Report Date


Case Against

A GP Practice in the area of Betsi Cadwaladr University Health Board


Clinical treatment outside hospital; GP

Case Reference Number



Upheld in whole or in part

Mr A complained about his late mother (Ms B)’s management and care and the GPs’ failure to see her face-to-face when she telephoned and raised concerns about weight loss and white patches over her gums and mouth. He was also dissatisfied with the robustness of the GP Practice’s complaint response.

The Ombudsman was satisfied that the clinical failings by the GPs led to a delay in Ms B’s ongoing mouth symptoms being properly reviewed and assessed at a face-to-face consultation. The investigation found that the delays meant that a timely urgent suspected cancer (“USC”) referral to the Hospital’s Maxillofacial team had not been made by the GP Practice. This did not accord with clinical guidance. The Ombudsman also found shortcomings in the GP Practice’s record-keeping which meant that the USC referral did not provide a complete clinical picture in relation to the telephone calls that Ms B had made to the GP Practice regarding her symptoms. As it was not possible to say whether an earlier USC referral would have changed Ms B’s outcome or her treatment options this uncertainty was the injustice for Ms B, Mr A and the family. The Ombudsman also identified shortcomings in the GP Practice’s handling of Mr A’s complaint. Mr A’s complaint was upheld.

The Ombudsman welcomed the steps taken by the GP Practice as part of learning from Mr A’s complaint to address the failings around clinical care and record-keeping. The GP Practice was asked to apologise to Mr A for the failings and to evidence the learning from Ms B’s case.