A practice in the Leeds area

5. Miss K complains about aspects of care she received from the Practice between February and June 2025.

6. Specifically, Miss K said the Practice: • failed to respond, assess, and triage her online request for an urgent mental health appointment on 6 February 2025 • failed to communicate effectively and provide her with routine follow-up check in call backs for her mental health support between February and June 2025.

7. Miss K said these issues caused a serious decline in her mental health. She said she felt overwhelmed, distressed, and emotionally unstable. On 6 February she told us she experienced frightening suicidal thoughts. She said she felt unsafe and out of control and had never experienced thoughts like this before.

8. Miss K said the lack of contact from the Practice left her feeling abandoned when she was in crisis. She said this increased her anxiety and depression and left her crying daily. She also said the situation affected her ability to work and caused worry for her daughter at home.

9. Miss K said not having follow up calls caused more stress. She said she became frustrated and felt the Practice did not listen or act on important information. She said the ongoing communication problems caused further emotional strain over several months.

10. Miss K is looking for an apology, an acknowledgement, service improvements and a financial remedy.

11. Miss K had a history of ongoing mental health difficulties before the events complained about.

12. On 6 February 2025, she submitted an online triage request to the Practice about worsening mental health symptoms and panic attacks. She reported three panic attacks that morning, worsening symptoms, that propranolol was not working, and said ‘don’t want to be here’. She selected phone contact and named Dr N as her preferred clinician.

13. The Practice marked the request as read and a GP assigned the request a Green triage rating. This means the Practice considered the request needed medical attention, but it was not assessed as requiring an immediate or emergency response.

14. The Practice sent a text message to Miss K. The message said the request had been triaged as routine and the admin team would book an appointment. The message advised her to contact reception or NHS 111 if symptoms worsened.

15. On 12 February, the Practice sent a text message to Miss K confirming a telephone appointment on 14 February, between 2pm and 6pm.

16. On 14 February, Miss K had a telephone consultation with the GP regarding her mental health and previous contact with Community Mental Health Team (CMHT).

17. Miss K later made a complaint to the Practice her triage request should have been treated as urgent.

18. She also complained the Practice failed to maintain appropriate communication and follow-up support regarding her mental health between February and June 2025.

The Trust failed to respond, assess, and triage her online request for an urgent mental health appointment on 6 February 2025

22. 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.

23. In her complaint to the Practice and to us, Miss K said she submitted an online triage request on 6 February 2025 because she was struggling with her mental health. She said she experienced panic attacks, worsening symptoms, and felt she did not want to be here.

24. Miss K said the Practice should have identified she required urgent support and contacted her sooner. She said the Practice categorised the request as routine and failed to assess the seriousness of her presentation appropriately. Miss K said the delay left her unsupported during a mental health crisis and caused significant distress.

25. We are sorry to hear about Miss K’s concerns and the distress this experience caused her. From what she told us, it is clear the events surrounding her mental health were upsetting and continue to affect her.

26. The Practice said clinicians triaged requests using the information patients provided at the time. The Practice said the request did not indicate an acute mental health crisis requiring emergency intervention.

27. It also said Miss K already had a planned appointment booked with her preferred GP the following week.

28. NICE NG222 says clinicians should assess mental health symptoms, deterioration, and risk appropriately. It does not define exact triage timescales for patients reporting panic attacks within primary care. GMC Good Medical Practice also says clinicians should use professional judgement and provide patient-centred care.

29. We obtained independent advice from a GP clinical adviser experienced in primary care mental health presentations.

30. We reviewed the clinical records, online request, complaint correspondence, and the Practice’s responses with our adviser. We can see Miss K has a longstanding history of mental health difficulties. Our adviser told us clinicians rely on professional judgement, presentation, risk, history, and existing support arrangements when making triage decisions.

31. Miss K’s medical records show Miss K her request referred to worsening mental health symptoms and panic attacks. They also show Miss K already had a follow-up appointment arranged with her preferred GP the following week. Our adviser considered the presentation on 6 February 2025 appeared consistent with worsening ongoing symptoms, rather than an acute new psychiatric presentation.

32. We recognise continuity of care is important for patients with chronic mental health conditions. For this reason, we considered it was appropriate for Miss K to continue care with a GP familiar with her history.

33. Miss K said the wording ‘I don’t want to be here’ should have triggered urgent intervention. Our adviser explained patients with longstanding mental health difficulties may express hopelessness or distress during periods of deterioration without presenting as acutely suicidal.

34. We understand this wording required clinical judgement within the context of Miss K’s wider presentation and mental health history. Based on our review of the available evidence, on the balance of probabilities, this wording did not indicate acute suicidal intent requiring emergency intervention.

35. Miss K’s medical records also show the Practice provided safety-netting advice. The Practice staff advised Miss K to contact the Practice or NHS 111 if symptoms worsened or changed.

36. Miss K’s medical records further show Miss K she contacted the crisis team. We have seen no evidence the crisis service identified an acute mental health crisis requiring emergency escalation at that stage.

37. Taking this into consideration, we are satisfied the Practice appropriately responded to, assessed and triaged Miss K’s online triage request on 6 February 2025. The Practice assessed the information available and acted within the range of reasonable clinical judgement available at the time.

38. From what Miss K told us, it is clear she went through a difficult time following her mental health deterioration. We hope our explanation helps to reassure her that it appears the Practice followed relevant guidelines.

The Trust failed to communicate effectively and provide her with routine follow-up check in call backs for her mental health support between February and June 2025

39. Miss K said the Practice agreed to provide regular mental health check-in calls following the events of 6 February 2025.

40. Miss K said these calls did not continue consistently. She said communication became unclear and she felt unsupported during a difficult period for her mental health. She also said the lack of regular contact increased her anxiety and emotional distress.

41. We were sorry to hear about Miss K’s concerns and the distress she experienced during her mental health support. From what she told us, it is clear this was a very distressing experience for her.

42. The Practice said it continued to communicate with Miss K regarding appointments, referrals, support options, and ongoing management during the relevant period. It said Miss K had ongoing involvement from specialist mental health services.

43. NICE guidance says continuity of care and ongoing management are important for patients experiencing mental health difficulties. GMC Good Medical Practice also says clinicians should communicate clearly and support continuity of care where possible.

44. We reviewed the records relating to appointments, referrals, communication, follow-up arrangements, and mental health management during the relevant period with our adviser.

45. Miss K’s medical records show the Practice arranged follow-up appointments during periods of deterioration. Her medical records also show ongoing communication regarding appointments, referrals, support options, ongoing management, and safety-netting advice.

46. Miss K’s medical records further show Miss K she had involvement from specialist mental health services during this period. This included referral to the CMHT and a follow-up appointment in April 2025.

47. Based upon the evidence we have reviewed, we consider there are indications the Practice maintained appropriate oversight of Miss K’s mental health during this period.

48. We recognise Miss K expected more regular contact from the Practice.

49. Our adviser also told us routine ongoing check-in calls are not always clinically indicated and may not always be feasible within primary care. They explained general practice services must balance proactive follow-up with clinical capacity and patient need. While practices should provide appropriate safety-netting and follow up where indicated, we also understand patients are generally expected to contact their Practice if their symptoms worsen, fail to improve, or if they have further concerns.

50. Our adviser also explained that once specialist mental health services become involved, it is reasonable for those services to take the lead in terms of ongoing support and monitoring, while the Practice continues to provide primary care support where needed.

51. From the evidence we have seen, we are satisfied the Practice appropriately communicated with Miss K and arranged follow-up support for her mental health in line with NICE and GMC guidance. We recognise Miss K was distressed during her mental health deterioration. Especially as she felt unsupported during a difficult period for her mental health. We do not underestimate the impact this will have had on her.

52. We hope we have clearly explained why we consider the Practice acted in line with guidance and expected primary care standards. We also hope our explanations help bring Miss K reassurance and clarity about whether the Practice should have responded differently to her mental health concerns.

1. We have carefully considered Miss K’s complaint about a Practice in the Leeds area (the Practice) about aspects of care she received between February and June 2025. We are sorry to hear her concerns about how the Practice managed her care. From what she told us, this has clearly been a difficult time for her and concerns about her care continue to cause her ongoing distress.

2. Miss K is concerned the Practice failed to respond appropriately to her online request for an urgent mental health appoint at the beginning of February 2025. Based on the information we have considered, the Practice reviewed and clinically triaged the request on the day it was received, provided safety-netting advice, and arranged follow-up care with a GP familiar with her history. We have seen no indication the Practice acted outside the range of reasonable clinical judgement available at the time. We have decided to take no further action on this aspect of the complaint for this reason.

3. We also considered Miss K’s concerns the Practice failed to communicate effectively and provide routine follow-up check-in calls regarding her mental health support between February and June 2025. Based on the information we have considered, we are satisfied the Practice maintained appropriate communication. We have seen no anything went wrong. We have decided to take no further action on this aspect of the complaint for this reason.

4. We recognise how important this complaint is to Miss K, and we would like to take this opportunity to thank her for bringing her complaint to our attention. We hope our explanations below show how we have considered this complaint. We also hope our explanations provides her with some reassurance the Trust followed relevant guidelines when it managed her care in March 2025.