Clinical treatment outside hospital; GP:A GP Practice in the area of Hywel Dda University Health Board Report Date 07/10/2025 Case Against A GP Practice in the area of Hywel Dda University Health Board Subject Clinical treatment outside hospital; GP Case Reference Number 202404815 Outcome Early resolution Mrs A complained that the GP Practice had failed to provide appropriate care and treatment in relation to swabs and urine samples. She also had concerns about the safety of the swab that she had used, which had been placed in a charcoal solution, and that it might have been used on a previous patient. Mrs A was also dissatisfied with the GP Practice’s complaint handling and its complaint response.
The Ombudsman’s investigation found that there was a missed opportunity to have stopped Mrs A using the swab when she initially contacted the GP Practice querying whether it was safe. The situation caused Mrs A considerable anxiety and for this reason, and to this extent only, this part of Mrs A’s complaint was upheld.
The Ombudsman found no evidence that would suggest that the charcoal swab had been used or might have been used prior to Mrs A, nor was there any evidence that the charcoal was unsafe and may therefore have caused Mrs A physical harm. This aspect of Mrs A’s complaint was not upheld.
The Ombudsman’s investigation did identify administrative shortcomings amounting to maladministration in the GP Practice’s complaint handling process, especially around record keeping. As a result the investigation process was not as robust as it could have been and this caused Mrs A an injustice. This part of Mrs A’s complaint was upheld.
The GP Practice agreed with the Ombudsman’s recommendation that it review its handling of Mrs A’s complaint as a point of learning and that it develop an action plan to address any failings/additional failings identified, which it should share with the Ombudsman’s office.