Summary: Ms Y complains about the care and treatment provided to her daughter, Ms X, mostly over a period of six days. The Ombudsmen do not find good reasons to criticise the clinical decisions taken about her care. However, there is evidence of fault causing injustice in the way NHS England dealt with the complaint. To remedy the outstanding injustice, the Ombudsmen recommend NHS England offers a symbolic payment of £100 to Ms X’s mother, Ms Y, for the inconvenience caused by its delays.

The complaint

1. Ms Y complains about the care provided to her daughter Ms X by five organisations: Highbridge Medical Centre (the Practice), Somerset-wide Integrated Sexual Health Service (SWISH commissioned by Somerset County Council), Somerset Doctors Urgent Care (SDUC responsible for the local 111 service), Lloyds Pharmacy (the Pharmacy) and NHS England (manages GP services in the community and is responsible for dealing with complaints against GP services).
2. Ms Y feels early opportunities to diagnose Ms X’s medical conditions and prescribe appropriate pain relief were missed by the Practice, SWISH and SDUC. Her complaint against Lloyds Pharmacy relates to a later incident when she says it failed to inform Ms X promptly that there was a prescription awaiting collection.
3. Ms Y highlights the delayed complaints investigation by NHSE and its failure to keep in touch with her.

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What I have investigated

4. I have investigated Ms Y’s complaints above against the Practice, SWISH, SDUC, and NHS England. The final section of this statement explains my reasons for not investigating the Pharmacy.

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The Ombudsmen’s role and powers

5. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)
6. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
7. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
8. The Ombudsmen provide a free service but must use public money carefully. They may decide not to start or continue with an investigation if they believe it is unlikely they could add to any previous investigation by the bodies (Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)
9. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)
10. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weight up the available evidence and base our findings on what we think was more likely to have happened.
11. The law says we cannot normally investigate a complaint when someone could take the matter to court. However, we may decide to investigate if we consider it would be unreasonable to expect the person to go to court. (Local Government Act 1974, section 26(6)(c), as amended and Health Service Commissioners Act 1993, section 4(1b))

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How I considered this complaint

12. I have read the complaint information Ms Y provided to us alongside information from the organisations named in this complaint. I have considered the law and guidance relevant to this complaint. I sent my draft decision to Ms Y and all the organisations involved. Ms Y responded with comments as did NHS England. The Practice, SDUC, the Council and the Pharmacy did not send any response to my draft decision.

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What I found

13. Ms Y describes what happened to Ms X during six days in January 2017. I outline her account of events which triggered the complaint:
• 23 January – Ms X woke experiencing vomiting, dizziness and pain when urinating. She was given an appointment with a GP. However, she was too unwell to attend so Ms Y attended with a urine sample. The GP diagnosed a urine infection and prescribed antibiotics.
• 24 January (day) – The vomiting stopped, and Ms X felt slightly better. However, pain on urination remained. Ms X attended a GP appointment and provided an additional urine sample for testing.
• 24 January (evening) – Ms Y said Ms X was ‘screaming’ due to the pain. Ms Y called 111 for advice. Ms Y says the initial call handler suggested a possible sexually transmitted infection (STI). However, when she was passed on to a doctor at the 111 service, she says she was told it could not be a STI as Ms X was not experiencing any discharge. The doctor advised pain relief.
• 25 January (morning) – Ms X attended a further GP appointment. Ms X advised the GP the pain relief medication was not working, and the infection did not seem to be clearing. The GP prescribed a different antibiotic. Ms Y says the GP also excluded the possibility of a STI on the basis there was no discharge.
• 25 January (afternoon) – Ms Y says that due to Ms X’s continuing symptoms she arranged an appointment for Ms X to attend SWISH. It was here that Ms X was diagnosed with a medical condition and received medication.
• 26 January – Ms X was continuing to suffer pain, so she called 111. She was advised to continue taking medication.
• 26 January – Ms Y says Ms X’s pain worsened and she called an ambulance. However, she was advised to contact her GP.
• 26 January – Ms Y called the GP and asked for strong pain relief. The GP prescribed morphine. But the pharmacy advised Ms Y the morphine could not be taken immediately as Ms X had taken other pain medication. Ms Y also says the GP agreed, to her request, to notify the local A&E that Ms X would be attending if the pain did not resolve.
• 27 January (early hours) – Ms X called 111 and was advised to attend A&E as that was the only place where Ms X would receive pain relief stronger than morphine. At A&E Ms Y says reception staff were unaware of any referral of Ms X’s case by the Practice. Ms Y says that after 2 and half hours of waiting the A&E doctor said the morphine dose should be increased and antibiotics should be continued. She says the A&E doctor advised it was possible Ms X still had a urine infection.
• 28 January – Ms X’s pain reduced.
• A week later Ms Y says SWISH diagnosed Ms X with another medical condition.

Complaints handling

14. Ms Y promptly raised her complaint on 30 January 2017 to her local Clinical Commissioning Group (CCG). The CCG redirected her to NHS England to respond.
15. Where a complaint concerns more than one responsible body, they must cooperate in handling the complaint. This includes duties to settle who will lead the process; share relevant information; and, provide the complainant with a coordinated response. (Regulation 9, Local Authority Social Services and national Health Services Complaints (England) Regulations 2009)
16. The complaint regulations also say timescales for progressing a complaint should be agreed with a complainant and a response should be expected no more than six months from the date of your complaint. If it is to be longer than this or than agreed, staff should tell you why and send a response as soon as possible. (Regulation 14, Local Authority Social Services and national Health Services Complaints (England) Regulations 2009)
17. NHS England responded on 24 February with a complaint investigation plan covering the complaint against the Practice and 111 Service. The plan recorded NHSE’s deadline to respond as 18 April 2017.
18. Ms Y responded with some amendments and asked if the complaint could include her concerns about SWISH.
19. In May Ms Y chased NHSE for a response. She added another issue regarding a visit to the GP in March.

Incident in March

20. Ms Y said Ms X went back to the Practice after suffering more symptoms. A GP carried out a swab test. Ms Y says Ms X rang a week after for the results but was told they were not back yet. She reported that Ms X was told the surgery would ring her if the results showed anything adverse. But, she says, they were not contacted until May 2017 by the Pharmacy (attached to the Practice) which said it had been holding a prescription for her since March.

Complaints investigation delays

21. The NHSE complaints officer replied to Ms X in May and apologised for the delay. She said the investigation was ongoing and ‘it should be concluded shortly’. She said the Practice was aware of the complaint and was about to provide a response to NHSE. She said (once NHSE received it) it would send it to an Independent Clinical Advisor for a review.
22. However, the Practice responded directly to Ms Y with a written response to her complaint. The Practice said it had interviewed the two doctors involved. It said the doctors understood the ‘distress' caused to Ms X and Ms Y. The Practice wrote the doctors felt they had acted in good faith and included two emails from the doctors with their comments on the complaint. It also offered Ms Y a meeting towards resolving her concerns.
23. Unfortunately, one of the emails from the doctor included the comment “complaints are very tiresome and more so very demoralizing”.
24. On 4 June Ms Y asked the NHSE complaints officer to escalate her complaint to a manager due to her dissatisfaction.
25. On 17 July Ms Y received a response from NHSE’s local complaints manager. She apologised for the delay and for the failure by the complaints officer to escalate the complaint promptly. She also apologised for the fact the Practice responded directly with comments that ‘inflamed the situation’. She said if the Practice had sent the response to the NHSE, as it should have done, it would have been asked to address the issues again. She confirmed the Practice had been asked to reconsider the complaint.
26. The complaints manager also acknowledged Ms Y’s complaint about Somerset-wide Integrated Sexual Health. She said it would be dealt with as a formal complaint by SWISH.
27. During July and August Ms Y chased NHSE again.
28. In mid-August NHSE advised Ms Y it had received the relevant information from the Practice. It said this was now with an independent clinical advisor and hopefully the investigation would be concluded soon.
29. In September Ms Y again chased NHSE.
30. A week later Ms Y received a response saying SWISH would respond in the next few days and the NHSE complaints team expected to send a complete response by 3 October. NHSE apologised for the delay.

NHSE complaint response

31. In mid-October NHSE sent its response. It apologised for the delay in responding and said this was ‘clearly below the standard we aim to achieve’.
32. Commenting on the Practice’s actions in January 2017, NHSE said the GP’s initial diagnosis of a urinary infection was reasonable and the painkillers proscribed were appropriate. In answer to Ms Y’s specific request it said it was not appropriate to refund the prescription fees for the painkillers and the antibiotics. It added that it was ‘highly probable’ that Ms X did have a urinary infection alongside the medical condition diagnosed later by SWISH. It mentioned this was the view of the A&E doctor who saw Ms X.
33. Turning to events in March, NHSE said the swab result indicated another medical condition. It found a GP acted correctly by raising a prescription. It said it could not be certain of the exact circumstances as the GP concerned had left the Practice. It said there was no evidence to show that Ms X telephoned for the results. However, it accepted the Practice should have advised Ms X of the result and that there was a prescription for her. It apologised for this omission. The Practice said it was looking at ‘putting systems and processes in place’ to prevent this happening again.
34. To explain the Practice’s direct complaint response to Ms Y at the end of May, NHSE said the Practice had felt under ‘pressure’ to get a response to Ms Y. It said the Practice explained the GPs comments about complaints being ‘tiresome’ as not a direct comment on her complaint but rather to wider service improvements Practice staff were involved in. Apparently, this was becoming ‘wearing’ on GPs being asked to provide information at short notice. NHSE acknowledged the ‘angst and distress’ caused. It added it was ‘disappointing’ the Practice felt it was ‘acceptable’ to provide this explanation.
35. NHSE sought the views of other professionals in its complaint response. An Independent Clinical Reviewer found the GP’s actions were ‘generally appropriate’. But the Reviewer said it would have been ‘good practice’ for the GP to examine Miss X (at the second GP appointment). The Reviewer recommended the Practice review the case at a ‘Significant Event Meeting’ to consider management/guidelines of STIs and UTIs.
36. NHSE said it agreed with the Independent Clinical Reviewer’s recommendations. It said if Ms Y wished to be advised of the outcome of the review meeting NHSE could arrange for this to be done.
37. NHSE also advised that it had referred the Practice to the NHS England Performance team. This is the NHS team responsible for addressing the performance of individuals GPs. It said it could not feedback on any actions as this was a confidential process.
38. In terms of its own actions, NHSE passed its own complaints handling to a senior complaints officer not previously involved in the case. The officer found it “fell far short of the standard NHS England aims to achieve”. It provided another apology and said the local complaints team had made several changes in work practices directly arising from Ms Y’s complaint. It said staff would have no more than 30 complaints, managers would also have reduced caseloads to enable them to work on complex cases and manage complaints staff. It also advised that staff had been advised to reflect on the complaint and the effects of failing to keep Miss Y informed.
39. NHSE also enclosed responses from the other parties to the complaint: SDUC and SWISH.

SDUC’s complaint response

40. SDUC’s response was dated 8 June 2017. In summary, SDUC’s complaints investigator said it considered Ms Y’s complaint in some detail including reviewing the recordings of the telephone calls. Overall it said there was no evidence to uphold Ms Y’s complaint of misdiagnosis and incorrect advice regarding pain management.

SWISH’s complaint response

41. SWISH’s response was dated September 2017. It noted its staff had tested Ms Y and then prescribed medication to treat her diagnosed condition. It said its records showed saltwater bathing had been recommended for pain relief. It noted a leaflet had been provided explaining the symptoms and treatment.
42. Answering Miss Y’s specific concerns, SWISH accepted pain management had not been discussed on Ms X’s first meeting with the service despite it recording that Ms X said she was in pain. It apologised for this. It said it was appropriate to recommend pain relief should the non-medicated approaches, such as saltwater bathing, not work. It noted Ms Y’s concerns that they had not been provided with enough information about the pain Ms X might experience. It said that after staff had met with Ms Y and Ms X to discuss their concerns, it would review all the leaflets provided to patients to ensure that clear information is provided.

Complaint against Lloyds Pharmacy

43. Between June and September 2017 Ms Y exchanged correspondence with Lloyds Pharmacy referring to a ‘legal claim for compensation’. This arose from the Pharmacy’s delay in alerting Ms X that there was medication awaiting collection. She requested compensation for ‘stress’. She said Ms X had been concerned that the infection requiring prescription had been left untreated for two months.
44. The Pharmacy agreed to refund the cost of the prescription. Ms Y found this unacceptable. So, the Pharmacy passed the claim for compensation to its insurers.
45. The insurers found there was no legal requirement on pharmacies to notify people about outstanding prescriptions. It also said there was no breach of duty by the Pharmacy that had caused harm to Ms X and it denied any liability for compensation.

My analysis

46. I do not see good reasons to intervene in the clinical decision making around Miss X’s medical conditions and pain management. The independent clinical reviewer has found the actions taken by clinicians to be ‘generally appropriate’.
47. I particularly note that other doctors consulted by Ms X in A&E and over the telephone (SDUC service) agreed with her GP’s diagnosis and advised she should continue with the antibiotics prescribed by her GP. I note one SDUC doctor advising Miss Y, the urine infection should be treated first and, if symptoms persisted STI investigation should be considered. That Miss X was later diagnosed with other infections does not necessarily invalidate the initial diagnoses or indicate delay in diagnosing additional infections.
48. Ms Y seeks compensation for the pain and suffering endured by Ms X during this period. As I cannot link Ms X’s symptoms to any clinical fault by NHS staff, I cannot recommend her preferred outcome.
49. However, I do find Miss Y was put to some inconvenience between April and September when chasing NHSE for a response to her complaint. In line with the complaint regulations and its own policy, NHSE should have kept in regular touch with Miss Y to explain the reasons for lack of progress. While the complaint regulations allow up to six months for a coordinated multi agency response, Miss Y was promised in February that she would receive a response by April. She received a response six months later - in October - and only after sending several emails.
50. Ms Y is particularly concerned that she was told an STI could not exist without a discharge and that this is untrue. I cannot establish whether the GPs did say this or not. I do note the independent clinical reviewer recommended that GPs hold a meeting to review the clinical guidance for STIs and UTIs. Also, they were reported to the NHS Performance team. I consider these satisfactorily addresses this issue. With respect to SDUC staff, I have listened to the recordings of Ms Y and Ms X’s telephone calls with SDUC. There is no evidence that SDUC staff said a sexually transmitted infection could not exist without a discharge.
51. Ms Y also says Ms X did call the surgery to chase the outcome of the swab result. The Surgery denies that she called. While I understand the reasons for Ms Y’s concerns, I do not find there is anything to further to be achieved by investigating. The Ombudsmen would not be able to establish if Ms X called and, in any event, it has been established the onus was on the Practice to notify Ms X. Furthermore, there is no evidence that harm was caused to Miss X by this delay in taking medication and a follow up test confirmed this.
52. I have considered Ms Y’s concerns about SDUC’s complaint response referring to her complaint being received in April (even though she raised her complaint to NHSE in January). Also, that the response includes the comment ‘I hope that this letter finds your father well’. Ms Y says all of this shows NHSE delayed by not sending her complaint to SDUC promptly and that her complaint was not taken seriously. I do not see that we could achieve anything significant here. NHSE has admitted delays so it may well be, as Ms Y says, it delayed in sending her complaint to SDUC. The reference to ‘father’ rather than ‘daughter’ is clearly an error by SDUC.
53. Overall, there is no doubt that NHSE failed to deal with her complaint properly in line with its own complaints policy and the statutory complaints regulations.
54. Although delayed, I do find that NHSE’s final complaint response is comprehensive and it has provided several apologies for its delay and failures to keep Ms Y informed. I can see it organised two other professionals not previously involved in the complaint, one a clinician, to cast a ‘fresh pair of eyes’ over the complaint subject matters.
55. I particularly note the systemic service improvement recommendations to review services at the Practice, the information provided by SWISH to patients and, finally, the practical changes to the local NHSE’s teams complaint investigation process. These are all in line with the Ombudsmen’s guidance on remedying injustice.

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Agreed Recommendations

56. Within a month of the final decision I recommend NHSE offer Ms Y a symbolic payment of £100 to acknowledge the inconvenience caused to her by its complaints handling. NHSE have agreed to my recommendations.

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Final decision

57. I have completed my investigation. There was no fault by Highbridge Medical Centre, Somerset-wide Integrated Sexual Health Service or Somerset Doctors Urgent Care. There was fault by NHS England as it failed to deal with Ms Y’s complaints according to its complaints policy which caused Ms Y inconvenience. It has agreed to make a symbolic payment to remedy Ms Y’s injustice. I have not investigated Ms Y’s complaint about Lloyds Pharmacy for the reasons explained below.

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Parts of the complaint that I did not investigate

58. I will not investigate the complaint against Lloyds Pharmacy given the matter has already been considered by its insurers. The Ombudsman does not normally get involved in insurance matters. As outlined in paragraph 8, I consider it would be reasonable to expect Ms Y to pursue her insurance claim in the county court as a civil matter.

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Investigator's decision on behalf of the Ombudsman