unable to see any indications of failings for this aspect of the complaint.

The Practice reduced the frequency of his medications and did not tell him beforehand

33. In late February 2024, the Practice reduced the frequency of Mr Y’s medications due to being worried about his mental state following the death of his mother. Mr Y does not think this is a valid reason. He also states he is autistic and the change to medication has been unwelcome and problematic.

34. In late January 2024, the Practice received a message from the hospital Trust where Mr Y’s mum had recently died. This message asked the Practice to assess Mr Y as he had alluded to wanting to end his own life to staff on the ward. In February 2024 Mr Y told the Practice he had lost the will to live after the death of his mother.

35. In late February 2024, the Practice reduced the frequency of medications in Mr Y’s prescription. The Practice then began inviting Mr Y to structured medication reviews. When Mr Y complained to the Practice about this and requested they be returned to the previous frequency, the Practice told him this would need to be done with careful monitoring, observation and regular reviews with his cooperation.

36. The NICE depression guidelines advises for anyone suffering with a low mood or loss of interest/enjoyment in ordinary things, limiting the amount of medication available to a person to reduce the risk of death or medical complications if taken in overdose.

37. The GMC prescribing guidance states clinicians must use clinical judgment when making decisions about medication changes. This includes decisions about frequency and structured medication reviews and includes considering a patient’s history and relevant psychological factors.

38. Our adviser said it was appropriate based on the clinical picture at the time for the Practice to reduce Mr Y’s medication. Our adviser said structured medication reviews are part of safe prescribing and therefore it was appropriate for the Practice to implement these at this time.

39. We can see this was a very difficult time for Mr Y, and he communicated to the Practice he was experiencing low mood following the death of his mother.

40. We have seen that in response to this, the Practice followed the NICE and GMC prescribing guidance in reducing his medication frequency. It considered how best to prescribe the medication Mr Y required while ensuring that decisions were made to keep him safe and support him in line with clinical judgement at the time. Therefore, we have not seen any indications of failings for this aspect of the complaint.

41. Mr Y also complains that he was not told about the change in medication.

42. When the Practice reduced the frequency of Mr Y’s medication, it sent a message to the pharmacy team to relay this to him. Unfortunately, this message was not relayed, and Mr Y received no warning of a change to his medication frequency.

43. As above, the GMC guidance says patients should be given the information they want or need to know. It also says that the patients’ understanding of the information they’ve been given should be checked.

44. As the Practice did not communicate with Mr Y about his medication change and did not check that he understood the reasoning for this, we do not consider this is in line with the GMC guidance and is an indication of a failing.

45. Mr Y said he is autistic and this change to his medication was unwelcome and problematic. He says he has tried to explain this to the Practice but to no avail.

46. In early March 2024, the Practice apologised in an email message to Mr Y that the message was not passed on to him and explained the reason for the change in medication. In its complaint response to Mr Y in February 2025, the Practice apologised and said it was a source of regret that Mr Y was not informed of the change to his medication and further explained the reason for the change in medication frequency.

47. Our NHS Complaint Standards say wherever possible, staff should explain why things went wrong and should give sincere apologies. We are satisfied the Trust has appropriately acknowledged that its communication was not up to the expected standard and apologised for this. For these reasons, we feel it has done enough, in line with our NHS Complaint Standards, to put this aspect of the complaint right. As such we will not take any further action on this aspect of the complaint.

The Practice inappropriately documented Mr Y mentioned suicide in March 2024

48. Mr Y says the Practice inappropriately documented that he mentioned suicide in March 2024 and made an inappropriate referral to signpost him to a therapy and counselling service.

49. In mid-February 2024, Mr Y attended the Practice and spoke to his GP about how he was feeling following the death of his mother. We have seen in the records, he told the Practice he did not want support from the mental health team but agreed he would contact the crisis support team if he felt he needed help before next speaking to his GP in two weeks.

50. After the appointment, the Practice sent Mr Y an email signposting him to several services, including the crisis support team as discussed and a therapy and counselling service. The email the Practice sent to Mr Y was a generic email which included more resources than were discussed with him during his appointment.

51. The GMC guidance says if a patient has specifically declined an intervention, the GP should listen to their preference. However, it also says that doctors should help patients to access information and support to manage their health successfully and provide information on all the options for treatment.

52. As Mr Y agreed to contact the crisis team if he needed this, in line with the GMC guidance, the Practice appropriately sent him the details for this so he could access support services if needed.

53. Unfortunately, the information the Practice has with the crisis team details is a generic email that lists multiple support services in the area. Therefore, this included a therapy and counselling service.

54. We appreciate that Mr Y feels that the Practice sharing this information with him was unwelcome and made him feel his preferences weren’t being listened to.

55. As the Practice needed to provide Mr Y the crisis support details, we do not consider it was a failing that the Practice sent Mr Y an email with these details, and other services in the area. This meant that Mr Y could then choose the options he wanted to manage his health successfully.

56. In mid-March 2024, the Practice received a phone call from a funeral home stating it was concerned about Mr Y as he had been talking about suicide when he went to collect his mother’s ashes. This interaction was recorded in his medical records by the Practice.

57. Mr Y believes this should not have been recorded in his records as he says it was acquired via hearsay and should only have been used in his records when it had been substantiated.

58. The GMC guidance states that staff must use risk management structures and processes to keep patients safe. This includes documenting concerns that may indicate a risk to a patient’s safety or wellbeing and supporting the recognition of potential adverse events.

59. Our adviser said the Practice were correct to record this call from the funeral home in his medical records as a risk was raised by a third party.

60. As Mr Y disagreed with this specific information, the Practice have now updated his records to reflect this.

61. Therefore, we consider it was appropriate and in line with the GMC guidance for the Practice to have recorded this in the records and have not seen any indications of failings with this aspect of the complaint.

62. Mr Y says he was also unhappy with the Practice’s lack of understanding about grief as he feels some staff member’s comments showed a lack of understanding, were ill considered and he felt the Practice were not taking into account the individual way people deal with grief. He says this caused him distress at an already difficult time.

63. In its complaint response, the Practice sincerely apologised and said its words came from a place of compassion and it intended to express empathy with sincerity.

64. Our NHS Complaint Standards say staff should give sincere apologies. We are satisfied the Practice has appropriately acknowledged the impact this had on Mr Y and apologised for this. For these reasons, we would not recommend any further action as we feel it has done enough, in line with Our NHS Complaint Standards, to put this aspect of the complaint right. Therefore, we will not take any further action.

The Practice continued to contact Mr Y through the online portal, PATCHS, despite him asking the Practice not to do so

65. The Practice use a web-based triage and messaging system. Mr Y told the Practice he did not want to use this service and preferred to have contact over the phone as he found the messages unsettling and intrusive. In response to this the Practice tried to update Mr Y’s preferences on the system. Unfortunately, Mr Y continued to receive messages through the system.

66. In its complaint response to Mr Y, the Practice said his request was not properly coded and that is why he continued to receive messages through the system. The Practice explained it took steps to update Mr Y’s information again in line with his preferences.

67. Our Principles of Good Administration say organisations should respond to people’s needs flexibly, and ensure decisions and actions are proportionate, appropriate and fair. Our NHS Complaint Standards say that wherever possible, staff should explain why things went wrong and identify suitable ways to put things right. We consider the Practice acted in line with this by explaining to Mr Y why he was continuing to receive message and by updating Mr Y’s details on the system to ensure his communication preferences were met.

68. The Practice have confirmed to us that Mr Y’s mobile number and email have been removed from the system. Mr Y told us he has blocked the address of the online system and has not received messages since mid-May 2025. Therefore, we consider the Practice have taken appropriate steps to put this right for Mr Y and respond to Mr Y’s needs, as such we will not take any further action.

The Practice did not respond to emails he sent in April and May 2024

69. Mr Y sent two emails to the Practice in April and May 2024 but never received a reply or acknowledgment. In these emails Mr Y told the Practice he wanted to make a complaint and asked for details on how to do this.

70. Our NHS Complaint Standards say organisations will acknowledge a complaint within three working days. The Regulations say complainants will, so far as is reasonably practical, be given assistance to enable them to understand the complaints procedure or advice on where they may obtain such assistance. The Regulations also say organisations should make a written record of the complaint.

71. The Practice did not acknowledge Mr Y’s email within three working days, give him information on how to make a formal complaint or make a record of his complaint. This is not in line with Our NHS Complaint Standards or the Regulations and we consider it is an indication of a failing by the Practice.

72. The Practice did register Mr Y’s formal complaint in August 2024 after Mr Y contacted the ICB in July 2024 and provided him with a final response to his concerns in February 2025.

73. Mr Y told us the lack of response to his emails made him feel his concerns were not being taken seriously and added to the feelings of being belittled, humiliated and condescended.

74. As we had seen an indication of a failing that had led to an injustice, we asked the Practice to apologise in writing to Mr Y and acknowledge the impact he told us this had had. The Practice has agreed to issue a written apology to Mr Y.

75. Our NHS Complaint Standards say staff should give sincere apologies. The Practice have agreed to do this, and we consider this appropriate to remedy the impact caused to Mr Y and we therefore consider this aspect of the complaint resolved.

76. We realise this is unlikely to be the outcome Mr Y was looking for when he approached us. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it. We appreciate that this was a stressful and worrying experience for Mr Y and would like to thank him for bringing his concerns to our attention.

1. We have carefully considered Mr Y’s complaint about a GP Surgery in the Blackpool area (the Practice). We have seen no indication anything went seriously wrong.

2. We can see the events Mr Y has complained about left him feeling disrespected and caused him concern.

3. We have seen an indication of a failing in the Practice’s communication about reducing his medication and communication and record keeping regarding Mr Y trying to make a complaint. We have seen the Practice has already apologised for the lack of communication about reducing his medication and it has agreed to apologise for the lack of communication and record keeping regarding Mr Y trying to make a complaint. As such, we consider the Practice has already done enough, or has agreed to do enough, to remedy the impact of this, so we will take no further action.

4. We have not seen any indication of failings with the care or treatment provided by the Practice. We have seen when making decisions about medication, trying to contact Mr Y about test results and recording information on Mr Y’s records the Practice acted in line with guidance. We explain this in more detail below.