A practice in the Calderdale area

4. Mr D complains about aspects of the care and treatment provided to him by the Practice between February 2023 and May 2025. Specifically, he complains that the Practice: • reduced, limited or stopped his pain and antidepressant medications and did not involve him in this decision making between February 2023 and November 2024 • delayed or failed to refer him to memory, ADHD, and sleep services and did not follow up specialist requests, including an ENT examination request in a timely way between February 2023 and May 2025 • recorded that his behaviour during a telephone consultation was threatening, issued a behaviour warning and then removed him from the Practice in May 2025.

5. Mr D says that these cumulative events led to a worsening of his physical and mental health. He says this has caused a loss of independence. He also says he was caused distress and frustration and has lost trust in GP services.

6. As an outcome to his complaint, he would like acknowledgement of failings, an apology, correction of records, and service improvements.

7. Mr D was registered with the Practice until May 2025.

8. Between February 2023 and May 2025, Mr D raised concerns about the management of his medication, referrals to specialist services, the Practice's communication with him, access to his medical records and information, and the Practice's decision to issue him with a behavioural warning and remove him from its patient list.

9. Mr D's complaint covered a period of more than two years and included concerns about a number of different events. As Mr D has memory issues, he was unable to link many of these concerns to specific dates or consultations. So we agreed with Mr D that we would use the Practice's complaint responses and the clinical records to establish the chronology of events and identify the issues we could consider as part of our assessment.

10. The Practice considered Mr D's concerns through its complaints process and provided several complaint responses. Mr D remained dissatisfied with those responses and brought his complaint to us.

Reduced, limited or stopped his pain and antidepressant medications and did not involve him in this decision making between February 2023 and November 2024

14. Mr D complains that the Practice reduced or stopped his pain and antidepressant medications, including opioid medication, limited prescription issue intervals, and did not involve him in decisions about medication changes. He says this caused pain, distress, worsening mental health and loss of independence.

Antidepressant (sertraline) prescribing

15. In its complaint response, the Practice said it authorised a repeat dispensing prescription for sertraline on 14 June 2024 consisting of 12 future issues. It said this should have provided a continuous supply until 6 September 2024 and that there had been no prescribing gap. It said any problems obtaining medication earlier than expected appeared to be related to the way the pharmacy had dispensed the prescriptions.

16. The Practice also said the decision to prescribe sertraline in 7-day supplies was a clinical decision. It said where a prescriber suspected there was a risk of misuse or overdose, this had to be taken into account when deciding how much medication to prescribe.

17. The records show that on 14 June 2024 Mr D asked the Practice to prescribe sertraline in larger quantities because he said the pharmacy regularly delivered his medication late and he was missing doses. The Practice issued a repeat dispensing prescription consisting of 12 future-dated prescriptions, each providing a 7-day supply of sertraline.

18. The records show that Mr D continued to ask for larger prescriptions during August 2024 because he said the weekly prescriptions caused delays in receiving his medication. The records also show the Practice considered his request for longer prescriptions and reviewed the weekly prescribing arrangements.

19. The records show that by November 2024 Mr D remained on 7-day prescriptions. On 20 November 2024 he again asked for longer sertraline prescriptions.

20. The clinician recorded that Mr D was currently receiving weekly prescriptions and noted his history of suicidal thoughts. The plan was for sertraline to continue to be prescribed in 7-day supplies. The records also show that, following discussion with colleagues, the Practice confirmed to Mr D that it would continue 7-day dispensing.

21. On 11 December 2024, when Mr D again asked for a larger quantity of sertraline, the clinician recorded that he had low mood, suicidal thoughts and thoughts of deliberate self-harm. The clinician explained it would not be safe to prescribe a larger quantity of sertraline because of these risks.

22. The NICE guidance on depression in adults says that when there is a risk of suicide, clinicians should consider the toxicity of medication in overdose and may need to limit the amount of medicine supplied.

23. We asked our adviser whether the Practice acted appropriately when managing Mr D's sertraline prescribing. Our adviser explained that limiting the quantity of sertraline prescribed is appropriate where there are concerns about overdose risk. They said this is a recognised safeguarding measure to reduce the risk of overdose.

24. They also explained that although it is good practice to explain these decisions to patients, a lack of detailed communication would not, by itself, amount to a clinical failing where prescribing decisions were made to reduce risk.

25. The records show the Practice reviewed the arrangement after Mr D repeatedly asked for larger prescriptions. The records also show the Practice told Mr D in November 2024 that it would continue prescribing sertraline in 7-day supplies and, when he again asked for a larger quantity in December 2024, explained that it would not be safe to prescribe a larger quantity because of the recorded suicidal thoughts and thoughts of deliberate self-harm. This is in line with the above NICE guidance.

26. We understand that Mr D was unhappy with the Practice prescribing sertraline in 7-day supplies and believed this caused him to miss doses of medication. We consider the Practice acted in line with the NICE guidance when managing Mr D's sertraline prescribing. We also would not be able to hold the Practice responsible for any delays in the delivery of the prescription which may have resulted in any missed doses. Therefore, we have not seen any indications of failings in relation to this issue.

Opioid prescribing

27. In its complaint response, the Practice explained that it discussed opioid prescribing with Mr D on several occasions during 2023. It said opioids can be appropriate for short-term acute pain but are not generally suitable for the long-term management of chronic pain because of the risks of dependence, tolerance and addiction.

28. The medication records show that the opioid prescribed by the Practice was codeine. The records also show Mr D had previously taken tramadol before codeine was prescribed. On 1 April 2022, the Practice prescribed 28 codeine 15mg tablets. By December 2022, Mr D was receiving 224 codeine 30mg tablets, with directions to take one or two tablets up to four times a day when required.

29. The records show that the Practice issued a further prescription for 224 codeine 30mg tablets on 13 February 2023. On 5 April 2023, it issued a reduced quantity of 50 tablets. On 17 April 2023, following a review, it issued 224 tablets again.

30. The records include a pain clinic letter dated 17 February 2023. The letter advised that codeine could be used at a low dose for a short period but should not be used in the longer term because of the risks associated with opioid treatment.

31. On 24 February 2023, Mr D had a lengthy consultation with the Practice about his chronic pain, reduced mobility and care needs. The records show he said he had previously taken tramadol and believed his health had declined after it was stopped. He was concerned his codeine would also be stopped.

32. The clinician discussed his concerns about pain medication before agreeing to make referrals for specialist assessment and support. They also arranged for Mr D to see a GP about his memory concerns, mental health and overall care.

33. On 17 April 2023, Mr D told the Practice that he had previously been prescribed around 224 codeine tablets every two months, but that the reduced prescription of 50 tablets was not lasting. He said he was taking two 30mg tablets four times a day and that this helped his pain. Following the consultation, the clinician prescribed 224 codeine 30mg tablets.

34. On 21 June 2023, the Practice discussed Mr D's medication requests with him. The clinician noted that his request for codeine would be discussed at a multidisciplinary team meeting. The clinician also discussed duloxetine (is an antidepressant that can also be used to treat chronic pain), which had been recommended by the pain clinic, and explained that Mr D would need to stop taking sertraline before starting it. The records state that Mr D had no further questions and seemed happy with the consultation.

35. The Practice considered Mr D's request for codeine at a multidisciplinary team meeting on 5 July 2023. The meeting record notes that Mr D had fibromyalgia (chronic disorder that provides pain) and back pain. It records the clinical decision that analgesia (pain relief) was not indicated, noting the pain clinic's view that it would be counterproductive. The record also states that a joint consultation should take place.

36. On 24 July 2023, Mr D again asked about codeine. He told the GP that codeine helped his pain and that he had not experienced side effects. The GP discussed the pain clinic letter and the option of duloxetine. Mr D said he did not wish to try duloxetine. The GP told him they would confirm the outcome of the multidisciplinary meeting and sent him a copy of the pain clinic letter for his information.

37. On 14 August 2023, the Practice discussed the outcome of the multidisciplinary meeting with Mr D. The records show the GP explained that the team had agreed that no further opioids would be prescribed.

38. Mr D questioned why the risk of dependence was considered greater than the effect the decision would have on his quality of life and said he believed codeine was a mild painkiller. The GP explained that codeine could cause dependence and other serious harms, they also discussed the pain clinic recommendations and explained the evidence supporting non-pharmacological and psychological approaches to managing chronic pain.

39. The GMC guidance says doctors must prescribe safely, act in patients’ best interests, and provide appropriate care.

40. The NICE guidance says clinicians should not initiate opioids for chronic primary pain in people aged 16 and over. It explains opioids are not recommended for long-term use because of limited benefit and risks such as dependence and tolerance.

41. The GMC's guidance on decision making and consent says doctors should listen to patients, provide the information they need to make informed decisions, and involve them in decisions about their care.

42. We asked our adviser whether the Practice acted appropriately when reviewing Mr D's opioid prescribing. Our adviser explained that codeine is an opioid and that long-term opioid treatment is not recommended for chronic pain conditions such as fibromyalgia because of the risks of tolerance and dependence.

43. Our adviser also explained that the Practice's approach to reducing and limiting Mr D's opioid prescribing was clinically appropriate and consistent with the pain clinic's advice and NICE guidance. Although Mr D believed codeine improved his pain, the Practice also had to consider the risks associated with long-term opioid prescribing, including tolerance and dependence.

44. We have also considered whether the Practice involved Mr D in this decision.

45. The records show the Practice discussed opioid prescribing with Mr D on several occasions between February and August 2023. It discussed his concerns about opioid medication, the recommendations made by the pain clinic, and alternative treatment options.

46. Following the multidisciplinary team meeting on 5 July 2023, the Practice discussed its decision with Mr D on 14 August 2023. It explained that no further opioids would be prescribed, the reasons for that decision, and the risks associated with long-term opioid use. This is in line with the GMC guidance on decision making and consent

47. We understand that Mr D disagreed with the Practice's decision to reduce and ultimately stop long-term opioid prescribing because he believed codeine improved his pain and quality of life.

48. Having considered all the evidence, we consider the Practice acted in line with the NICE and GMC guidance when managing Mr D's opioid prescribing. The records also show the Practice discussed the proposed changes with Mr D, in line with the GMC guidance on decision making and consent, on several occasions before confirming its decision. We have therefore not seen any indications of failings in relation to this issue.

Delayed or failed to refer him to memory, ADHD, and sleep services and did not follow up specialist requests, including an ENT examination request in a timely way between February 2023 to May 2025

49. Mr D says the Practice delayed or failed to refer him to memory, ADHD (a condition that can affect attention, activity levels and impulse control), and sleep services.

50. He also says it did not follow up specialist recommendations, including an ENT (ear, nose and throat) examination request, or progress a memory assessment in a timely way. He says this delayed diagnosis and treatment and caused him avoidable distress.

51. In its complaint response, the Practice accepted there had been a delay in referring Mr D for an ADHD assessment and apologised. It said Mr D mentioned in 2023 that he thought he may have ADHD but did not request a referral at that time.

52. It also said Mr D had been referred to the sleep clinic but was discharged after he did not complete the required sleep study. The Practice later made a further referral. It acknowledged that a request from the sleep clinic for an ENT examination was not initially passed to a GP for action, but said the examination was later completed.

53. In relation to Mr D's memory concerns, the Practice said severe memory problems would be unusual in someone of his age and could be related to other causes, including depression. It said a memory clinic referral had since been made.

54. On 14 August 2023, Mr D told the Practice he thought he had ADHD and possibly autism.

55. During November 2024, Mr D contacted the Practice asking for updates on his ADHD, and sleep referrals. The records show the Practice was informed he had been discharged from the sleep clinic because the required sleep study had not been completed. The Practice made a further referral to the sleep clinic.

56. On 24 February 2025, Mr D requested a referral to Psychiatry UK under the NHS Right to Choose pathway for an ADHD assessment. The Practice completed the referral on 25 February 2025.

57. In March 2025, the sleep clinic arranged a sleep study. It also asked the Practice to examine Mr D's nose and throat before deciding whether any onward referral to ENT was required.

58. On 25 April 2025, the sleep clinic confirmed the sleep study showed no evidence of obstructive sleep apnoea. It noted it had previously asked the Practice to examine Mr D's nose and throat and advised him to see his GP so that examination could be carried out and any onward ENT referral considered.

59. On 6 May 2025, the Practice sent a referral to the memory clinic. On the same day, it carried out a home visit. The clinician recorded Mr D was under investigation for sleep apnoea and that an ENT assessment had been advised before any further referral. Examination of his ears, nose and throat was normal.

60. On 27 June 2025, Psychiatry UK assessed Mr D and diagnosed ADHD. It recommended treatment with Elvanse (a medicine used to treat ADHD) and confirmed it would manage titration (starting the medicine and adjusting the dose until the most effective dose was found) before consideration of a shared care agreement with the Practice.

61. The GMC guidance says doctors should assess patients' needs and use their clinical judgement to decide what investigation, treatment or referral is appropriate. It says doctors should arrange suitable investigations or treatment where necessary, seek advice from colleagues where appropriate, and refer patients to another suitably qualified practitioner when this serves the patient's needs.

62. The NHS guidance on GP referrals to specialist services explains that patients may ask their GP to refer them for specialist treatment. Whether a referral is made depends on the GP's clinical judgement about whether a referral is clinically necessary. It also explains that a GP may suggest investigations or treatment before making a referral.

63. We can see that Mr D first mentioned autism and ADHD in August 2023, but at that time he did not request a referral for an assessment, so no referral was made. Mr D then asked about a referral he thought had already been made in November 2024. At this stage the Practice was aware that Mr D wanted a referral for an assessment. The Practice did not appear to consider or action this request. This is not in line with the GMC guidance and is an indication of a failing.

64. Mr D asked about a referral again on 24 February 2025 and the Practice actioned this the next day. Therefore, we consider there was a delay of around two to three months in the Practice making a referral for assessment.

65. Our NHS Complaint Standards say that organisations should identify instances where things have gone wrong and give sincere apologies for the impact on the people concerned. They also say that Organisations should identify ways to put things right.

66. We can see that the Practice have acknowledged there was a delay in referring Mr D for an ADHD assessment and apologised. It had already put this right for Mr D by making the referral promptly when the mistake was identified in February 2025. We consider this is in line with Our NHS Complaint Standards and do not consider that any further action is necessary.

67. In relation to the sleep referral, we can see that the Practice did make a referral to the sleep clinic, in line with the GMC guidance, but Mr D was discharged because he did not complete the sleep study. Our adviser explained that, once a GP has made an appropriate referral, responsibility for arranging appointments and investigations generally rests with the specialist service.

68. We can see that the Practice re-referred Mr D when asked. The sleep clinic then asked the Practice to conduct an ENT examination in March. This was not marked as an urgent request. The Practice did this at a home visit on 6 May 2025. This is in line with the GMC guidance.

69. In relation to the memory referral, our adviser explained that memory clinic referrals are generally considered where there are concerns about cognitive decline, such as dementia. Given Mr D's age, dementia would have been very unlikely and there were other possible explanations for his reported memory problems, including depression and medication.

70. Our adviser said that it was clinically appropriate to not make a memory clinic referral until May 2025. They also noted that, once the referral process had started, Mr D missed two CT head scan appointments, which delayed progress with the memory assessment.

71. Having considered all of the evidence, we consider the Practice acted in line with the GMC and NHS guidance on GP referrals in the management of the referrals, and follow-up of specialist recommendations. Whilst we have seen a delay in the ADHD referral, we consider the Practice have already appropriately acknowledged this, apologised, and put this right. Therefore, we will not consider these issues further.

Recorded that his behaviour during a telephone consultation was threatening, issued a behaviour warning and then removed him from the Practice in May 2025.

72. Mr D says the Practice wrongly recorded that his behaviour during a telephone consultation was threatening. He says he was raising concerns about his care rather than behaving aggressively. He also complains that the Practice should not have issued him with a behavioural warning or removed him from its patient list.

73. The BMA guidance on removing patients from a GP list says a Practice may remove a patient where there has been an irretrievable breakdown in the doctor-patient relationship. Before doing so, it should normally warn the patient, preferably in writing, explaining that they may be removed if their behaviour continues. The guidance also says Practices should keep a written record of the warning and the reasons for it.

74. In its complaint response, the Practice explained that it considered the doctor-patient relationship had broken down.

75. In correspondence with us, the Practice confirmed that it issued Mr D with a written behavioural warning on 14 March 2025 because it considered his repeated telephone calls and emails were making it increasingly difficult to maintain a therapeutic relationship. It explained that the warning informed Mr D that if this behaviour continued, it would ask for him to be removed from its patient list.

76. We also considered internal Practice correspondence created before Mr D's removal. This shows that during late 2024 and early 2025 Mr D made a number of complaints and Subject Access Requests and repeatedly raised concerns about the care he had received, including allegations of medical negligence.

77. The correspondence also shows that the Practice accepted some of Mr D's concerns were justified, including delays progressing his ADHD referral, but clinicians were increasingly concerned that the therapeutic relationship had deteriorated and discussed whether it had become increasingly difficult to continue providing care.

78. The records show that on 2 May 2025 a GP telephoned Mr D to complete a memory assessment. The consultation lasted almost 20 minutes. During the call, the GP completed an initial cognitive assessment, recorded that Mr D had scored poorly on the screening test and discussed referring him to the memory clinic. The GP also arranged the investigations required before the referral, including a CT head scan and blood tests. The records show Mr D agreed with this plan.

79. After discussing the memory assessment, Mr D raised a number of concerns about his care, including why he did not have a care plan, why his messages and emails had not been responded to, and why the memory assessment had taken several years to arrange. The GP recorded that they attempted to bring the consultation to a close because they had other patients waiting, but that Mr D continued raising concerns. The GP recorded that they felt Mr D's behaviour had become threatening and ended the call because they felt uncomfortable.

80. We asked our adviser whether it was appropriate for the Practice to issue the behavioural warning and subsequently remove Mr D from its patient list. Our adviser explained that, although it is not possible to determine exactly what happened during the telephone consultation, the contemporaneous records demonstrate a sustained deterioration in the therapeutic relationship over several months. They considered that the warning and subsequent removal were appropriate in the circumstances.

81. We appreciate Mr D strongly disagrees with the Practice's account of the telephone consultation and says he was raising concerns about his care rather than behaving aggressively. We cannot make a finding about exactly what was said during the telephone consultation because there is no independent record of the conversation, such as an audio recording. We therefore cannot determine whether Mr D's behaviour was threatening.

82. However, we can consider whether the Practice acted appropriately based on the information available to it at the time. The records show that the Practice issued Mr D with a written warning explaining why it believed the therapeutic relationship had deteriorated before later deciding that the relationship had irretrievably broken down and requesting his removal from the Practice list. This is in line with the BMA guidance.

83. Therefore, whilst we cannot say whether Mr D’s behaviour was threatening or not on 2 May, we can see that the doctor felt that the behaviour was threatening and felt uncomfortable. We can see that the relationship between Mr D and the Practice had broken down over a period of time, and the Practice followed the process set out in the BMA guidance for removing him. Therefore, we have not seen any indications of failings for this aspect of the complaint.

84. We are sorry Mr D remains unhappy with the care and treatment he received from the Practice. We recognise the significant impact he says these events have had on his health, wellbeing and independence. We thank him for bringing his concerns to our attention.

1. We have carefully considered Mr D’s complaint about the Practice. We are sorry to hear about his experience, and we recognise the distress and frustration he says these events caused him.

2. We thank Mr D for taking the time to bring his concerns to us. We have reviewed the available records, relevant guidance, and independent clinical advice. We have not seen any indication of failings in the care provided by the Practice.

3. We understand Mr D’s concerns about his care and treatment, including decisions about his medication and referrals, and the impact he says this had on his health, independence, and wellbeing. We have not seen any evidence that these difficulties resulted from failings by the Practice. We will not be taking any further action on this complaint.