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 care and treatment by the Practice in its prescribing of opioid medication to manage his pain after he had undergone weight loss (bariatric) surgery, and whether appropriate investigations were undertaken following his collapse. He also complained about the Practice’s handling and investigation of his complaint.

The investigation found that the Practice had limited options available to it in order to manage Mr A’s pain, and that it was clinically appropriate to prescribe Mr A with opiates given there was no national guidance preventing that. Furthermore, it was found that appropriate investigations were undertaken when Mr A collapsed. Both these aspects of Mr A’s complaint were not upheld. In relation to the handling of Mr A’s complaint, the investigation found that the Practice’s complaint response was not in line with “Putting Things Right” (the formal process for handling complaints about the NHS in Wales), in that it lacked detail and was poorly drafted ,leaving Mr A feeling that his concerns had not been taken seriously. This was an injustice to him and might also have avoided a complaint to the Ombudsman if undertaken properly. This complaint was upheld.

The Practice accepted the Ombudsman’s recommendations to apologise to Mr A for the complaint handling failings, and to liaise with the local Health Board to undergo complaint handling training.