Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board

4. Mr E complains about the care and treatment provided to his brother, Mr C, by the Surgery between late 2023 and early 2025. Mr E raises the following concerns:

• the Surgery failed to that • from December 2023 the Surgery did not provide adequate support to help Mr E obtain a diagnosis for Mr C’s Severe Mental Impairment • in March 2025, the Surgery removed both he and Mr C from patient list without a clear explanation • in 2025 ICB B failed to properly address his concerns about the appeal of the deregistration of him and his brother from the Surgery

5. As a result of the above issues, Mr E explains he was left without the additional support appropriate for a carer for someone with severe learning difficulties, which have since been formally diagnosed by the new GP surgery. He experienced inconvenience and disruption in having to register with a new GP surgery. He says he incurred significant personal costs while pursuing a diagnosis for Mr C and he believes the Surgery’s actions failed to meet the expected standards and caused him distress.

6. By bringing his complaint to us Mr E seeks:

• a formal apology from the Surgery • an explanation of whether the care and treatment provided were in line with national guidelines • financial compensation for the costs incurred and the emotional distress caused

9. Mr E is the carer for his brother Mr C.

10. In December 2023 a social prescriber, acting on behalf of Mr E and Mr C, contacted the Surgery to obtain a sign off for a Council Tax Reduction. The Surgery refused to do so.

11. The Surgery had referred Mr C to the Adult Autism Department earlier in the year. The appointment had not been arranged, and no formal diagnosis was in place.

12. Mr E complained to the Surgery through an advocate service in June 2024.

13. The Surgery issued a response in August. Mr E then complained to ICB A.

14. ICB A responded to Mr E’s complaint in November.

15. The Surgery responded to Mr E’s further issues on 23 January 2025. It confirmed it had a response from the Adult Learning Disability Team who stated the referral did not meet their criteria and it would be unable to help further.

16. On 18 March the Surgery sent Mr E a letter informing Mr E it had taken the decision to remove both Mr E and Mr C from the Surgery. It cited the reason as a breakdown in the patient-practitioner relationship.

17. The Surgery provided a two-week deadline for Mr E to transfer to another GP practice and provided him with guidance on what to do should any urgent medical issues arise in the meantime. It confirmed Mr E could appeal the removal decision or raise a complaint with ICB A.

18. On 24 March, Mr E submitted an appeal to ICB A’s complaint team about the Surgery’s decision to remove him.

19. On 25 March, Mr E was advised he would need to submit an appeal regarding the removal to ICB B and was provided with the relevant PALS and complaints contact address.

20. On 2 April, Mr E emailed ICB B stating he was awaiting a response to his complaint concerning the removal of both himself and Mr C from the Surgery’s patient list.

21. On 19 May, ICB B’s Complaints team responded to Mr E, explaining if he remained dissatisfied after its involvement, he could escalate the matter to our service. It signposted him accordingly.

22. On 23 June, Mr E formally referred his complaint to our service for further review.

23. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs of service failings or maladministration which the organisation has not put right.

The surgery failed to sign off a council tax discount form 24. In December 2023, a Social Prescriber acting on behalf of Mr E and Mr C contacted the Surgery to request a GP complete the council’s Council Tax reduction form.

25. Mr E believed Mr C met the criteria for a council tax reduction and the Surgery should confirm this. The Surgery declined to sign the form, explaining that although Mr C had been referred for an autism assessment earlier in the year to the Adult Autism Department, the assessment had not yet taken place. Because no formal diagnosis was in place, the Surgery felt unable to certify Mr C met the criteria.

26. The Surgery had referred Mr C for an autism assessment.

27. In response to Mr E’s complaint, in August 2024 the Surgery reiterated it could not confirm Mr C suffered from a severe mental impairment without a formal diagnosis.

28. Mr E complained to his local ICB B who reviewed the matter in November 2024. The clinician consulted as part of the complaint process agreed with the Surgery’s position, stating it had acted appropriately in declining to sign the form and in referring Mr C for further assessment.

29. In December, Mr E stated the Surgery had referred Mr C for an autism assessment rather than a learning disability assessment, which he believed was necessary for the council tax reduction. He stated the pathway to obtain an autism diagnosis would not result in a diagnosis of severe mental impairment and therefore felt the Surgery had acted incorrectly. In response the Surgery referred Mr C to the Adult Learning Disability Team.

30. In January 2025 the Surgery responded to Mr E again confirming the autism referral was still pending and the Adult Learning Disability Team had advised Mr C did not meet their criteria for assessment.

31. Throughout this period, the Surgery maintained the position that without a formal diagnosis it could not complete the Council Tax form.

32. The Council’s published criteria for Severe Mental Impairment states a person qualifies if they have “a severe impairment of intelligence and social functioning (however caused) which appears to be permanent”.

33. The guidance says, “to qualify, a doctor must write a letter confirming the severe mental impairment”. The council provide a template of a certificate for a doctor to complete.

34. We also got advice from a GP (our adviser) who has 19 years of experience as a GP, so they are familiar with the clinical issues in this case.

35. Our adviser told us the Council’s guidance does not define “severe mental impairment”, nor does it require a particular specialist service to have confirmed a diagnosis.

36. Our adviser told us, in the absence of more detailed statutory guidance the GP’s professional assessment of Mr C’s cognitive and social functioning should have been the determining factor.

37. Our adviser considered the GP had sufficient information about Mr C to decide whether he met the functional definition of a Severe Mental Impairment at the time the request was made. They said the Surgery should have assessed whether Mr C’s everyday functioning met the council’s definition, rather than relying on the presence or absence of a specific diagnosis or the outcome of a pending referral.

38. The Surgery’s decision making was based on the assumption a formal diagnosis was required before the council’s form could be completed. This was a misunderstanding of the council’s criteria.

39. The Surgery focused on diagnostic pathways particularly the pending autism assessment and used the absence of a completed assessment as the reason not to sign the form. The criteria do not depend on a particular diagnosis or on the involvement of a specific specialist service. As a result, Mr E’s request was not considered in the way the guidance intended.

40. The Surgery should have considered using clinical judgement to determine whether Mr C met the definition of severe mental impairment for the council tax form. We consider this is an indication of a failing.

41. We understand Mr E’s frustration with this prolonged delay. The Surgery’s misunderstanding caused unnecessary stress, particularly as Mr E was advocating for his brother’s needs during an already challenging time.

in December 2023 the Surgery did not provide adequate support to help Mr E obtain a diagnosis for Mr C’s learning difficulties 42. The records show the Surgery referred Mr C to the Adult Autism Diagnostic Service before Mr E approached it to sign his council tax form.

43. In June 2024 Mr E complained to the Surgery, stating it had failed to support in making an appropriate referral to obtain a diagnosis for Mr C. The Surgery responded in August, explaining the referral to the Adult Autism Diagnostic Centre had been made.

44. In December, the Surgery made further referrals to the Community Learning Disability Health Team and the Adult Mental Health Team.

45. On 3 January 2025, the Community Learning Disability Health Team responded, stating Mr C did not have a mental health need and instead required a diagnosis in order to access benefits, and therefore rejected the referral.

46. On 8 January the Adult Mental Health Team redirected the referral to the Older Adults Mental Health Team due to age criteria.

47. On 26 February, the Older Adults Mental Health Team confirmed it had referred Mr C to the Community Learning Disability Team for a formal diagnosis. The same team that rejected the referral in January 2025.

48. During our discussions Mr E expressed frustration that he feels he is going around in circles as the outstanding referrals remain with the Adult Autism Diagnostic Service and the Community Learning Disability Team, both of which he believes cannot provide the severe mental impairment diagnosis requested.

49. He explained the Surgery has not supported him or his brother in obtaining the necessary diagnosis and the referrals made since 2023 have not met the criteria required for their needs. This led to Mr E pursuing assessments privately at personal cost.

50. We have seen the Surgery referred Mr C to the standard commissioned pathway for suspected autism, sought advice from the Community Learning Disability Team when concerns were raised, attempted additional referrals to Adult Mental Health Services and Older Adult Mental Health Services. It also explored alternative options when initial referrals were unsuccessful. It engaged with the Social Prescriber to ensure Mr E and Mr C had access to wider support while awaiting specialist input.

51. GMC’s guidance states doctors must ensure referrals are safe, appropriate, and directed to professionals or services with the necessary skills and expertise. Doctors must act in the patient’s best interests, provide clear and relevant information to support referrals, and seek advice when the appropriate pathway is unclear.

52. We can see the Surgery acted in line with GMC guidance in making referrals to other professionals to support Mr C. Our adviser told us all the referrals were appropriate.

53. The Surgery made appropriate referrals, sought advice from multiple specialist teams, and attempted to identify alternative services when initial referrals were unsuccessful.

54. The difficulties encountered appear to stem primarily from the Surgery’s incorrect understanding it needed a formal diagnosis to complete the council tax form and the lack of a commissioned service able to provide the specific assessment Mr E was seeking, rather than from any failure by the Surgery to seek appropriate referrals.

55. In summary, while we can understand Mr E’s frustration with the difficulties he has faced in obtaining the diagnosis, the Surgery acted in line with guidance. We have not seen any indications of service failings.

56. While no failings were found in how the Surgery pursued appropriate referrals for Mr C, we do not underestimate the toll this complex and unclear process may have taken on Mr E. We recognise the effort required to secure the right assessments for his brother.

Deregistration from the Surgery

57. Mr E complains the Surgery removed both him and his brother, Mr C, from its patient list without any prior warning. He believes the decision was unfair and was linked to his earlier complaint about how the Surgery handled a request for a Council Tax Reduction form and confirmation of Mr C’s diagnosis.

58. Our review of the evidence shows Mr E had accused clinicians of being “vindictive or incompetent” in correspondence to the ICB on 2 December 2024, and he referenced potential legal action.

59. Internal notes from a meeting held at the Surgery on 14 January 2025 show staff felt Mr E’s communications had become increasingly challenging. They recorded Mr E had made derogatory remarks about clinicians, accused the Surgery of dishonesty, and repeatedly threatened legal action. Staff considered this behaviour demonstrated a loss of trust and a breakdown in the patient–practitioner relationship.

60. On 18 March, the Surgery wrote to Mr E informing him that both he and Mr C were being removed from the patient list due to a breakdown in the relationship. The letter gave them until 3 April to register elsewhere and signposted Mr E to the ICB if he wished to appeal.

61. It also explained it had authorised a months’ worth of medication from 18 March.

62. The removal letter did not refer to any previous warning, and when asked the Surgery has not provided evidence a warning was given.

63. The British Medical Association (BMA) guidance on removing patients states a Practice should not remove a patient solely because they have made a complaint. An exception may apply where the complaint contains personal attacks or unfounded allegations demonstrating a serious breakdown in the relationship.

64. The guidance also states immediate removal is only justified in cases involving violence or threatened violence, and only where there has been police involvement. In all other situations, Practices must give the patient a warning, preferably in writing, so they have an opportunity to change their behaviour and avoid removal.

65. Practices are expected to have an internal policy on patient removals reflecting the BMA guidance. This should include documenting unacceptable behaviour, issuing warnings, and recording steps taken to repair the relationship before removal. The Surgery was unable to provide such a policy.

66. While the Surgery’s internal notes record concerns about Mr E’s behaviour, there is no evidence it issued any written or verbal warning to Mr E or Mr C before the removal letter was sent.

67. There is no evidence the removal was triggered by Mr E’s complaint. His complaint was raised in June 2024, and the removal was not communicated until March 2025, around nine months later.

68. There is no evidence the Surgery attempted to deescalate the situation, set expectations for communication, or offer Mr E an opportunity to modify his behaviour. These steps are required under the BMA guidance unless exceptional circumstances apply.

69. There is no evidence of violence, threats of violence, or police involvement. Therefore, the Surgery did not follow guidance when it removed Mr E and Mr C without having issued a warning.

70. Taking all the evidence into account, we are satisfied the removal was not due to Mr E raising a complaint. The evidence shows the Surgery did not issue a warning, it did not demonstrate exceptional circumstances justifying an immediate removal, and it did not take steps to repair the relationship. We therefore have found an indication of a failing.

71. We understand why Mr E feels the Surgery acted unfairly and unprofessionally. The lack of warning denied him the opportunity to address the Surgery’s concerns and rebuild the relationship.

72. We also recognise the additional distress and inconvenience caused by the need to find a new GP Practice, particularly given Mr C’s vulnerabilities.

in 2025 the local ICB failed to properly address his concerns about the appeal of the deregistration of him and his brother from the Surgery

73. In the letter in which the Surgery informed Mr E of the removal it told him, if he wished to appeal the decision, he should contact the local ICB.

74. Mr E contacted ICB A on 24 March 2025 to appeal the deregistration of from the Practice and was advised to contact ICB B instead, which he did on 2 April. Mr E explained the Practice removed him because of false allegations and these actions were discriminatory.

75. On 19 May, ICB B responded to him. However, its response did not address the concerns he had raised about the removal from the patient list. Instead, it signposted him to escalate the matter to our service if he remained dissatisfied.

76. Mr E subsequently brought his complaint to us, explaining his primary concern was the unfair removal from the patient list and the lack of a meaningful response from the ICB to the issues he had raised.

77. As part of our investigation, we asked ICB B about the process for appealing a removal from a GP practice list. ICB B informed us no appeals process exists for patients to challenge a GP’s decision to remove them. This means ICB B was not required to consider an appeal or consider overturning the Surgery’s decision.

78. ICB B was expected to meet the Principles of Good Administration. The standards emphasise the importance of being customer focused. In a situation involving removal from a GP practice, a decision with significant impact, ICB B should have ensured its response was full, clear, and understandable. Doing so would have demonstrated it had taken Mr E’s concerns seriously and had sought to resolve the matter locally.

79. When Mr E approached ICB B seeking clarity and raising concerns about the removal, ICB B still had a responsibility to provide a clear and informative response even when no formal appeals process was in place. It should have outlined the limits of its role, explaining its role was to look into complaints, it did not deal with appeals.

80. The ICB’s response did not address Mr E’s concerns about the removal decision or explaining no appeals process exists. However, it did correctly signpost him to our service. Whilst we have seen the ICB was not as clear as it could have been in its response to Mr E we do not consider this shortfall to be so serious as to constitute a service failing.

81. Central to Mr E’s complaint is his concern his removal from the Practice was left unaddressed. Mr E approached ICB B to appeal his removal decision. The ICB could not have done this. We have seen the ICB did appropriately signpost Mr E to us.

82. We appreciate how frustrating it must have been for Mr E to feel his appeal about deregistration were not meaningfully addressed. We acknowledge the confusion this experience may have caused, adding to an already difficult situation.

Impact 83. We found indications of failings in the way the Surgery did not use clinical judgement to determine whether Mr C met the definition of severe mental impairment for the Council Tax form, and it did not follow guidance when deregistering Mr E and Mr C.

84. Following deregistration, the Surgery provided a 14-day notice period from 18 March to 3 April 2025. This exceeds the BMA guidance, which specifies that for non-immediate removals, patients should generally be given at least seven days’ notice and removed on the eighth day. This extended timeframe provided Mr E additional time to secure alternative care. By May 2025, under two months later, Mr E and Mr C successfully registered with a new GP practice, minimising the disruption caused.

85. Mr E described this period as stressful. Mr E was left without the additional support appropriate for a carer for someone with learning difficulties, which have since been formally diagnosed by the new GP surgery.

86. Mr E experienced inconvenience and disruption in having to register with a new GP practice. Mr E incurred personal costs while pursuing a diagnosis for Mr C.

87. When he suffered an asthma attack Mr E had to seek support from a local hospital service for people without a GP. He needed to contact NHS 111 twice to obtain medication for Mr C when it ran out.

88. We regret to hear of the issues Mr E experienced during this period. We have not found this failing lead to significant impacts beyond inconvenience, and do not consider financial redress appropriate for this issue given the extended time allowed to register at a new practice.

89. The Surgery’s misunderstanding of the Council’s criteria led to a 17-month delay in certifying Mr C’s eligibility for the Council Tax discount. This caused avoidable frustration and stress.

90. During this period, Mr E pursued a formal diagnosis for his brother and incurred private healthcare costs as a result of this. We only recommend reimbursement of private fees if we consider it was necessary for them to be incurred as a result of a failing.

91. While the Surgery failed to understand and apply the correct criteria for the council tax form, this misunderstanding did not directly mean private treatment was required. The Surgery made appropriate efforts to meet Mr C’s needs through NHS pathways, including multiple referrals and exploring alternative options when referrals were unsuccessful.

92. The Surgery’s failings caused inconvenience and frustration, but they did not create circumstances where private treatment was necessary.

93. While it is clear the Surgery’s failings contributed to the stress of this situation, the decision to seek a diagnosis was not solely motivated by the need for the Council Tax form certification. Mr E confirmed he wanted a formal diagnosis to help access support for his brother which included, but was not limited to, the Council tax discount. Therefore, we do not consider it appropriate to recommend reimbursement of private healthcare costs in this case.

94. After consideration of the above, we have not seen evidence of a significant impact on Mr E’s financial stability or ability to live a normal life during this period. Once registered at the new practice, the form was signed, and the issue was resolved.

95. In terms of both financial and emotional impacts, we understand the difficulties Mr E faced in pursuing a diagnosis for Mr C, as well as the additional personal costs he likely incurred.

96. Taking into account the circumstances, we conclude the impacts identified fall within level two on our severity of injustice scale. This category is defined by short-term inconvenience, frustration, or distress that does not significantly impair day-to-day functioning or result in ongoing effects.

97. Level two cases typically involve distress, worry, or inconvenience a healthy adult might reasonably manage without external support, and where the impact diminishes over time. Based on the evidence available, this is the appropriate level of severity for Mr E’s complaint.

98. While Mr E sought a financial remedy of around £10,000, which aligns with a level five case, we do not consider the failings identified in this case to justify such a high level of severity. Level five cases involve particularly serious consequences, such as lasting financial hardship, permanent minor disability, or a marked impact on life expectancy.

99. In recognition of the impact of the Surgery’s failings, we consider a financial remedy appropriate, in line with level two of our severity scale. To ensure this is the correct level, we reviewed similar level two cases our service has dealt with and are satisfied this is the correct level for the injustice identified.

100. After careful consideration of the circumstances of Mr E’s case, approached the Surgery to explore a resolution. We asked the Surgery to apologise to Mr E for the impact he suffered as a result of the indicated failings and asked it to pay him a financial remedy of £550 for the frustration and inconvenience Mr E endured.

101. The Surgery have agreed to our proposed resolution.

Conclusion 102. To resolve Mr E’s complaint, he sought an apology, an explanation of whether the care and treatment were in line with national guidance and a financial remedy. We hope our report provides Mr E with the explanations he seeks.

103. We thank Mr E for raising his concerns and allowing the Surgery the opportunity to learn from his complaint, and hope our decision provides him with clarity and acknowledgement of the weight of his experience.

1. We have carefully considered Mr E’s complaint about a GP Surgery in the Buckinghamshire area (the Surgery). Having done so we have seen indications of failings in the Surgery not signing the Council Tax reduction form and when it deregistered Mr E and Mr C from the Surgery. We have not seen any maladministration with how it requested specialist services to diagnose Mr C.

2. We have found that the Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board (ICB B) dealt with Mr E’s complaint about the deregistration of Mr E and Mr C from the Surgery, by directing his complaint to our service for review.

3. We are sorry to hear about the circumstances of Mr E’s complaint. We understand the challenges he has faced and his continued struggles in receiving the support he feels his brother needs. We recognise the strength of feeling and how important it is to him to receive this support.