Source · PHSO decision

A practice in the Fareham area

Ref: P-005975 Statement Decision date: 16 August 2026 Jurisdiction: NHS in England Closed After Initial Enquiries

Publisher summary

Mr W complains that between January and July 2025 the Practice failed to provide appropriate treatment or referrals for his deteriorating mental health and failed to offer an appropriate triage response

Find the original decision on the PHSO website ↗ · Reference P-005975

Topics and themes

1 PHSO issue

PHSO issue classifications

  • Treatment

The following sections reproduce the PHSO decision. First-person wording refers to the Ombudsman.

The complaint

3. Mr W complains that between 1 January and 17 July 2025 the Practice failed to provide appropriate treatment or referrals for his deteriorating mental health and failed to offer an appropriate triage response on 28 February 2025.

4. Mr W says the Practice’s lack of early intervention, delayed his treatment and contributed to his mental deterioration. He says this led to a psychotic episode and admission to hospital on 17 July where he remained for five days. He says this could have been avoided, along with the additional stress and further decline. He says a ‘chain reaction’ of further avoidable impacts followed this and his life has never been the same. He says he is now constantly grieving the life he had. He wants an apology, service improvements and financial remedy.

Background

5. In early 2025, Mr W experienced worsening mental health symptoms and attended the Practice with physical issues and mental exhaustion. Mr W spoke to several of the Practice’s out-of-hours GPs at this time about lack of sleep, tiredness and thoughts of self-harm.

6. In February, Mr W suffered a mental health crisis and called the Practice for support. The Practice staff advised him to call 111 instead. With support from 111, Mr W attended an out-of-hours appointment at a different surgery who referred him to the Emergency Department (ED).

7. Between March and April, Mr W attended the Practice for further consultations. In July 2025 he suffered a severe mental health crisis and was hospitalised for assessment and treatment.

Findings

10. The law says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider this is (or was) unreasonable in the circumstances. We have discussed this with Mr W to understand his circumstances and the outcomes he wants. We do not consider whether legal action would succeed, but whether it would be a reasonable option to look in to.

11. Complainants can pursue clinical negligence claims in court. Clinical negligence is when a healthcare professional delivers care that falls below the accepted standard and causes harm. These claims can cover a wide range of failures.

12. Mr W believes the Practice made failings that placed him at risk and caused him harm. If he is correct and the Practice’s failings caused harm, he may have grounds for a clinical negligence claim in court. When deciding whether a legal remedy exists, we consider not only whether a claim is available, but also whether it achieves the outcome sought by the complainant.

13. One of the desired outcomes of this complaint is financial compensation. Mr W has advised us that he feels the impact he faced is at level six (the highest one) of our SOI. He says he is seeking ‘at least £20,000’ for him to feel the impact he faced has been put right.

14. We understand the lasting impact Mr W describes, he says the events have left him constantly grieving the life he had, and we want to ensure he pursues the most effective remedy.

15. Claims of clinical negligence and large financial payments of compensation are usually matters that are better pursued through the legal system. We therefore think it is important he explores this option by seeking legal advice within the legal three-year time limit.

16. Mr W may also secure the apologies and improvements he is looking for. If he does not achieve all the outcomes he is seeking via legal action, or he does not pursue legal action, he can bring his complaint back to us and we could consider it as a new complaint. At that point, we would need to carefully consider the outcome of any legal enquiries he made and the outcomes he is seeking.

17. We would also need to consider the time which has elapsed, as our time limits would still apply. It is therefore important that Mr W takes legal advice without any avoidable delays.

18. Considering all these factors, we have decided not to consider Mr W’s complaint further because there is alternative legal action which is reasonable for him to explore. The law requires complainants to first explore whether the legal system can address their concerns.

19. We thank Mr W for bringing this complaint to us. We were sorry to hear how deeply affected Mr W has been by this complaint. We hope we have provided reassurance as to the next steps should they wish to return to us following exploration of potential legal routes.

PHSO decision

1. We have carefully considered Mr W’s complaint about a GP Surgery in Hampshire (the Practice). We were sorry to hear about Mr W’s experience and the difficulties he has faced with his mental health.

2. We have looked at all the evidence provided to us by Mr W. We consider Mr W could take legal action on the matter he has brought to us and that it is reasonable for him to do so. This means we have decided not to consider his complaint further. We hope our reasons below explain how we have fully considered this.

Decision details

Reference
P-005975
Decision type
Statement
Jurisdiction
NHS in England
Decision date
16 August 2026
Outcome
Closed After Initial Enquiries

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