A practice in the Bradford area

4. Mr R complains that the Practice did not respond appropriately when he attended with symptoms of a stroke on 3 October 2024. Specifically, he complains the Practice: • did not respond urgently to his stroke symptoms • told him to go home and telephone for an appointment • made him wait to see a GP • told him to make his own way to hospital after the GP identified he had suffered a stroke • showed a lack of care and compassion • gave an inaccurate account of events in its complaint responses.

5. Mr R says he felt frightened, unsupported, and distressed during a medical emergency. He also says the Practice’s responses caused him to lose trust in the Practice and healthcare professionals.

6. Mr R wants apologies and service improvements, particularly around the care and support offered to patients with suspected stroke.

7. On 2 October 2024, Mr R felt seriously unwell whilst working away from home. He attended an Emergency Department in the city where he had been working with symptoms including numbness, tingling, and vision loss. After waiting four hours to be seen, he left the Emergency Department as his colleague had to return home and he needed a lift from him. Mr R felt that he had had a stroke.

8. The following morning, Mr R attended the Practice to request an appointment. At 9.25am, a GP carried out a telephone consultation and recorded symptoms including loss of vision and pins and needles and weakness on Mr R's right side. The GP recorded a possible acute stroke and arranged to see Mr R face to face later that morning.

9. At 10.40am, the GP examined Mr R, recorded a suspected acute stroke and advised him to attend A&E for further assessment.

Response to suspected stroke symptoms

13. Mr R says the Practice did not respond urgently when he attended on 3 October 2024 with symptoms of a stroke. He says the receptionist told him to go home and telephone for an appointment, despite him saying he thought he had suffered a stroke. He says this meant he had to wait to speak to and see a GP.

14. The Practice says Mr R attended reception at 8.05am and it arranged a telephone appointment for him. It says he later contacted the Practice after missing a call. A GP called back at around 9.25am, considered a possible stroke and arranged to see Mr R face to face later that morning.

15. We have not seen a record of what was said between Mr R and the receptionist when he first attended the Practice. We are therefore unable to establish exactly what information Mr R gave the receptionist or what the receptionist said to him.

16. However, the Practice have provided a screenshot from their computer system to show that the receptionist booked a telephone appointment for Mr R for that morning.

17. The telephone recordings show Mr R contacted the Practice at 9.22am after missing a call. A woman who identified herself as his daughter took over the call and asked for the GP to call back as soon as possible. The receptionist said she would pass the request to the GP but could not say exactly when the GP would call.

18. Therefore, whilst Mr R says that the receptionist did not provide him with an appointment and told him to go home and telephone for an appointment, we have seen evidence to suggest that this was not the case. The screenshot shows that the receptionist booked a telephone appointment and the telephone recordings show that the Practice attempted to conduct this appointment at just before 9.22am, but Mr R missed the call. Therefore, we have seen no indications of failings for this aspect of the complaint.

19. The GP called back at around 9.25am. During the call, the GP was told Mr R had suddenly lost his vision the previous day and had pins and needles and weakness on his right side. The GP considered a possible stroke and told Mr R’s daughter that he might have to go to the hospital but arranged to see Mr R face to face later that morning to properly assess him.

20. Mr R attended for this appointment and the GP examined him at 10.40am. The records show he had blurred vision, reduced sensation and pins and needles in his right forearm, and an unsteady gait. The GP recorded a suspected acute stroke and advised him to attend ED for further assessment.

21. Our adviser said reception staff should recognise symptoms which may need emergency medical attention. We do not know exactly what Mr R told the receptionist about his symptoms or when they started. Our adviser said it was therefore reasonable for the Practice to arrange for a GP to speak to him and get more information. This is what the Practice did.

22. NICE CKS guidance says that if a person has ongoing symptoms suggesting a stroke, they should be treated as having a suspected stroke until this is confirmed. It says for assessment of a person with suspected stroke you should ask about symptoms and conduct an examination of consciousness level, vital signs, and perform a neurological examination.

23. It says if an acute stroke is suspected, then immediate emergency transfer to a specialist stroke centre should be arranged. This guidance also explains that some treatments for stroke are time sensitive. For example, certain treatments to dissolve a blood clot may be given within 4.5 hours of symptoms starting. In Mr R’s case, his symptoms started the previous day.

24. GMC guidance says doctors must provide a good standard of care. They should properly assess a patient's condition, including their symptoms and medical history, carry out an examination where needed, and promptly provide or arrange appropriate advice, investigation or treatment.

25. By the 9.25am telephone consultation, the GP had information suggesting Mr R may have had a stroke. Our adviser said many GPs may have advised him to go straight to ED at this point. Instead, the GP arranged to examine him at the Practice. Mr R was given a face-to-face appointment quickly thereafter. This meant there was just over an hour between the telephone consultation and the GP examining him and advising him to attend ED.

26. Our adviser said the GP was trying to properly assess Mr R. The GP took a history of his symptoms, took his vital signs, conducted an examination of consciousness level and performed a neurological examination. This confirmed that he had a suspected stroke so the GP advised him to urgently attend the ED. Our adviser said this was appropriate. We consider this was in line with the NICE CKS and GMC guidance.

27. We appreciate that Mr R was very unwell at this time and recognise he believes the Practice should have acted more urgently.

28. We have considered Mr R’s concerns alongside the clinical records, telephone recordings, relevant guidance and our adviser’s comments. Although the GP could have advised Mr R to go directly to ED during the telephone consultation, we consider it was appropriate and in line with the above guidance for the GP to examine Mr R before making this decision. We have therefore seen no indication of a failing in how the Practice responded to his stroke symptoms.

Advice and support to attend hospital

29. Mr R says that after the GP identified he may have had a stroke, he asked whether the Practice would arrange an ambulance. He says the GP instead told him to make his own way to ED by taxi or bus. He says he had to walk home, get money and arrange a taxi himself. He says this left him feeling unsupported and that the Practice did not show him care and compassion during a frightening medical emergency.

30. The Practice disputes Mr R’s account. It says the clinical records do not show what was discussed about how he should travel to ED. In its second complaint response, the GP said he did not tell Mr R to take a bus or point out the bus stops. The Practice said the GP would usually advise a patient to use the quickest appropriate means of transport depending on their clinical condition.

31. The clinical record from 10.59am says the GP suspected an acute stroke and advised Mr R to attend ED for further assessment. It does not record what was discussed about transport, whether Mr R asked for an ambulance, or what the GP said in response.

32. As above, the NICE CKS says if an acute stroke is suspected, then immediate emergency transfer to a specialist stroke centre should be arranged. This guidance doesn’t say that this needs to be via ambulance. Therefore, if a taxi would have got Mr R to hospital quicker, then this could still be an appropriate transfer.

33. We recognise Mr R strongly disputes the Practice’s account of what happened. When there are different accounts of the same events, we consider the available evidence, including contemporaneous records, to decide whether there is enough evidence for us to reach a view.

34. In this case, there is no contemporaneous evidence that allows us to establish what was said between Mr R and the GP about transport to ED and whether they showed him care and compassion. We are therefore unable to reach a view on this part of the complaint and will not take it further.

Accuracy of the Practice’s complaint responses

35. Mr R says the Practice gave an inaccurate account of what happened on 3 October 2024. He remains dissatisfied with its responses and wants the Practice to acknowledge what happened and make improvements to prevent something similar happening again.

36. Our NHS Complaint Standards say organisations should provide clear and accountable responses to complaints. They also say organisations should use learning to improve its service.

37. The Practice responded to Mr R’s complaint on 24 March 2025. It acknowledged that his symptoms required urgent attention and apologised that they were not escalated when he attended reception. It also acknowledged the distress this caused him and said it would learn from his complaint.

38. Mr R disputed parts of this response. The Practice provided a further response on 13 August 2025. It addressed the individual points he raised and explained where its account was based on the clinical records, appointment information, and telephone calls.

39. We have considered the telephone recordings and records available to us. The recordings support the Practice’s account that Mr R missed a call, later contacted the Practice and that a woman who identified herself as his daughter spoke to both reception and the GP. We have not seen evidence that the Practice inaccurately transcribed these calls.

40. The Practice said it discussed the case at its monthly clinical meeting and discussed NICE and national stroke guidance. It also told us it had updated discussions on stroke pathways, provided further information and training to reception staff on care navigation, introduced a total triage system, and put clear safety and clinical pathways in place within its triage system.

41. Our adviser said the actions the Practice have taken following Mr R’s complaint are appropriate.

42. We recognise Mr R remains dissatisfied and does not accept parts of the Practice’s account.

43. We have seen that in line with Our NHS Complaint Standards the Practice provided a clear response to the complaint. We have seen no evidence to suggest that the Practice provided an inaccurate account of what happened.

44. We have also seen that, in line with Our NHS Complaint Standards, the Practice have used his complaint to improve its service.

45. Having considered all the evidence, we have seen no indication of failings in this complaint. We will therefore take no further action. We appreciate that this was a distressing and frightening time for Mr R and thank him for bringing his concerns to our attention.

1. We have carefully considered Mr R’s complaint about the Practice. We are sorry to hear about his experience and recognise how frightening and distressing it was for him to experience symptoms of a stroke.

2. We thank Mr R for taking the time to bring his concerns to us. After reviewing the available records, relevant guidance and independent clinical advice, we have seen no indication of failings in how the Practice responded to his stroke symptoms.

3. We recognise Mr R’s concerns about the urgency of the care he received and the distress this caused him. We have not seen any indication that these concerns resulted from failings by the Practice. Therefore, we will not be taking any further action.