A practice in the Lincoln area

5. Mrs M is unhappy with the service which she received from the Practice following a 24-hour ECG at a local hospital in December 2024. Specifically, Mrs M says that:

• the Practice failed to follow up with the hospital regarding the results of her ECG and asked Mrs M to chase the hospital instead • the Practice mismanaged appointments in May 2025, and • the Practice delayed uploading an urgent letter from her psychiatrist to her records.

6. Mrs M says that the Practice’s failures had a big impact on her, specifically that she feels her health was put at risk. Mrs M also says that she experienced unnecessary distress, felt dismissed and feels that she wasted her time by being unsupported.

7. As a result of the Practice’s failures, Mrs M seeks an acknowledgement that delays in reviewing her ECG and lack of follow up could have put her health at risk and recognition that repeated miscommunication about mental health referrals and appointments caused unnecessary emotional distress and delays in care. Mrs M wants the Practice to improve on how they track and act on referrals, test results and third-party correspondence along with a formal apology and financial redress.

8. Mrs M is unhappy with the service and care which she received from the Practice when she followed up with them regarding a 24-hour electrocardiogram (ECG) result. Mrs M says that the actions which the Practice took to chase the results from a third-party hospital were inappropriate.

9. Mrs M is unhappy with the administration of the Practice when actioning third-party letters, and also the Practice’s communication around GP appointments.

14. 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.

Communication

15. Mrs M is unhappy that when she contacted the Practice in March 2025 to advise them that she had not received her ECG results that that took place in December 2024, the Practice did not chase the results directly. Furthermore, Mrs M is unhappy that the Practice asked Mrs M to chase the ECG results herself directly with the hospital.

16. In its response dated 17 July 2025, the Practice advised that they do chase test results, however their secretaries have the same contact number as patients, and with the high volume of work that they have they sometimes ask their patients to chase the results themselves.

17. There is no clinical guidance available to show that Practices should chase test results within any specific timeframe, or that a Practice should not request that a patient should chase their own test results. This has been verified by our lead clinician.

18. We asked our advisor if it is reasonable for a GP Practice to chase all test results. Our advisor said that this would not be reasonable for a GP Practice to track all referrals which it has sent, and that the onus is more on the patient to chase the GP Practice if they have not received their results.

19. We asked our advisor if it is reasonable for a GP Practice to ask a patient to chase their own test results. Our advisor said that this is reasonable due to capacity and that the NHS puts more responsibility onto the patient to chase their own test results.

20. However, given that the complainant had already waited four months since the date of the ECG test, an amount of time which is unusual for a patient to wait, the Practice could have done more. Due to the abnormal wait time, the Practice could have contacted the Trust directly to chase the results, rather than requesting that Mrs M does this in the first instance.

21. Based on the information we have seen, we consider the Practice could have done more, which we consider to be a shortcoming, but their actions were not such that we would consider them to be a failing.

22. As such, we have found no indications of maladministration.

Access

23. Mrs M says that the Practice mismanaged her appointments on 22 May 2025 and 30 May 2025. Mrs M says that she believed these appointments were to discuss her mental health but when attending the appointment, the clinician discussed other conditions/ symptoms.

24. Mrs M had a PiP assessment completed by a third party on 20 May 2025. The third part sent an email to the Practice the same day to raise their concerns from during the assessment regarding Mrs M’s mental health.

25. Mrs M believed that the appointments on 22 May 2025 and 30 May 2025 were to discuss her mental health.

26. In its response dated 17 July 2025, the Practice say that the appointment which Mrs M had on 22 May 2025 was in relation to an appointment request which Mrs M submitted on 30 April 2025 for a high pulse rate and chest pains.

27. We asked our advisor if there was any indication from Mrs M’s medical records that the appointment on 22 May 2025 was to discuss her mental health. Our advisor confirmed that there was no evidence to suggest this, and that the Practice’s internal task suggests that their response provided the correct information.

28. In its response, date 17 July 2025, the Practice says that Mrs M’s appointment on 30 May 2025 discussed Tachycardia (fast heart rate over 100bpm), and a request from Mrs M’s Psychologist to refer Mrs M for another ECG, to a Dietician and to Haematology.

29. We asked our advisor if there was any indication from Mrs M’s medical records that the appointment on 30 May 2025 was to discuss her mental health. Our advisor confirmed that there was no evidence to suggest this, and that the evidence from Mrs M’s medical records show that the Practice’s response provided the correct information.

30. Based on the information we have seen, we consider the Practice was reasonable with their approach and their approach was in line with good clinical care and treatment. We have not seen any evidence which would indicate that the Practice ever told Mrs M that the appointments on 22 May 2025 or 30 May 2025 would be to discuss her mental health.

31. We have seen nothing to indicate the Practice acted inappropriately or that it acted outside of good clinical practice.

32. As such, we have found no indications of maladministration.

Administration

33. Mrs M is unhappy with the length of time which the Practice took to upload a third-party clinical letter to her medical records. Mrs M says that this delayed a coordinated response to her care and treatment.

34. Mrs M says that she spoke with her psychologist who advised that the Practice would receive their letter on 30 May 2025. The letter would contain requests for further tests and referrals which the psychologist could not refer for.

35. In its response dated 17 July 2025, the Practice says that they did not receive the letter from the psychologist until 9 June 2025. It says that the letter was not marked as urgent, and the appointments and referrals requested by the psychologist were booked around staff availability.

36. The Practice have advised us that they do not have a specific policy to follow regarding third-party letters, however documents are scanned onto their system by reception and referred to their secretaries who request action by clinicians if any is needed.

37. There is no clinical guidance available to show how Practices should add third-party documents within any specific timeframe. This has been verified by our lead clinician.

38. We asked our advisor if the actions of the Practice were reasonable which they confirmed that they were. The advisor said that although there is no formal guidance, documents need to be actioned within safe limits to confirm required actions are completed. There is no specific policy which state what the ‘safe limit’ is, however they confirmed the Practice acted reasonably.

39. We can see from Mrs M’s medical records that following her appointment with the GP on 30 May 2026, all of the requested referrals were completed by the GP. Mrs M was referred to a dietician on 30 May 2025, had an ECG on 9 June 2025 and blood tests on 18 June 2025.

40. We have carefully considered Mrs M’s complaint; we consider that the Practice were proactive in actioning the requests outlined in the psychologist’s letter before waiting to receive the letter. The adding of the letter to Mrs M’s medical records had no bearing on her care or treatment, as the actions required had already been completed.

41. Based on the information we have seen, we consider the Practice was reasonable with their approach and their approach was in line with good clinical care and treatment.

42. We have seen nothing to indicate the Practice acted inappropriately or that it acted outside of good clinical practice.

43. As such, we have found no indications of maladministration.

44. We recognise that this will be disappointing for Mrs M, given the impact that this has had on her wellbeing. We thank Mrs M for bringing her concerns to us.

1. We have carefully considered Mrs M’s complaint about a GP Practice in Lincoln (the Practice). We are sorry to hear how Mrs M has been affected by the concerns that she has brought to us.

2. There are elements of Mrs M’s complaint where we have not seen any indications that things went wrong. This means that that from the evidence we have considered, it appears that the Practice provided appropriate care and treatment to Mrs M.

3. We have found indications of a short coming in some aspects of Mrs M’s complaint. However, we have not seen any evidence to suggest that these shortcomings amount to a service failure.

4. We will explain the reasons for our decision in this statement. Complaints give us valuable insight into the organisations we investigate, so we would like to thank Mrs M for sharing her experience with us. It is important to acknowledge that although we are unable to look at the concerns she has raised, this does not detract from the experience Mrs M had, or the impact this had on her.