GP oversight of specialist care
GPs lacking internal systems and a clear monitoring role to assess the quality and outcomes of specialist services.
Source spread
Where this theme appears
This theme appears across 11 independent accountability sources, so the source mix matters as much as the headline total.
8 inquiry recs
91 PFD reports
11 committee recs
4 CQC actions
8 PPO recs
2 DHR recs
69 PHSO decisions
12 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(8)
F123 — Responsibility for monitoring delivery of standards and quality
Recommendation: GPs need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services. They should be an independent, professionally qualified check on the quality of service, in particular in relation to an assessment …
Gov response: Accepted. GPs, both in their roles as care providers and in clinical commissioning groups, should be continuously reviewing the quality of care provided by the acute hospital and specialised services they commission. NHS England continues …
Accepted
18 — Role of general practitioners
Recommendation: The employment of general practitioners should be rationalised to cover the day-to-day needs of long-stay patients: but their valuable contribution should not be regarded as a substitute for specialist services.
Unknown
IBI-6a(vi) — Commissioning Hepatology Services
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those bodies responsible for commissioning hepatology services in each of the home nations should publish the steps they have taken to satisfy …
Gov response: We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease was acquired, …
Accepted
IBI-6a(v) — Consultant Hepatologist Access
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have had Hepatitis C which is attributable to infected blood or blood products should be seen by a consultant hepatologist, …
Gov response: We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease was acquired, …
Accepted in part
IBI-6a(iv) — Fibroscan for Liver Imaging
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Fibroscan technology should be used for liver imaging, rather than alternatives
Gov response: We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease was acquired, …
Accepted
IBI-6a(iii) — Uncertainty About Fibrosis
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Where there is any uncertainty about whether a patient has fibrosis they should receive the same care
Gov response: We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease was acquired, …
Accepted
IBI-6a(ii) — Specialist Hepatology Centre Access
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have fibrosis should receive the same care
Gov response: We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease was acquired, …
Accepted in part
IBI-6a(i) — Hepatologist Oversight and Fibroscan Access
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have been diagnosed with cirrhosis at any point should receive lifetime monitoring by way of six-monthly fibroscans and annual clinical …
Gov response: We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease was acquired, …
Accepted
Prevention of Future Deaths reports(91)— showing 50 strongest matches
Amna Umer Ahmed
Concerns: The coroner noted a potential low awareness of Sudden Arrhythmic Death (SAD) in general practice, alongside an apparent lack of, or awareness of, guidelines for GPs regarding urgent referrals for patients vulnerable to SAD.
Response (Royal College of General Practitioners): • The Royal College of General Practitioners stated that its GP Curriculum, which forms the foundation for GP training, covers cardiovascular disease, including prevention, cardiac arrhythmias, and emergency care. • … (AI summary)
Overdue
Jonathan Thorpe
Concerns: During GP consultations for a patient with depression and a history of self-harm, the coroner noted no reference to Mental Health Services, nor was advice sought regarding previous involvement or need for further input.
Overdue
Lucy Goulding
Concerns: Concerns were raised regarding the lack of consultant supervision for on-call paediatric trainees admitting emergency patients and the absence of independent consultant assessment for paediatric admissions at Worthing Hospital. The report also noted a lack of national guidelines for assessing and investigating headaches in children.
Response (Womens Childrens Division): • The Trust strengthened paediatric consultant involvement in all three handovers between shifts. • A baton bleep was introduced for the Attending Physician, and discussion of paediatric patients not yet … (AI summary)
Overdue
Jacqueline Allwood
Concerns: The coroner identified concerns regarding the absence of an agreed protocol for managing calf pain and suspected DVT at the Urgent Care Centre. Additionally, questions were raised about a specific GP's understanding and acceptance of normative diagnostic standards and the adequacy of practice changes.
Response (NHS England): • The Urgent Care Centre and Cator Medical Centre reported amendments to their triage process and the introduction of a new screening form. • The GP stated that the case … (AI summary)
Overdue
Yuki Ivy Norman-Knight
Concerns: The coroner identified concerns regarding St Stephens Gate Medical Practice's systems for practice nurses to access patient medical history, a lack of guidelines for nurses to refer patients to doctors, and no triggers for receptionists to book doctor's appointments, particularly for young children or babies.
Response (St Stephens Gate): • The practice reviewed and reinforced the need for all clinicians to check patient past clinical history at each appointment. • The practice is arranging for a paediatrician to present … (AI summary)
Responded
Michael Tarratt
Concerns: The coroner raised concerns about the infrequent communication between the Drug and Alcohol team and the GP, and the lack of routine information exchange between services regarding patient prescriptions.
Response (Leicestershire Partnership NHS Trust): • An urgent memo was sent to all Drug & Alcohol team members outlining new standards for GP communication, including initial assessment summaries, quarterly updates, and discharge notifications. • Standard … (AI summary)
Responded
Phyllis Barnes
Concerns: The coroner noted a visiting GP did not fully appreciate the patient's serious post-operative condition, and a nurse-led telephone consultation appeared superficial. Additionally, there was no formal opportunity for the patient's daughter to relay her mother's condition to healthcare providers.
Overdue
Rosemary Oladejo
Concerns: A lack of adequate communication between the GP practice and the responsible clinician meant the responsible clinician was unaware of the GP's unilateral titration of a patient's amitriptyline and its prescribed timing.
Response (Hillingdon Commissioning Group): • The CCG initiated an investigation into the case and requested a report from Central North West London Trust (CNWL). • Recommendations on medicines reconciliation were shared with Hillingdon, Brent, … (AI summary)
Response (Central North West London NHS Trust): • The Trust stated it would circulate a Clinical Risk Alert in the coming weeks, referencing this case in an anonymised form. • The Trust indicated it would present this … (AI summary)
Responded
Lisa Webb
Concerns: The coroner raised concerns about a general practitioner's suboptimal asthma management, citing insufficient respiratory assessment and monitoring. Additionally, the prescription of Diazepam for anxiety was noted as poor treatment, especially with sleep apnoea or respiratory distress.
Response (Basildon Road Surgery): • The GP stated they have improved record-keeping practices and now ensure patient reviews are up to date, medication is reviewed, and tests are requested at consultations. • A practice … (AI summary)
Overdue
Aimee Varney
Concerns: The coroner noted that the NICE Guidelines for referring a patient with suspected epilepsy to a Specialist Tertiary Centre were not followed.
Response (Luton Dunstable University Hospital): • The Trust described its existing systems for logging and disseminating NICE Guidelines. • The Trust stated it maintains a risk register for guidelines it cannot immediately comply with. • … (AI summary)
Responded
Sadik Miah
Concerns: The coroner identified a lack of regular consultant physician input for inpatients with physical health problems in psychiatric settings, which led to delays in obtaining specialist medical opinions for conditions such as hyponatraemia.
Overdue
Paul Hyde
Concerns: Concerns were raised regarding the advice provided by Community Mental Health Services to a GP, who sought guidance on a patient's deteriorating condition, to re-refer the patient to the Assessment and Treatment Service.
Response (Sussex Partnership NHS): • A meeting was held with clinical leads and managers to review referral management data and ensure triage decisions are clinically led. • The Service Manager for the Assessment & … (AI summary)
Overdue
Phyllis Barlow
Concerns: The coroner noted insufficient awareness among GP practices in Wales regarding NICE guidelines for head injuries in patients on warfarin, which recommend immediate hospital admission and CT scanning.
Response (NHS Wales): • Welsh Government officials are developing a Patient Safety Notice. • The notice will be issued to all local health boards and general practices in Wales to raise awareness of … (AI summary)
Responded
Brian Francis
Concerns: Concerns were raised about the reliability of a 'tick in the box' system for consultant attendance and the impact of unavailable community medical records at the time of hospital admission.
Response: • The hospital implemented an enhanced system requiring consultants to sign a new register after reviewing emergency medical patients in the ED and AMU. • The Health Board is piloting … (AI summary)
Overdue
Mary Marshall
Concerns: The coroner identified a lack of awareness among healthcare practitioners, especially General Practitioners, regarding the significance of GDH positive results for Clostridium Difficile risk and future antibiotic prescriptions. Concerns were also raised about the absence of consistent procedures in hospitals nationwide for communicating these results to primary care providers.
Response (Department of Health1): • NHS England's Antimicrobial Resistance work programme has promoted C. diff testing through national workshops and a study, making materials available online. • NHS England will work with partners to … (AI summary)
Responded
Jorge Castro
Concerns: The coroner noted a lack of systems at Springfield Medical Centre to identify uncollected prescriptions, particularly for vulnerable patients needing anti-epileptic medication. This meant General Practitioners were not alerted when the patient did not collect vital medication, despite prior consultant concerns about adherence.
Response (Springfield Medical Centre): • The practice implemented an alert system in patient records to highlight known medication compliance issues. • The IT system was amended to highlight overdue prescriptions after three months, and … (AI summary)
Responded
Michael Uriely
Concerns: The care management for chronic asthma lacked coordination, long-term planning, and adherence to clinical guidelines. Concerns also included insufficient communication between primary and secondary care, and a failure to refer to a tertiary respiratory service.
Response (Uriely): • NHS England detailed several ongoing initiatives, including the National Paediatric Asthma Collaborative, a national asthma audit, and the development of an e-learning pack and a severe paediatric asthma database. … (AI summary)
Response (Uriely Response2): • NICE has produced a quality standard on asthma that includes statements on coordinated care, personalised action plans, and specialist reviews. • NICE is developing new guidelines on asthma diagnosis, … (AI summary)
Overdue
Grant Richards
Concerns: The coroner noted the GP surgery's failure to action a recommended chest clinic follow-up from an A&E discharge summary, alongside a lack of contingency systems and poor attention to documents, including faxes from mental health agencies.
Overdue
Jamie Elliott
Concerns: The coroner raised concerns that mental health clinicians did not contact external providers when a patient was receiving treatment elsewhere, and that a worsened patient's condition did not trigger a prompt consultant psychiatric assessment.
Response (East London NHS Trust): • The issue of clinicians not contacting external providers is due to be discussed at an Incidents and Lessons Forum, with information to be disseminated to borough teams. • New … (AI summary)
Responded
Michael Halfpenny
Concerns: The coroner raised concerns about a GP's incorrect referral for vascular screening and a lack of a hospital system to direct such requests, leading to refusal. Issues also included GP uncertainty regarding the screening programme criteria.
Response (Glenfield Surgery): • The practice conducted a significant event analysis, discussed the case with all practitioners, and escalated the incident to a serious incident with the Clinical Commissioning Group (CCG). • The … (AI summary)
Response (University Hospitals of Leicester NHS Trust): • The Trust confirmed it had implemented a new system for redirecting imaging referrals sent to incorrect teams. • The Trust stated it would update the guideline for rejecting imaging … (AI summary)
Response (East Leicestershire and Rutland Clincial Commisioning Group): • The signed final report regarding the Serious Incident investigation has been enclosed. • The family has been contacted to share the report. • The final report will be shared … (AI summary)
Responded
Dean Rowland
Concerns: The coroner noted delays in the deceased's ability to discuss antidepressant medication with a GP and concerns about his discharge from the community mental health team after a single consultation without a follow-up plan, despite prior suicide attempts.
Response (South Staffordshire and Shropshire Healthcare): • The Community Mental Health Team (CMHT) conducted an assessment of Mr. Rowland's needs within expected referral timeframes. • The CMHT determined Mr. Rowland was at low risk for self-harm … (AI summary)
Response (Peel Medical Practice): • The practice has instituted a duty doctor and telephone triage system. • Patients requiring an appointment sooner than a routine slot are offered a callback from the duty team. … (AI summary)
Responded
Violet Nelson
Concerns: The coroner noted insufficient oversight by consultant radiologists for ultrasonography reports and a potential lack of awareness among general practitioners regarding the implications of supra-renal aortic aneurysm findings for thoracic aortic aneurysms.
Response (NHS Engalnd): • NHS England will ensure the NICE lead for the Abdominal Aortic Aneurysm Clinical Guideline is made aware of the Regulation 28 letter and the concerns raised. • NHS England … (AI summary)
Response (Royal College of General Practitioners): • The Royal College of General Practitioners (RCGP) agreed that general practitioners (GPs) are generally unlikely to be aware that a supra-renal aortic aneurysm should raise concerns about a thoracic … (AI summary)
Response (SoR): • The Society of Radiographers (SCoR) will review its 2017 guidelines with the British Medical Ultrasound Society (BMUS) to include guidance on referring suspected supra-renal abdominal aortic aneurysms for thoracic … (AI summary)
Responded
Stuart Campbell
Concerns: The coroner noted that an escalation policy between ADS and Pennine Care was not followed, and ADS workers lacked clear guidance and clinical support. There were also concerns regarding the documentation and facilitation of shared care discussions, especially as the GP had not seen the deceased.
Response (Addiction Dependency Solutions): • All shared care staff will receive additional training and re-training on the standard operating protocol, escalation procedures, and multi-disciplinary shared care discussions by 20th December 2017. • Full care … (AI summary)
Responded
Keith Harwood
Concerns: The coroner is concerned that medical staff may lack access to urgent specialist advice when faced with unfamiliar conditions, potentially leading to families needing to educate staff about their condition's implications.
Response: • The Trust appointed a Consultant Physician in Care of the Elderly with expertise in Parkinson's disease in August 2016. • A procedure for the acute management of in-patients with … (AI summary)
Responded
John Worthington
Concerns: The A&E department did not conduct further imaging for a significant head injury in a borderline case. A GP later did not take full observations for persistent back pain, potentially delaying diagnosis of a developing problem.
Response (MDDUS): • The GP stated she would always take and document a full set of observations when examining patients in future. • The GP stated she would consider referrals for x-rays … (AI summary)
Overdue
Rita Taylor
Concerns: The coroner identified failures in the appropriate management of hyponatraemia, including a lack of adherence to national guidelines for treatment and monitoring serum sodium levels. Concerns were also raised about inadequate medical planning, poor documentation, and an insufficient understanding of hyponatraemia management by some consultants.
Response (Epsom and St Helier University Hospitals NHS Trust): • The Trust updated and made accessible its guidance on hyponatraemia management and committed to further staff education. • A new pro forma for patient monitoring plans is being devised, … (AI summary)
Overdue
Daniel Young
Concerns: GP surgeries do not routinely monitor that psychiatric patients are collecting their antipsychotic medication, which can lead to relapse and increased risk of harm.
Response (Department of Health Social Care): • NHS England will write to GP practices to raise awareness of monitoring antipsychotic prescription collection. • NHS England will explore with NHS Digital opportunities for primary care systems to … (AI summary)
Responded
Michelle Roach
Concerns: The coroner identified a need for a GP to review knowledge of venous thromboembolism signs and symptoms and record-keeping practices, and for the practice to improve its system for investigating unexpected deaths. Concerns were also raised regarding the hospital trust's level of medical registrar cover at night.
Overdue
Robin McEwan
Concerns: The coroner identified a lack of direct communication between private therapy and the GP regarding the patient's welfare, and insufficient exploration of potential family support when professional help was not immediately available.
Response (Harrogate CCG): • The CCG will review the referral process for private counselling services to ensure GPs are informed of patient progress. • The CCG will review and further develop its website … (AI summary)
Responded
Ursula Keogh
Concerns: The coroner highlighted a need to review GP referral practices to schools for CAMHS consideration and improve communication between health and education professionals to eliminate contradictory advice. Additionally, the report called for consideration of fast-tracking preventative measures at North Bridge, Halifax.
Response (Department of Health and Social Care): • The Department for Education updated its guidance, 'Mental health and behaviour in schools,' to include advice on identifying mental health problems and making efficient CAMHS referrals. • The Department … (AI summary)
Response (Calderdale CCG): • A review of the existing CAMHS referral pathway for GPs and schools was completed, and new actions for external training and education were identified. • The multi-agency Open Mind … (AI summary)
Responded
Sylvia Mitchell
Concerns: The coroner identified inadequate communication between the Trust and GP advising on the urgent removal of a pessary. Concerns were also raised regarding insufficient follow-up, routine cleansing, and monitoring of vaginal integrity during pessary use.
Response (Oaks Medical Centre): • The practice stated that a referral for pessary removal was made in 2016, following a patient cancellation in 2013. • A home visit in February 2017 identified no visible … (AI summary)
Response (Sandwell and West Birmingham Hospital NHS Trust): • The Trust stated that the patient had been sent two appointments for the removal of her ring pessary. • The Trust indicated it would provide a new appointment date … (AI summary)
Response (Sandwell and West Birmingham NHS Trust): • The Trust confirmed that patients receiving pessary insertions now receive an information leaflet outlining follow-up needs and risks, which will be shared with primary care colleagues. • The Trust … (AI summary)
Responded
Megan Jones
Concerns: The coroner identified a lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding regular QTc recording, which is particularly crucial for those prescribed high doses.
Overdue
Nathan Cooke
Concerns: The coroner noted the absence of a formal process for primary care practices to manage patients prescribed medication requiring regular monitoring, particularly when patients do not attend reviews.
Overdue
Miriam Tighe
Concerns: The coroner noted a lack of awareness between GPs and a psychiatrist regarding medication decisions, leading to continued prescribing of a drug after it was advised to be stopped, and subsequent over-sedation.
Overdue
Graham Earl
Concerns: The coroner noted GPs' insufficient understanding of a medication's link to pulmonary fibrosis and their lack of awareness regarding escalation procedures for side effects. Additionally, a GP amended a secondary care prescription without consulting the prescribing physician.
Overdue
Kaiya Campbell
Concerns: The coroner noted a gap in GP records regarding prescribed anticonvulsant medication. Clinical staff at GP and midwifery appointments did not identify the need for urgent neurology guidance concerning medication for an epileptic mother, leading to a routine rather than high-risk consultant appointment.
Overdue
Sharon Reeve
Concerns: The coroner noted a lack of clear pathways for district general hospital radiologists to obtain direct specialist neuroradiological opinions, leading to inappropriate referrals. Suboptimal communication between the hospitals further delayed accurate diagnosis due to unclear questions, incomplete information, and slow image transfer.
Overdue
Stuart Clarke
Concerns: The coroner noted the absence of national guidelines for referring patients with known valve disease from primary to secondary care, or secondary to tertiary care.
Response (NHS Eng and NHS Imp): • Manchester Foundation Trust has begun reviewing systems between its two cardiac centres to expedite service for patients with this heart condition. • The Greater Manchester Cardiac Network will explore … (AI summary)
Response (Department of Health and Social Care): • NICE is developing a clinical guideline on heart valve disease in adults, which is expected to cover investigation, management, and referral indications. • The concerns from the coroner's report … (AI summary)
Response (National Institute for Health and Care Excellence): • NICE stated it is developing a new clinical guideline on heart valve disease in adults, which will include indications for patient referral from primary care to a specialist. • … (AI summary)
Response (BCIS): • The British Cardiovascular Intervention Society (BCIS) published an updated service specification for Transcatheter Aortic Valve Intervention (TAVI). • The specification recommends a maximum waiting time of 18 weeks between … (AI summary)
Overdue
Joanna Flynn
Concerns: The coroner identified a lack of specialised assistance and referral agencies for General Practitioners to help patients wean off addictive prescription opiates. Concerns were also raised about the sufficiency of training and education for GPs in this area of care.
Response (NHS England): • A review group has been established to address dependence on and withdrawal from prescribed medicines, including opiates. • NHS England continues to provide primary care with additional funding, staff, … (AI summary)
Response (the Department of Health and Social Care): • Public Health England published an evidence review in September 2019 on the scale and causes of prescription drug dependence. • The National Institute for Health and Care Excellence (NICE) … (AI summary)
Response (Mid Essex CCG): • The CCG has developed and is implementing a Local Enhanced Service to provide multi-professional expert support and education for GPs and patients managing prescribed opioid dependence. • The CCG … (AI summary)
Overdue
Brenda McWilliams
Concerns: Medical practitioners did not continue VTE preventative medication for Mrs McWilliams after discharge despite her high risk. This reflects a broader concern that the interpretation of NICE guidance may lead to high-risk community patients not receiving VTE-minimising medication.
Overdue
Brenda Drew
Concerns: The coroner noted a lack of formal GP review for repeat Oramorph prescriptions and raised concerns that pharmacists requested repeat medications from GPs without confirming the patient's wishes.
Response (RPS): • The RPS confirmed it published guidance in 2015 for pharmacy teams on requests for prescriptions to GPs, covering consent and pharmaceutical care. • The RPS stated it would continue … (AI summary)
Responded
Anita Loi
Concerns: The coroner noted a lack of action on managing a patient's leg wound despite multiple referrals, and community nursing teams did not engage with the GP to discuss the death. Concerns were also raised about the adequacy of referral policies and response protocols.
Response (Central London Community Healthcare NHS Trust): • The Trust updated its Triaging Standard Operating Procedures to ensure robust management and response to referrals, including checks for patients open to multiple services and initiating joint working. • … (AI summary)
Responded
Darren King
Concerns: The coroner identified gaps in effective follow-up for high-risk patients with learning disabilities who disengage, and a lack of clear escalation processes. A missing structured medication review in care plans also limited staff awareness of compliance and referral routes.
Overdue
Jake Perry
Concerns: Variations in parenteral nutrition management and communication were identified for patients with medical conditions overseen by other hospitals. The coroner noted the need for a named local consultant and for specialist departments to be consulted upon admission.
Response (Birmingham Women and Childrens NHS Trust): • The Trust commissioned an investigation into the care and treatment provided to Jake. • The Trust implemented national guidance on homecare medicines and submitted evidence to a national review … (AI summary)
Response (Wye Valley NHS Trust): • The Trust developed and implemented standard operating procedures for its medical and surgical divisions. • These procedures address the need for a named local consultant for patients with medical … (AI summary)
Responded
Natasha Abrahart
Concerns: The mental health trust and GP practice did not follow NICE guideline CG90, which requires a 1-week follow-up for patients under 30 or with increased suicide risk when starting antidepressants, to monitor for side effects including suicide risk.
Response (AWP): • The Trust distributed a Red Top Alert to relevant personnel, instructing them to follow NICE Guidance for antidepressant prescribing, including requirements for communication with primary care and documentation. • … (AI summary)
Response (the Department for Health and Social Care): • Health Education England (HEE) launched Self Harm and Suicide Prevention Frameworks in October 2018, which highlight the importance of health professionals having knowledge of national guidance, including NICE guidelines, … (AI summary)
Response (University of Bristol): • The practice amended its health assessment template to include a prompt for follow-up after commencing SSRIs and added a field regarding SSRI and suicidality. • The practice moved to … (AI summary)
Responded
Patricia McAdam
Concerns: The coroner identified a lack of a robust system to ensure regular assessment of patients who decline contact or care from healthcare providers but continue to receive repeat prescriptions.
Overdue
Sam Pringle
Concerns: The coroner noted that some psychiatrists ask GPs to instigate Lithium prescriptions, contravening the shared care protocol. This practice leads to delays or non-provision of essential medication for mentally ill patients.
Response (Greater Manchester Medicines Management Group NHS Stockport Clinical Commission Groupw): • Stockport CCG communicated with General Practice colleagues to highlight shared care issues and ensure reporting for oversight. • Pennine Care senior managers and clinicians reasserted the importance of communication … (AI summary)
Responded
Katie Corrigan
Concerns: The coroner noted that other doctors and dispensing pharmacists did not contact the patient's registered GP about opiate prescriptions. There is also no formal national procedure for circulating patient alerts to pharmacies, limiting their effectiveness.
Response (CQC): • The CQC inspected the registered online providers identified in the inquest and took regulatory action where concerns were found. • The CQC identified two unregistered online providers and is … (AI summary)
Response (Dept of Health and Social Care): • Officials brought the coroner's concerns regarding the effectiveness of NHS England and NHS Improvement’s (NHSEI’s) alert system to NHSEI’s attention. • The response outlined the existing NHSEI Controlled Drugs … (AI summary)
Responded
Andrew Biddlecombe
Concerns: The deceased was not advised about the impact of his medical conditions and medications on driving safety or the legal requirement to notify the DVLA. Additionally, the medical practice did not inform the DVLA of these conditions.
Response (Emsworth Surgery): • The surgery undertook a significant event analysis. • The surgery reviewed chronic disease review templates to ensure they include questions on patient driving status. • The surgery wrote to … (AI summary)
Responded
Rory Attwood
Concerns: The coroner noted that the patient's General Practitioner was not involved in the serious untoward incident investigation, despite the patient being under community care. This raised concerns about learning opportunities and better partnership working in such reviews.
Responded
Select committee recommendations(11)
#3 —
Recommendation: NHS England’s existing oversight arrangements are not improving GPs’ assessment and support of people with frailty. It is not clear exactly who is responsible for improving performance. NHSE considers that ICBs are responsible for commissioning services to meet the needs …
Response attribution not verified
#4 —
Recommendation: NHS England has overloaded GPs, who have limited capacity, with new and expanding priorities. NHSE has prioritised improving patients’ access and digital access to general practice. It recognises that pushing to improve one aspect of care inevitably causes consequences to …
Response attribution not verified
#14 —
Recommendation: NHSE&I was not responsible for managing any local variations and did not challenge local clinical decisions.28 DHSC has told us that NHSE&I and NHS Digital considered that ultimately additions were a decision for local clinicians. It noted that the approach …
Response attribution not verified
#3 —
Recommendation: Huge local variation strongly suggests that GPs were inconsistent when judging who was clinically extremely vulnerable and should therefore be advised to shield and be eligible for support. As well as NHS Digital using national data to identify clinically vulnerable …
Response attribution not verified
#17 —
Recommendation: We asked about how patients other than the longest waiters and those with the highest clinical priority would be supported while they waited. NHSE&I stated that GPs had a role in managing these patients and that it was also asking …
Response attribution not verified
#15 —
Recommendation: NHS Digital told us that for the people whom it had identified and added centrally to the list, in line with the clinical criteria set by the chief medical officers, there is very little variation by area.30 DHSC acknowledged that …
Response attribution not verified
#83 —
Recommendation: If a review concludes that it is inadvisable to make GPs’ engagement with the firearms licensing process mandatory, we recommend that statutory guidance emphasise the strong expectation that GPs who object conscientiously to engaging with the firearms licensing process will …
Response attribution not verified
#15 — GP advice and guidance scheme demonstrates significant growth in specialist input
Recommendation: NHSE said that it had made progress in some areas, partly where necessity during the Covid 19 pandemic had driven the adoption of technology. NHSE highlighted the advice and guidance scheme, which allows GPs to request specialist input without going …
Response attribution not verified
#13 —
Recommendation: NHSE&I asked GPs and hospital doctors to add or remove people from the list, based on their clinical judgement, and as their patients’ conditions or treatments changed over time.26 However, the extent to which the list grew between 12 April …
Response attribution not verified
#11 —
Recommendation: As well as NHS Digital using patient data to add people to the shielding list, GPs and hospital doctors were asked to review the list and use their clinical judgement to add or remove people. GP and hospital doctors’ additions …
Response attribution not verified
#73 —
Recommendation: GPs’ involvement is key to the firearms licensing process. For example, Superintendent Steven Duncan, Head of National Firearms and Explosives Licensing for Police Scotland, told us: “We are quite clear that if your GP practice is not willing to put …
Response attribution not verified
CQC inspection actions(4)
Charlton House Medical Centre
Although the practice had introduced a formal programme of clinical meetings there was no evidence of links with multidisciplinary teams to adequately review treatment and monitoring of patients with complex medical issues this continued to place patients at risk of …
Must Do
Gillmoss Medical Centre
Continuetoundertakemedicationreviewsforpatientsprescribedrepeatmedicines.
Should Do
Reside at Southwood
people's nutrition and hydration needs were not being met. Advice from health care professionals was not always sought or followed up, to ensure people received care in a safe way.
Must Do
Oakleigh House Nursing Home
The care and treatment of service users did not always meet their medical needs appropriately, by discussing the service users' treatment choices with a competent health care professional or other competent person to manage the service users care and treatment. …
Must Do
PPO death in custody recommendations(8)
The Head of Healthcare and the Lead GP (HMP Oakwood)
The Head of Healthcare and the Lead GP should review the terms of reference of the multi-professional complex case clinic/conference (MPCCC) process to ensure that: • crucial information is appropriately reviewed and shared at meetings, and • patients receive continuity …
The Head of Healthcare
The Head of Healthcare should ensure that GPs conduct a full, documented clinical assessment, in line with relevant guidance, to inform medication reviews and changes.
The Head of Healthcare
The Head of Healthcare should ensure that patients with long-term conditions undergo reviews and receive treatment as outlined in NICE guidelines.
The Head of Healthcare
The Head of Healthcare should ensure that long-term conditions, such as diabetes, are managed in line with national guidance.
The Head of Healthcare
The Head of Healthcare should ensure that specialist advice is sought to manage long-term conditions such as diabetes.
The Head of Healthcare
The Head of Healthcare should review the GP triage process to ensure prisoners are placed on the correct waitlist depending on their need.
The Head of Healthcare and the provider’s Lead GP (HMP …
The Head of Healthcare and the provider’s Lead GP must be assured that all staff are fully aware of the local operating procedure related to “GP referrals to hospital” and that this is followed at all times.
The Head of Healthcare
The Head of Healthcare should ensure that: • newly arrived prisoners are seen by a GP if they are referred for a GP assessment; and • if a prisoner is not seen, the GP records the reason in the prisoner’s …
Health investigations(17)
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 40
The Royal Colleges should provide guidance as to the circumstances (if any) when GPs should maintain sole care of a patient with severe and enduring mental health needs, including the prescribing, administering and monitoring of psychiatric medication, without any secondary care involvement.
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 39
There should be a clear statement from the Royal College of General Practitioners dealing with the issue of GPs taking primary frontline decisions about treatment and prescribing medication for mentally disordered patients. These matters should also be considered by the College as a training issue.
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 9
The prescribing and administration of depot anti-psychotic medication in primary care should be reviewed. We suggest the following: (cid:2) Depot medication should normally be prescribed and given by the CMHT (cid:2) Depot medication should not be initiated in primary care (cid:2) If the patient prefers to receive his/her depot medication …
london
Independent investigation: Asiya Khatun, Newham (2000) — Rec 17
Newham Primary Care Trust, having consulted with the Medical Director of East London and The City Mental Health NHS Trust, should issue advice to GPs through its clinical governance arrangements regarding best practice in the prescription of anti-psychotic medication, updating the advice from time to time. Prescribing patterns should be …
london
Independent investigation: Asiya Khatun, Newham (2000) — Rec 3
East London and The City Mental Health NHS Trust and Newham Primary Care Trust should put in place shared care protocols for the clinical management of people with severe mental illness; the protocols should allow for the availability of informal advice to GPs from consultant psychiatrists.
london
Independent investigation: Valerie Jozunas, Wimbish, Saffron Walden (2020) — Rec 8
This investigation fully supports the recommendation from the EPUT investigation that they should ensure any significant concerns from the GP regarding a patient’s health must be brought to the attention of the patient’s consultant Psychiatrist.
east_of_england
Independent investigation: Sandra Crawford, St Albans (2010) — Rec 12
GP surgeries should ensure that even when such specialist care is received by patients with long term conditions, regular, yearly visits to the primary care team should be maintained.
east_of_england
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 30
Bearing in mind the current variations of counselling practice that currently exist, guidance should be made available to G.P.s as to the most effective use of the differing forms of counselling.
midlands
Independent investigation: Beata Slomiana, Finchley (2010) — Rec R3
The trust should examine whether a route for direct consultation by GPs with consultants is needed and whether this can be offered without undermining the general referral processes.
london
Independent investigation into the care and treatment of Mrs A … — Rec 5
NHS Greenwich CCG must assure themselves that there are systems in primary care to monitor the treatment of patients under secondary mental health care.
Mrs A and Miss B, published on 03 July 2019. Mrs A and Miss B was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation into the care and treatment of Mr M … — Rec 8
This investigation fully supports the recommendation from the EPUT investigation that they should ensure any significant concerns from the GP regarding a patient’s health must be brought to the attention of the patient’s consultant Psychiatrist.
east_of_england
*Independent investigation into the care and treatment of Mr A: … — Rec 12
GP surgeries should ensure that even when such specialist care is received by patients with long term conditions, regular, yearly visits to the primary care team should be maintained.
Hertfordshire Partnership NHS Foundation Trust
east_of_england
Independent investigation: Karina Menzies, Cardiff (2012) — Rec 7
The Welsh Government should seek assurance that there are protocols in place between Health Boards and Primary Care for all patients with psychoses. The protocols should include arrangements for medication monitoring and routine physical health checks in accordance with existing guidance. They should be clear about the respective responsibilities of …
wales
Independent investigation: Joanne Butler, East Shilton, Leics (2006) — Rec R6
NHS Leicestershire County and Rutland PCT should review the support available to GPs who act as the main contact for people with mental health problems (B).
midlands
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (vii)
The Trust should devise and implement a procedure whereby a patient who has attended at the Out-patient Clinic for a period in excess of one year is thereafter invariably seen by a Consultant.
london
Independent investigation: Peter Hartley, Keighley (2001) — Rec 6.1.3
Develop GP training relating to referrals into secondary care, agreeing joint access criteria.
north_east_yorkshire
Independent investigation into the care and treatment of Mr DB: … — Rec 6
Pennine Care NHS Foundation Trust, Stockport CCG : implement a system for follow up and monitoring of GP physical health checks re psychiatric medication
Mr DB . At the time of homicide December 2014 Mr DB was receiving care and treatment from Pennine Care NHS Foundation Trust
north_west
PHSO casework decisions(69)
P-001511 — A healthcare provider in the Nottingham area
Mr D complained about a delayed urgent dermatology appointment due to an administrative error and a consultant prescribing medication for vasculitis without prior examination or biopsy.
NHS in England
Partly Upheld
Jul 2022
P-002669 — A practice in the Suffolk area (the Surgery)
Mrs A complained multiple NHS organisations provided inadequate care to her late mother, including delayed cancer treatment, poor follow-up, and communication failures.
NHS in England
Jun 2024
P-003710 — A practice in the Croydon area
Mr F complained the Practice failed to communicate blood pressure test results and delayed GP appointments following a lung health check and cardiology letter, causing distress.
NHS in England
Jul 2025
P-003932 — A practice in the Exeter area
Miss B complained the Practice failed to arrange timely specialist support for her mother, and a GP was unprofessional and rude. She also complained about the Practice's poor complaint handling.
NHS in England
Partly Upheld
Sep 2025
P-004074 — A practice in the West Berkshire area
Mrs H complained her brother's GP failed to monitor his Atorvastatin use and blood pressure, and did not refer him for persistent UTIs, contributing to his death.
NHS in England
Sep 2025
P-004272 — A practice in the Cotswold area
Mr M complained his GP failed to refer him for a hip replacement in November 2022, leading to prolonged pain and financial hardship from private treatment.
NHS in England
Nov 2025
P-004293 — A practice in the Stockport area
Mr A complained the GP practice delayed referring him for tests despite symptoms and a seizure, leading to a delayed diagnosis of temporal lobe epilepsy and a brain lump.
NHS in England
Nov 2025
P-004309 — Manchester University NHS Foundation Trust
Miss N complained a podiatrist failed to see her father in person or properly check his condition, leading to early discharge and delayed care, which she believes contributed to his death.
NHS in England
Nov 2025
P-004721 — A practice in the Stratford-on-Avon area
Mrs A claimed GPs failed to consider and refer her for ADHD diagnosis, inappropriately managed anxiety, and provided ineffective referrals, causing delayed diagnosis and prolonged symptoms.
NHS in England
Jan 2026
P-004722 — Wirral University Teaching Hospital NHS Foundation Trust
Mr F complained the Trust wrongly decided he was ineligible for an insulin pump, arguing he meets the criteria due to his inability to self-inject and reliance on family support.
NHS in England
Jan 2026
P-001347 — NHS Devon Clinical Commissioning Group
Miss T complained about delayed GP referrals by NHS Devon CCG, a hospital declining a rheumatology appointment, and the CCG refusing to address complaints older than a year.
NHS in England
Mar 2022
P-001320 — Barts Health NHS Trust
Ms U complained about inadequate care for a skin condition, unnecessary antidepressant prescription, and significant delays by Barts Health NHS Trust in handling her complaint.
NHS in England
Mar 2022
P-001605 — A medical practice in the Cambridgeshire area
Mrs P complained the GP failed to refer Mr P to the neurological rehabilitation team for Botox injections, causing a significant delay and severe deterioration of his arm.
NHS in England
Nov 2022
P-001765 — Mid Yorkshire Hospitals NHS Trust
Ms G complained the Trust missed a meningioma on a 2017 MRI scan and failed to arrange follow-up, leading to its growth and requiring urgent surgery in 2021.
NHS in England
Jan 2023
P-001698 — The Royal Wolverhampton NHS Trust
Mrs O complained a locum consultant mismanaged her mother's treatment and The Royal Wolverhampton NHS Trust failed to implement Root Cause Analysis report recommendations.
NHS in England
Partly Upheld
Jan 2023
P-001739 — A practice in the Worcestershire area
Mrs O complained her son's GP dismissed health concerns and mishandled blood tests, delaying his severe haemophilia A diagnosis, affecting treatment and subsequent family planning.
NHS in England
Jan 2023
P-001699 — A practice in the Lancashire area
Miss B complained her uncle's GP practice failed to properly assess and diagnose his condition, made an incorrect ambulance request, and mishandled her complaint.
NHS in England
Jan 2023
P-001718 — A GP practice in the Gateshead area
Mrs R alleged her GP practice failed to conduct a face-to-face assessment or hospital referral for her husband's serious symptoms, leading to his death from cardiac arrest.
NHS in England
Jan 2023
P-001839 — A practice in the Hertfordshire area
Mrs I alleged an out-of-hours GP missed diagnosing her mother's perforated colon, peritonitis, and sepsis due to inappropriate conduct and incomplete examination, leading to her death.
NHS in England
Jan 2023
P-001700 — University Hospitals Birmingham NHS Foundation Trust
Clinicians at the Trust did not take Mrs I's endometriosis seriously, delayed treatment, and advised her to 'persevere', causing ongoing pain and affecting potential fertility.
NHS in England
Jan 2023
P-001728 — A practice in the Liverpool area
The Practice misdiagnosed Mrs A with plantar fasciitis, offered inappropriate pain treatment, and refused referrals until private treatment was sought, causing pain and anxiety.
NHS in England
Jan 2023
P-001878 — The Newcastle Upon Tyne Hospitals NHS Foundation Trust
Mrs B complained the Trust did not recommend a stomach-lining medication with her anti-inflammatory drugs, causing an ulcer. She also alleged delayed treatment for her arthritis.
NHS in England
Mar 2023
P-003897 — A GP practice in the Wirral area
Ms E alleged misdiagnosis of her skin condition, inappropriate treatments, and delayed dermatology referral by GPs, causing suffering and financial strain.
NHS in England
Sep 2023
P-002260 — A GP practice in the Cornwall area
A patient complained a GP practice refused a urology referral and a GP used inappropriate language in her records, causing pain, bladder weakness, and distress.
NHS in England
Oct 2023
P-002632 — Royal Devon University Healthcare NHS Foundation Trust
Mr H complained the Trust's paediatrician mismanaged his grandson's medication and lacked leadership, causing his mental health to deteriorate.
NHS in England
May 2024
P-002599 — A practice in the Wigan area
Mr E complained the Practice failed to assess his father's severe pain and weight loss, leading to a delayed cancer diagnosis and death. Complaint handling was also poor.
NHS in England
Upheld
May 2024
P-002594 — Imperial College Healthcare NHS Trust
Mr E complained the Trust wrongly stopped his ambulatory oxygen prescription in February 2023, causing low oxygen saturation, restricted activity, and potential organ damage.
NHS in England
May 2024
P-002761 — A practice in the Hackney area
Miss P complained the Practice abruptly stopped her mother's medication without review, and then lied in its complaint response, which she believes led to her mother's death.
NHS in England
Jul 2024
P-002812 — A practice in the Oldham area
Mr O complained the Practice cancelled his monthly prescription, leaving him without medication for five days, which caused severe pain, asthma attacks, and suicidal thoughts.
NHS in England
Not Upheld
Jul 2024
P-002838 — A practice in the North West London area
Miss A complained about inadequate care for her mother's chesty cough and poor communication, leading to delayed diagnosis of pneumonia and lung cancer.
NHS in England
Aug 2024
P-002883 — A practice in the Solihull area
Miss A complained the Practice failed to identify her breast cancer or refer her for relevant tests, despite her feeling a lump.
NHS in England
Aug 2024
P-002896 — A practice in the Tameside area
Miss H complained the Trust and Practice failed to diagnose her son's pyloric stenosis, dismissed her concerns, and delayed hospital referral.
NHS in England
Aug 2024
P-002853 — A practice in the City of Bristol area
A complainant alleged a GP misdiagnosed her mother's symptoms and failed to suspect an aneurysm, denying treatment and preventing the family from saying goodbye before her death.
NHS in England
Aug 2024
P-002927 — A practice in the Northumberland area
Mr O complained the Practice failed to make correct referrals or treat his spine symptoms since 2019, resulting in permanent damage, weakness, and chronic pain.
NHS in England
Sep 2024
P-003224 — A practice in the Manchester area
Miss Q complains the Practice delayed referring her to a long COVID clinic and for dyslexia support, and failed to monitor her blood pressure.
NHS in England
Dec 2024
P-003235 — A practice in the Croydon area
Mrs T complained the Practice failed to adequately manage her mother's conditions, including delayed UTI referrals and poor follow-up on specialist recommendations, impacting her mother's suffering and cancer diagnosis.
NHS in England
Partly Upheld
Dec 2024
P-003592 — A practice in the North East Derbyshire area
Mrs A complained a GP practice failed to perform a physical examination for her severe pain, refused pain relief, and omitted crucial information from a neurosurgery referral, causing prolonged suffering and delayed diagnosis.
NHS in England
Jun 2025
P-003622 — Mid Yorkshire Teaching NHS Trust
Mr E complained Mid Yorkshire Teaching NHS Trust failed to action a rheumatology referral, blamed the GP, and provided false information to the PHSO, causing an eight-month delay in diagnosis and pain.
NHS in England
Jun 2025
P-003704 — Oxford University Hospitals NHS Foundation Trust
Mrs T complained the Trust inadequately considered evidence when declining an immunology referral for her daughter, whose recurring infections and seizures remain uninvestigated.
NHS in England
Jul 2025
P-003709 — North Middlesex University Hospital NHS Trust
Mrs B complained the Trust wrongly discharged her husband instead of referring him to oncology, believing it was a missed opportunity for earlier treatment or a better outcome.
NHS in England
Partly Upheld
Jul 2025
P-003691 — A practice in the Teignbridge area
Ms R complained the Practice did not appropriately respond to her blood test results, failing to refer her to a nephrologist, which she believes led to her stroke.
NHS in England
Not Upheld
Jul 2025
P-003648 — Royal Devon University Healthcare NHS Foundation Trust
Mr A complained the Trust failed to consider all his symptoms, monitor his blood appropriately, and follow an appropriate medication plan for his complex hypothyroidism, leading to distress.
NHS in England
Jul 2025
P-003735 — A practice in the Bromsgrove area
Mrs T complained her severe back pain was not taken seriously by the Practice, despite her spinal condition. She believes this contributed to declining mobility and needing a knee replacement.
NHS in England
Aug 2025
P-004733 — A practice in the Lambeth area
Mr S complained the Practice failed to provide updates on his funding request, caused delays, arranged unnecessary appointments, ignored medical record requests, and failed to ensure online record accuracy.
NHS in England
Jan 2026
P-001729 — A practice in the Hertfordshire area
Mr H complained the Practice misdiagnosed his father with gallstones, which was actually stage four cancer, failed to refer him, and did not provide a care plan, leading to pain.
NHS in England
Jan 2023
P-001827 — Liverpool University Hospitals NHS Foundation Trust
Ms A complained the Trust prescribed medication to her mother without explaining risks, failed to order a fibroscan, and didn't communicate abnormal test results, possibly causing her liver failure and death.
NHS in England
Feb 2023
P-002033 — A practice in the Leeds area
Mrs B complained the Practice failed to refer her to gynaecology for a prolapse in 2018, despite a GP promising a referral.
NHS in England
Jun 2023
P-002399 — A practice in the Essex area
Mrs E complained her husband's GP practice failed to refer him to a specialist promptly for a persistent cough, missing a chance to diagnose lung cancer sooner.
NHS in England
Jan 2024
P-002522 — Walsall Healthcare NHS Trust
Miss B complained the Trust declined to consider a second opinion for her superior mesenteric artery blood clot in January 2022, resulting in ongoing pain and illness.
NHS in England
Mar 2024
P-002664 — Sheffield Teaching Hospitals NHS Foundation Trust
Mrs J complained about a lack of diagnosis, unnecessary epilepsy medication, delayed/missed follow-up appointments, and slow communication of medication changes to her GP.
NHS in England
Partly Upheld
Jun 2024
LGO / SPSO decisions(12)
PSOW-202106438 — A GP Practice in the area of Aneurin …
A complainant complained about the delay in an agreed complaint meeting taking place, and the fact that the Medical Centre did not retain telephone recordings, which the complainant considered would provide evidence in support of their complaint. The complainant also complained that the Medical Centre made reference to highly sensitive …
PSOW (Public Services Om…
Health
Mar 2022
PSOW-202004634 — A GP Practice in the area of Swansea …
Mr Y complained that a GP Practice in the area of Swansea Bay University Health Board (“the Practice”) incorrectly removed him for its patient list at the end of 2020. He said the Practice failed to give him a written warning, failed to give him a reason for the decision …
PSOW (Public Services Om…
Health
Upheld
Jan 2022
PSOW-202106970 — A GP Practice in the area of Betsi …
Mrs B complained about the care and treatment provided to her by a GP Practice (“the Practice”) in the area of Betsi Cadwaladr University Health Board. The investigation considered whether the Practice misdiagnosed Mrs B’s symptoms, which led to a delay in the diagnosis of laryngopharyngeal reflux/silent reflux (when stomach …
PSOW (Public Services Om…
Health
Not Upheld
Mar 2024
PSOW-202108288 — A GP Practice in the area of Swansea …
The Ombudsman investigated a complaint from Mr Y about the way that a trainee GP at the Practice had managed the care of his late wife, Mrs Y, when she had contacted the Practice complaining of a history of 10 days constipation and abdominal pain. A telephone appointment was arranged …
PSOW (Public Services Om…
Health
Not Upheld
Mar 2024
PSOW-202208529 — Velindre University NHS Trust
The Ombudsman investigated a complaint from Mr Y about the way that a trainee GP at the Practice had managed the care of his late wife, Mrs Y, when she had contacted the Practice complaining of a history of 10 days constipation and abdominal pain. A telephone appointment was arranged …
PSOW (Public Services Om…
Health
Mar 2024
PSOW-202202134 — A GP Practice in the area of Betsi …
Ms X complained about the poor service she had received from a GP Practice in the area of Betsi Cadawaladr University Health Board. In making enquiries with the Practice, the Ombudsman was concerned that it had not formally responded to Ms X’s complaint despite receiving a complaint in writing from …
PSOW (Public Services Om…
Health
Jul 2022
PSOW-202201703 — A GP Practice in the area of Cardiff …
Miss A complained that she was experiencing communication issues with the Practice. She wanted a further assessment with a specific GP for her ongoing health problems. The Ombudsman was concerned because Miss A had not contacted the Practice in two months for a GP appointment. She contacted the Practice to …
PSOW (Public Services Om…
Health
Jul 2022
PSOW-202202071 — A GP Practice in the area of Cardiff …
Mr X complained that despite putting a complaint to his GP regarding issues with his prescription, he had yet to receive a response or resolution to his complaint. The Ombudsman was concerned that Mr X had yet to receive a response from the GP and therefore contacted the GP. As …
PSOW (Public Services Om…
Health
Jul 2022
PSOW-202401069 — Cardiff and Vale University Health Board
Miss C complained about the care and treatment she received from the Health Board, specifically; • Whether the Commissioning Team appropriately considered requests received on her behalf between 2022 and 2023 • Whether it was clinically appropriate that she was repatriated to the Spinal Team in June 2022 and whether …
PSOW (Public Services Om…
Health
Upheld
Apr 2025
201001207 — A medical practice, Ayrshire and Arran NHS Board
Ms A started to feel unwell while working abroad. She attended a hospital there for scans before returning to Scotland. Ms A attended her GP and explained the problems she was experiencing. She gave him the scans and medical reports, but as these were not in English, he was unable …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2011
PSOW-202304622 — A GP Practice in the area of Aneurin …
Mrs N complained that Aneurin Bevan University Health Board (“the Health Board”) failed to provide her with appropriate care while she received blood transfusions and discharged her inappropriately after the transfusions were complete. Mrs N also complained that the GP Practice failed to appropriately assess and treat Mrs N’s symptoms …
PSOW (Public Services Om…
Health
Upheld
Jun 2024
PSOW-202309518 — A GP Practice in the area of Hywel …
Mrs A complained that from October 2022 to March 2023 a GP Practice in the Hywel Dda University Health Board area (“the Practice”) failed to provide appropriate care and treatment for her late mother in respect of her presenting symptoms, condition and past medical history (aortic heart valve replacement in …
PSOW (Public Services Om…
Health
Not Upheld
Sep 2024
Domestic Homicide Reviews(2)
West Berkshire — recommendation 3
It is recommended that policy and practice within CPE is reviewed in relation to ensuring that GPs’ specific requests for a psychiatrist’s opinion are routinely referred to a CPE psychiatrist for consideration, particularly where there is evidence of failure to respond to treatment. Measure of success: An audit will show …
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
West Berkshire — recommendation 2
We recommend that updated information and advice be provided to GPs in the recognition and treatment of mental health needs. Furthermore we recommend that BHT put in place processes for regular updating of GPs about how and in what circumstances to refer to their services.
GPs | Berkshire Healthcare NHS Foundation …
Government Procurement Service