A practice in the Dover area

The Practice

3. Mr X is complaining about the care his father received from the Practice. Mr X complains the Practice were poor at record keeping, including:

• conflicting information about the administration of the vaccines • failure to upload a letter from a psychiatrist deeming his father to have no mental capacity • failure to inform the vaccination centre about his father’s dementia and lack of mental capacity • failure to record consent from him and his brother for previous vaccines • failure to record a home visit to his father by a nurse.

4. He also is unhappy with the way the Practice closed his complaint file and would not answer his further questions in June 2025.

5. Mr X believes the Practice’s poor record keeping and failure to pass information on to the vaccination centre led to the wrongful administration of the Covid-19 vaccine to his father. As outcomes to the complaint, Mr X is seeking service changes regarding more timely record keeping in the provision of patient consent and mental capacity.

The vaccination centre

6. Mr X complains about the vaccination centre who were acting on behalf of the Practice. Mr X explains they administered the Covid-19 vaccine in October 2023 to his father against his and his brother’s wishes despite them having power of attorney for their father. He says the vaccination centre:

• did not consider whether his father had mental capacity and gave his father the Covid-19 vaccine despite Mr X’s brother declining consent for this over the phone • did not record the phone call with Mr X’s brother about giving consent • did not leave an information leaflet regarding the Covid-19 vaccine • did not keep any of his father’s vaccination records from his home visit.

7. Mr X explains his father collapsed two days after receiving the vaccine and died two months later. He believes the Covid-19 vaccine ultimately led to the death of his father. He also states this caused distress to his family, especially to his mum who witnessed her husband collapsing. As outcomes to the complaint, Mr X is seeking a financial remedy.

10. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so. We have discussed this with Mr X to understand the reasons why he could not do so. We have also considered the time the organisations have taken to respond to Mr X.

The Practice

11. Mr X is complaining about insufficient record keeping and failures of the Practice to pass on information about his father’s lack of mental capacity. Mr X explains he emailed the Practice in April 2023 to let them know his father was not to receive any more Covid-19 vaccinations. Mr X tells us he believes the failure to pass on this information in October 2023 led to the vaccination centre administering the Covid-19 vaccine to his father against his and his brother’s wishes.

12. Mr X complained to the Practice on 2 November 2023 about his father receiving the Covid-19 vaccine in October 2023 and informed them his father was in hospital.

13. The Practice responded to Mr X on 7 November 2023 to advise Mr X his father was vaccinated by the vaccination centre. On 14 November 2023, the Practice passed Mr X’s complaint to Dr A at the vaccination centre.

14. Mr X asked further questions vaccine to the Practice regarding the administration of the vaccine. On 11 December 2023, it advised Dr A had offered his explanations and gave Mr X the information for progressing his complaint to the Parliamentary and Health Service Ombudsman (PHSO).

The vaccination centre

15. Mr X is complaining the vaccination centre vaccinated their father at home despite Mr X’s brother declining consent for the Covid-19 vaccine over the phone. Mr X explained there was no consideration of his father’s lack of mental capacity prior to his vaccination in October 2023. He also complains the phone call was not recorded, notes from the appointment were destroyed, and no information leaflet for the vaccine was left.

16. On 27 November 2023, Mr X spoke to Dr A at the vaccination centre after being referred to him by the Practice. This was over the phone, and no written transcript is available for this phone call.

Timeline of Mr X’s further complaints

17. Mr X first approached PHSO on 27 March 2024. We declined to consider Mr X’s complaint at this time as he had not yet made a written complaint to Dr A at the vaccination centre. This meant the complaint was not yet ready for us to consider.

18. On 15 April 2024, Mr X emailed Dr A with his complaint and requested a formal written response from Dr A. We acknowledge that Mr X chased Dr A up on 22 April 2024 for a response.

19. On 24 July 2024, a caseworker at PHSO contacted Dr A asking for a written response to Mr X’s concerns. Dr A responded to this on 27 July 2024 stating he was waiting for contact from PHSO before responding to Mr X in writing. We acknowledge this resulted in a delay to Mr X’s complaint and that Mr X had done what he could to progress his complaint at that point.

20. On 7 August 2024, Dr A confirmed he was happy to resolve Mr X’s complaint locally. He explained he did not realise Mr X’s email from 15 April constituted a complaint.

21. On 23 August 2024, the caseworker explained to Mr X that the vaccination centre was happy to resolve his compliant locally. They also explained it was important his complaint to the vaccination centre contained the same issues as those he wished to bring to PHSO, to ensure they had the opportunity to respond to his concerns. They asked Mr X to confirm if he was still complaining about the Practice as well as the vaccination centre. Mr X told us he was no longer complaining about the Practice.

22. On 2 September 2024, Mr X’s case with PHSO was closed as premature to allow for the The vaccination centre to resolve Mr X’s complaint locally. The caseworker explained to Mr X his case had been closed, and he could come back to us if he was unhappy with the response from the organisation.

23. Dr A replied to Mr X’s complaint on 4 September 2024. We acknowledge Dr A took five months to respond to Mr X, and we are sorry for the frustration this caused Mr X. We have taken this delay into account during our time limit consideration.

24. We can see that Mr X was unhappy with Dr A’s response and actively chased further answers to his concerns. On 6 September 2024, Mr X contacted the caseworker and explained he had additional concerns further to his original complaint with PHSO. The caseworker explained Mr X must first raise these complaints to Dr A before we were able to look at them. They also advised we could open a new case for Mr X if he remained unhappy after Dr A had addressed these outstanding concerns. The caseworker confirmed Mr X’s complaint remained closed with us whilst Mr X raised his concerns with Dr A.

25. We acknowledge Mr X then went back to Dr A to address his further concerns, as per our processes. Mr X asked if he could speak to the vaccinator who administered the Covid-19 vaccine to his father. The vaccinator responded to Mr X and Mr X requested a meeting with the vaccinator as he was unhappy with his response. The vaccinator declined this meeting as he stated he had nothing to add to his response.

26. On 14 October 2024, Dr A explained to Mr X that he believed the situation could not be resolved further. We believe at this point it would have been reasonable for Mr X to approach PHSO and for us to open a new case for him as Dr A did not know how else to respond to Mr X’s concerns.

27. On 18 October 2024, Mr X requested his father’s medical records from the Practice. Mr X received the records on 13 November 2024 and contacted the Practice with concerns after reviewing the records. We acknowledge there was confusion regarding the administrations of the vaccinations to Mr X’s father. We understand he was trying to resolve his concerns with the Practice locally between November 2024 and January 2025.

28. On 14 February 2025, Mr X emailed Dr A and PHSO to explain he is still looking into his father’s case. He told us about the sad death of his mother, for which we were very sorry to hear about.

29. Mr X emailed Dr A and the Practice with further questions on 28 April 2025. Between April 2025 and May 2025, we acknowledge Mr X continued to chase up both organisations with answers to his concerns. Mr X approached PHSO on 28 May 2025 requesting help with getting responses, and to complain about the way the organisations were handling his complaint.

30. On 3 June 2025, the caseworker informed Mr X a new case would need to be opened to include the additional parts of his complaint. During a phone call on 4 June 2025, the caseworker explained to Mr X that his previous case had been closed in September 2024 as premature. Mr X explained he would email a summary of his new complaint to the caseworker.

31. On 6 June 2025 and 9 June 2025, the Practice and Dr A at the vaccination centre confirmed respectively they had exhausted their local complaints procedure and were unable to further answer Mr X’s questions. A new case was opened for Mr X on 6 June 2025.

32. Mr X told us on 6 June 2025 he was preparing a submission which would take a few months to prepare. On 13 June 2025, the caseworker emailed Mr X to inform him a new case had been opened for him. They included a list of Mr X’s concerns as part of his complaint and asked him to confirm they were correct by 27 June 2025. Mr X replied explaining he would be unable to respond until 10 August 2025 due to being on a long holiday.

33. As Mr X was not available to pursue his complaint with us at that time, his case was closed. Whilst we acknowledge Mr X informed us he was preparing a submission, the caseworker informed Mr X he would need to contact us when he returned from his holiday. They informed Mr X about the time limit and that it was important he contacted us promptly if he wanted us to consider his concerns.

34. We had no correspondence from Mr X until 1 December 2025 where he informed us he was compiling his submission. The caseworker reminded Mr X again about our time limit and the importance of bringing his complaint to us promptly. He sent his submission to us on 9 December 2025. In December 2025, Mr X’s complaint was 14 months out of time.

35. We acknowledge Mr X waited five months for an initial response from Dr A. We understand Mr X was actively chasing responses to his concerns from both organisations between October 2023 and June 2025. We therefore can waive the time limit consideration between this period as we understand Mr X was trying to resolve his complaint locally.

36. When asking Mr X about the reason for his delay in bringing his case back to us between June 2025 and December 2025, he told us he was conducting his own investigation regarding his complaint. Mr X explained he was pressing for further answers from the Practice and Vaccination Centre to ensure he had all the details.

37. We have considered the reasons for Mr X’s delay between June and December 2025. For us to pursue a complaint, we ask for complainants to fill in our complaints form and for a copy of their complaint and final response from the organisations. We do not request any further documents from our complainants. We appreciate the time and effort Mr X put into his submission.

38. Whilst we understand Mr X’s reasons for doing this, signed consent to our complaint form gives us the authority to request any necessary documentation such as clinical records or other information. As such, it is not necessary for a complainant to obtain the medical records before complaining to us.

39. It is important to note we would have considered Mr X’s complaint ready for us to investigate in June 2025, and we did not ask for any further documents from Mr X for us to be able to consider his complaint. In June 2025, both the Practice and the vaccination centre confirmed they could not further answer Mr X’s questions. As a result, we did not need any further responses from either organisation, and we would have been ready to proceed with Mr X’s complaint at that point.

40. We apologise Mr X feels our communication fell short regarding this. As Mr X’s case was closed between June 2025 and December 2025, we would not have contacted Mr X unless he asked us for further advice.

41. We understand Mr X returned from his holiday in August 2025. When his case was closed in June 2025, Mr X was informed he must return to us promptly if he wanted us to consider his complaint. Mr X did not return to us until December 2025. We consider he could have brought his complaint back to us sooner than he did. We have decided Mr X’s complaint falls outside of our time limit and have not identified any exceptional circumstances which would allow us to set the legal time limit aside. For this reason, we are unable to consider his complaint further. We understand this may be frustrating for Mr X and we are sorry we are unable to put our time limit to one side.

42. It is important we act within the law, and that we apply our current approach and process fairly and consistently. We understand how important the complaint is to Mr X and we are grateful to him for sharing his concerns.

43. We are sorry for any upset this decision may cause. We hope this statement clearly explains the reason why we will not be considering the complaint further.

1. We have carefully considered Mr X’s complaint about the Practice and the vaccination centre. Mr X’s complaint falls outside of our time limit, and we have decided there is no sufficient reason for us to put our time limit aside to consider it further.

2. We thank Mr X for taking the time to tell us about his upsetting experience. We were sorry to read about the death of his father and the impact this complaint has had on him and his family. It is important to acknowledge that being unable to put our time limit to one side for Mr X’s complaint does not detract from his experience or the impact of this. We hope this statement explains the reasons for our decision.