Report Date


Case Against

A GP Surgery in the area of Aneurin Bevan University Health Board


Clinical treatment outside hospital; GP

Case Reference Number



Early resolution

Miss A complained about the care provided by the Surgery for her late father, Mr B, during four telephone consultations between 17 and 29 July 2020 when he presented with symptoms of anxiety. Miss A said that, although Mr B’s symptoms worsened, the Surgery failed to offer a face-to-face appointment and prescribed medication without making appropriate physical health checks. In particular, the GP failed to consider that Mr B’s symptoms of shortness of breath and swollen ankles may be due to heart failure. Mr B was admitted to hospital on 2 August by the out-of-hours GP service and sadly died the next day due to worsening heart failure and pneumonia.

The Ombudsman found that the latter two telephone consultations with the GP did not fall within the range of appropriate clinical practice as there were shortcomings in clinical assessment, prescribing and record keeping. Mr B should have been offered a face-to-face appointment in view of his symptoms and presentation and antibiotics should not have been prescribed. However, the Ombudsman could not say whether, but for the failings, Mr B would have been admitted to hospital or survived this episode of care.

In response to Miss A’s complaint, the GP who provided Mr B’s care said that ongoing learning from the complaint was being already addressed through their annual medical appraisals (the process by which a doctor demonstrates that their knowledge is up to date, and they are fit to practise). The Surgery had also carried out a Significant Event Analysis (a method of reflective learning to analyse an episode of care for learning opportunities and to inform future practice).

Although the Surgery had taken Miss A’s complaint seriously, the Ombudsman was concerned that it had not identified or acknowledged to Miss A that there were shortcomings in Mr B’s care. The Ombudsman’s provisional findings were shared with the Surgery, and it was asked to take some further action. The Surgery agreed to apologise to Miss A for the failings in Mr B’s care, to discuss them within the practice, and for the GP to address them in their annual medical appraisal.
These actions, together with the action already taken by the Surgery, reflected the kind of recommendations that the Ombudsman might make at the end of an investigation. As nothing more could be achieved through further investigation, the Ombudsman considered that it was proportionate to settle the complaint on that basis.