A practice in the Islington area

7. Ms P complains about aspects of the care and treatment she received from the Practice between May 2024 and May 2025. Specifically, she complains about:

• delays to a referral for an ADHD assessment caused by administration errors • not being able to access ADHD medication • the Practice providing incorrect information regarding a self-referral.

8. Ms P told us because of the delay of the referral:

• her mental health, wellbeing and quality of life has been impacted • the lack of access to medication has exacerbated her stress and anxiety • she has been left without vital support for an extended and unnecessary period.

9. As an outcome, Ms P wants:

• a thorough investigation • service improvements to prevent similar situations from occurring again • a financial remedy.

10. Ms P first attended the Practice on 16 May 2024 requesting to start ADHD medication. Ms P believed she had a private ADHD diagnosis at this point and sent evidence of this to the Practice.

11. Ms P understood another service needed to be involved before the Practice could provide her with ADHD medication. She thought the Practice had referred her appropriately at this point.

12. Ms P complained to the Practice in November 2024 about the delays in her referral for ADHD medication. In its response, the Practice advised Ms P she did not have an ADHD diagnosis. It said the evidence she sent suggested a possibility of ADHD and stated she may wish to ask her GP for a referral for a clinical ADHD assessment. It advised the steps Ms P should take if she wanted an ADHD assessment, involving a referral through an independent provider of psychiatry services (the independent provider) Right to Choose (RTC) pathway.

13. The independent provider offers psychiatry services, including ADHD assessments and medication titration. It provides both NHS and private services.

14. The RTC pathway is a framework within the NHS in England that allows patients to select an NHS-approved provider for their ADHD assessment.

15. The independent provider told Ms P she could not self-refer via the RTC pathway.

16. Ms P asked the Practice for updates again in March 2025 and May 2025. The Practice referred Ms P to the independent provider for an ADHD assessment via the RTC pathway on 28 May 2025.

17. Ms P received a diagnosis of ADHD on 11 September 2025. She was still waiting to start medication for ADHD in May 2026.

Issue 1 – delays in referral caused by administrative errors and information errors regarding self-referral

21. Ms P had a telephone appointment with the Practice on 16 May 2024. During this appointment, she requested to start ADHD medication and informed the GP she had a private diagnosis.

22. The GP asked Ms P to send evidence of her private ADHD diagnosis. Ms P sent evidence to the Practice on 20 May 2024. On the same day, the GP completed a ‘psychiatric referral’ stating Ms P has an ADHD diagnosis and would like to start medication.

23. We can see from the report Ms P sent to the GP she did not have a diagnosis and it is clearly stated on page 14 recommendation eight that she may wish to ask her GP for a referral for a clinical ADHD assessment.

24. The GMC’s Good Medical Practice says when providing clinical care, clinicians should promptly provide or arrange suitable advice or investigation where necessary and promptly refer a patient to another suitably qualified practitioner when this serves their needs.

25. We think this was a missed opportunity by the Practice in May 2024 to recognise Ms P did not have an ADHD diagnosis and take the appropriate steps to refer her for a diagnosis.

26. On 9 July 2024, the adult ADHD clinic, part of Camden and Islington NHS Foundation Trust, emailed the Practice advising it to complete the attached forms if it wished to refer Ms P.

27. We have not seen any evidence the Practice actioned this request. We think this was another missed opportunity for the Practice to identify Ms P did not have an ADHD diagnosis.

28. Ms P called the Practice on 7 November 2024 to ask about her ADHD referral. She says the receptionist informed her the Practice had not actioned the email from the adult ADHD clinic dated 9 July 2024 which she describes as critical to her medication request.

29. Following this, Ms P submitted a written complaint to the Practice.

30. We saw evidence the Practice emailed the adult ADHD clinic on 8 November 2024 to check Ms P was on their list.

31. Our ‘Principles of Good Administration’ say ‘public bodies should communicate effectively, using clear language that people can understand and that is appropriate to them and their circumstances. Public bodies should treat people with sensitivity, bearing in mind their individual needs, and respond flexibly to the circumstances of the case.’

32. In the complaint response dated 20 November 2024, the Practice says Ms P should access an ADHD assessment through the independent provider RTC scheme due to local NHS services having up to a four-year wait. The response contained a link to the independent provider’s website and said the referral can be done online, and that the website explains the process.

33. We think this was unclear information and we consider suggesting Ms P should self-refer is incorrect as the independent provider clearly states patients cannot self-refer via the RTC scheme, their referral must come from their GP.

34. We think the Practice could have considered Ms P’s individual needs more and responded more flexibly to the circumstances.

35. Ms P chased the Practice for an update on her ADHD assessment on 18 March 2025. The Practice responded advising she should self-refer via the independent provider RTC pathway, or if she wants a community ADHD referral, she should make an appointment with the GP to request this.

36. We think this was another indication of the Practice providing Ms P with unclear and incorrect information.

37. On 26 March 2025 during an appointment, Ms P asked the GP about her ADHD referral. The GP advised her the Practice sent her referral to the ADHD clinic on 8 November 2024 and there was a four-year wait.

38. We think this was another indication of confusing correspondence from the Practice, as the week before on 18 March 2025, it suggested the Practice had not sent the NHS referral and that Ms P should book an appointment if she wanted this.

39. As we identified indications something went wrong in this process, we considered what Ms P told us about the impact this had on her. We have considered whether we can link this to what we think went wrong.

40. The Practice referred Ms P to the independent provider on 28 May 2025, one year after she initially requested ADHD medication. She received an ADHD diagnosis on 11 September 2025, and the independent provider put her onto a waitlist for medication titration. The wait time for this was ten months. She informed us in May 2026 she is still waiting for ADHD medication.

41. Ms P says this has negatively affected her mental health, wellbeing and quality of life as she has been left without vital support for an extended and unnecessary period.

42. We think the Practice could have identified Ms P did not have an ADHD diagnosis, or did not have an appropriate referral in place on the following dates:

• May 2024 • July 2024 • November 2024 • March 2025

43. We recognise there were some periods of delay during this timeline which the Practice was not wholly responsible for.

44. Ms P did not ask the Practice who needed to complete the forms until 23 May 2025, after the Practice provided the link to the independent provider on 20 November 2024.

45. At some point between 20 November 2024 and 23 May 2025, Ms P contacted the independent provider who advised Ms P her GP needed to refer her. Ms P could not give us a date when she did this, nor provide a reason why she did not chase the Practice between November 2024 and March 2025. This means Ms P contributed to some of the delay.

46. Based on our understanding of the independent provider wait times at the time of these events, we consider it is more likely than not that if the Practice referred her at any of these points, Ms P would have received an ADHD diagnosis up to one year earlier. This means Ms P would have been on the ADHD medication titration waitlist sooner and would have most likely have started her ADHD medication by now.

47. We do not know the impact of the medication on Ms P as she has not started it yet. Therefore, we cannot say whether the medication would have improved Ms P’s mental health or symptoms in this period as we do not know if it would have been effective for her.

48. Despite this, we recognise this situation has caused Ms P a degree of stress and anxiety. She told us she approached the Practice requesting ADHD medication as she was struggling with ADHD symptoms. Ms P says the unmanaged symptoms impacted her daily functioning with organising appointments, completing tasks and regulating her emotions.

49. She says she felt dismissed as she was actively seeking support from the Practice, but she felt they were not listening to her. She says this negatively impacted her mental health, making her feel hopeless and anxious.

50. We have seen evidence Ms P attended the Practice nine times between May 2024 and June 2025 for her mental health. She reports symptoms such as low mood, insomnia and concentration difficulty. We recognise there appears to be multiple factors affecting Ms P’s mental health, not just her ADHD symptoms, including a bereavement and pre-existing depression.

51. Whilst we cannot say the indicated service failure has directly caused the impact Ms P tells us about, we think the delays in referral and conflicting and confusing information given may have contributed to her mental health difficulties at the time.

52. Our adviser says although the delays will not have resulted in long term or physical harm, they will have caused Ms P a degree of frustration and anxiety.

53. We think the multiple indications of shortcomings equate to an overall service failure. We think this was a missed opportunity for Ms P to receive a diagnosis, and treatment sooner. Although we do not think the failures have affected the outcome, as Ms P was still diagnosed with ADHD despite the delays, we think the delays caused Ms P distress, worry and upset for six to 12 months.

54. Our ‘Principles for Remedy’ say organisations should identify instances where things have gone wrong, take responsibility for these and find ways to put things right for those involved. The organisation should return complainants to the position they were in before the poor service took place, and if that is not possible, compensate them appropriately.

55. The Principles also say organisations should learn from complaints to improve services.

56. In its response dated 14 August 2025, the Practice acknowledged Ms P’s concerns about the delays and apologised for the distress caused. It recognised better communication could have prevented this situation, and outlined service improvements it has implemented to ensure it does not happen again.

57. The service improvements include:

• reviewing cases where patients experience difficulty with required forms • implementing a more robust system for ADHD referrals to ensure patients can complete all necessary documentation without delay • providing further training to relevant administrative staff to minimise the risk of errors or missed information • inviting patients in early if they experience issues completing the forms

58. We asked the Practice for more information on how it has implemented the changes. It told us it has shared the ADHD Policy including the patient pathway for RTC with clinicians. It also has several messages on the internal electronic patient record system with information about referring to the independent provider for ADHD assessments.

59. The Practice says it has emphasised with the team the referral process to the independent provider is not a self-referral process.

60. We are satisfied the service improvements the Practice has implemented address the issues Ms P has complained about and reduce the risk of this happening to someone else in the future.

61. We think the Practice could do more to put things right for Ms P, based on the impact she has faced, by a way of a personal remedy.

62. We use our ‘guidance on financial remedy’ to determine an amount of financial remedy. We think the impacts on Ms P fall into the level three bracket, in that it resulted in a degree of distress that lasted six to 12 months.

63. We contacted the Practice about paying Ms P a financial remedy. It agreed to pay Ms P £600 and apologised again for the service failure that led to Ms P complaining.

64. In conclusion, we have conducted a thorough assessment of Ms P’s complaint and identified indications something went wrong which had an impact on her. The Practice has apologised, implemented service improvements and offered a financial remedy of £600. On this basis, we consider the impact caused to Ms P has been remedied proportionately, and we will not consider it further. We hope we have clearly explained the reasons for our decisions.

65. We recognise the action the Practice has taken will not change the experience Ms P had. We hope the remedies the Practice has already provided, and agrees to provide, will bring some assurance to Ms P it has acknowledged the indications something went wrong and acted to put things right.

Issue 2 – Ms P was unable to access ADHD medication

66. Ms P complains the Practice have left her without access to ADHD medication. She says when she initially attended the Practice in May 2024, it informed her it could not directly prescribe her ADHD medication, and another organisation would need to be involved in the process.

67. The Practice says Ms P not being able to access ADHD medication was due to her not having a formal ADHD diagnosis from a psychiatrist. It says this needs to happen before any medication could be issued to her.

68. In a discussion with the Practice, it advised us it does engage with shared care agreements, but it cannot prescribe ADHD medication until the patient has a diagnosis and a specialist has started them on medication. It said it follows NICE guidelines.

69. NICE Guideline 87 states ‘all medication for ADHD should only be initiated by a healthcare professional with training and expertise in diagnosing and managing ADHD’.

70. We have considered what Ms P and the Practice have told us in relation to this issue and compared it to the relevant guidance.

71. Ms P did not have a formal ADHD diagnosis from a healthcare professional with appropriate expertise at the time of the events she complains about. Therefore, we are satisfied the Practice acted in line with NICE guideline 87 and could not provide Ms P ADHD medication at this time.

72. For these reasons, we have not identified any indications that anything went wrong in the way of the Practice not prescribing Ms P ADHD medication, and we will not take any further action on this part of the complaint.

73. We acknowledge Ms P has experienced delays in starting ADHD medication and we do not wish to dismiss the distress this has caused her.

74. We hope our explanation reassures Ms P the Practice acted in line with NICE guidelines by not prescribing her ADHD medication.

75. We appreciate the time and effort Ms P has taken to bring the complaint to us.

1. We have carefully considered Ms P’s complaint about the Practice. We are sorry to hear about the distress Ms P has experienced in relation to her referral for an attention deficit hyperactivity disorder (ADHD; a neurodevelopmental condition characterised by symptoms of inattention, hyperactivity and impulsivity) assessment and accessing ADHD medication.

2. Ms P raised concerns about delays to her referral for an ADHD assessment, the Practice providing her with incorrect information and her not being able to access ADHD medication.

3. We have reviewed the information provided by Ms P and the Practice, as well as seeking clinical advice from a general practitioner (GP) and considering the guidance and standards relevant to the care provided.

4. After doing so, we have seen indications something may have gone wrong with the Practice referring Ms P for an ADHD assessment and its communication about this. We have not seen anything went seriously wrong with Ms P being unable to access ADHD medication.

5. If we identify something has gone wrong at this stage, we consider if we can potentially resolve a complaint, without conducting a detailed investigation. The Practice has recognised its errors and has agreed to take steps to put this right. On this basis, we have agreed what we consider a suitable resolution. For this reason, we will not consider Ms P’s complaint further.

6. We fully acknowledge Ms P’s experience, and we hope the resolution we have achieved with the Practice remedies this in some way. We hope our explanation below explains our decision clearly.