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Case ref:202410827
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Date:September 2026
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Body:A Medical Practice in the Grampian NHS Board area
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:Clinical treatment
Summary
C complained about the care and treatment that they received from the practice during a time when C was under investigation by secondary care following a pathological fracture (when a bone breaks due to weakened bone structure, rather than from injury or trauma) in their spine. There was concern that C may have had a type of cancer that had spread to C’s spine.
C was concerned about the practice’s prescribing of opioid medications, access to appointments and complaints handling. The practice said that there were no shortcomings in the monitoring or prescribing of opioid medication in C’s case and that there was no lack of review of C during this period.
We took independent advice from a GP. We found that the conversion from one type of opioid medication to a stronger type of opioid medication was reasonable. However, we found that an increase in opioid medication prescribed to C was unreasonable, because it was not consistent with prescribing guidance from the British National Formulary. We found that opioid prescriptions were placed on repeat prescription for C without any planned review, when C’s pain management was not stable, and this was unreasonable. We found that C should have been offered an in-person review by the practice due to their clinical situation. We upheld C’s complaint.
We found that the Practice did not reasonably handle C’s complaint, because they did not confirm the points of complaint with C and did not refer to the SPSO in their complaint response. We upheld C’s complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for the failings identified in this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
What we said should change to put things right in future:
- GPs should be confident with the use, dosing and safe prescribing of opioid drugs.
- In-person review should be offered where clinically appropriate. The triage system should not act as a barrier to in-person review for patients with clinical need.
In relation to complaints handling, we recommended:
- The practice should comply with the NHS CHP. Apologies should be in line with SPSO’s guidance on apologies: www.spso.org.uk/meaningful-apologies.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.