A medical practice in the Havering area

6. Miss L complains about the following aspects of the care and treatment Mr L received from the Practice. Mr L went to multiple appointments at the Practice between 10 January 2020 and 26 February 2021. She is unhappy the Practice failed to refer him for a chest X-ray, MRI (a form of X-ray examination) or any initial tests including blood tests during this time.

7. She says the Practice treated Mr L’s back pain as a tendon tear even though the pain and symptoms he had were not equal to this. She says the Practice continued to treat a tendon tear even though the scans it used were outdated and no new ones were ordered.

8. Miss L also says when the Practice finally referred Mr L for an MRI scan and chest X-ray in February 2021, the Practice delayed processing the referral.

9. Miss L feels the Practice should have offered more face-to-face appointments and if it had it would have seen his decline. Miss L does not accept the Practice’s explanation that due to COVID-19 all appointments were triaged over the phone before deciding whether a face-to-face appointment was necessary. She says telephone appointments were not the only option.

10. Miss L says had the Practice referred Mr L for a chest X-ray or MRI before February 2021, his lung cancer would have been diagnosed earlier.

11. Miss L says due to the Practice’s failings Mr L did not get the right pain medication, palliative care and the opportunity to say goodbye to his family.

12. Miss L says by the time Mr L’s cancer was diagnosed it was untreatable and his death was near. She feels this would not have been the case had the Practice taken action sooner.

13. Miss L says while she knows Mr L’s death may not have been preventable, the circumstances in which he died and the pain he experienced could have been prevented.

14. Miss L says his death affected her and her whole family knowing he died alone, scared and confused. She says she also feels guilty as if he had gone to a different Practice, his care and treatment could have been different.

15. Miss L is looking for service improvements to help stop this from happening to somebody else. Miss L would like the Practice to accept its failings and an apology for the impact this has had on her and her family. Miss L would also like compensation.

16. Mr L joined the Practice as a new patient in January 2020.

17. On 2 March 2020 Mr L went to his first appointment at the Practice due to shoulder pain which started before Christmas 2020. The Practice referred him for an X-ray of his shoulder prescribed an anti-inflammatory gel.

18. Between 17 April 2020 and 19 March 2021, Mr L had eight telephone appointments with the Practice. At each appointment he reported worsening pain.

19. During these 11 months, the Practice prescribed several pain medications, and referred him for physiotherapy, an ultrasound scan, and for steroid injections. The Practice also referred Mr L to an orthopaedic specialist, for two MRI scans and blood tests.

20. On 25 March 2021, Mr L’s blood test results were returned as abnormal. On 26 March 2021 the Practice advised Mr L to go to A&E.

21. Mr L attended A&E on 29 March 2021. On 1 April 2021, CT scan results showed a tumour in his lung.

22. Mr L died of lung cancer in early April 2021.

Failure to refer for testing

26. We would like to thank Miss L for bringing this complaint to us. We can see Mr L was in considerable pain from March 2020. This must have been a very difficult time for Mr L and his family.

27. The Practice says, ‘It is clear he was in a significant amount of pain for many months and unfortunately none of the treatments offered provided real relief. I am sorry he went through this.’ It goes on to say, ‘He was examined at the outset in March 2020, again by an orthopaedic surgeon in December 2020 and again by Dr Murphy in March 2021. None of these doctors detected any signs of the cancer’.

28. Mr L attended appointments at the Practice on 2 March 2020, 17 April, 12 May, 18 June, 21 July, 7 October, 13 October, 27 November, 14 December and 26 February 2021. The reason for Mr L’s appointments was the ongoing pain he was suffering from in his shoulder. We can see from his medical records the Practice prescribed him with pain medication, referred him for steroid injections and referred him to orthopaedics. After this, the Practice referred him for an MRI of his thoracic spine (the central section of his spine) on 26 February 2021.

29. We got advice from our adviser to look at whether the Practice gave Mr L the right treatment.

30. The NICE guidance says, ‘Offer an urgent chest x-ray (to be done within 2 weeks) to assess for lung cancer in people aged 40 and over if they have 2 or more of the following unexplained symptoms, or if they have ever smoked and have 1 or more of the following unexplained symptoms:

• Cough • Fatigue • Shortness of breath • Chest pain • Weight loss • Appetite loss’.

31. It also goes on to say, ‘Consider a urgent chest x-ray (to be done within 2 weeks) to assess for lung cancer in people aged 40 and over with any of the following:

• Persistent or recurrent chest infection • Finer clubbing • Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy • Chest signs consistent with lung cancer.

• Thrombocytosis.’

We have reviewed Mr L’s symptoms at all his appointments from March 2020 to February 2021. He reported the following symptoms:

• 2 March 2020 - shoulder pain which he said was a result of an injury from moving a heavy object at home • 17 April 2020 - the Practice contacted Mr L about his X-ray result, during this telephone appointment Mr L says his pain is ongoing and has now started at night • 12 May - the Practice again contacted Mr L about his scan results. Mr L explained ibuprofen is not enough to control the pain all day • 18 June - Mr L went to the Practice because of ongoing pain • 21 July - pain overnight • 7 October - ongoing shoulder pain and not sleeping well at night • 13 October -pins and needles, shoulder is still aching and can tingle down his arm sometimes • 27 November - unable to cope with the pain from his shoulder • 14 December - ongoing pain in his shoulder with pins and needles in his arm and down to his fingers • 26 February 2021 - unable to cope with the pain, pain is now under his shoulder blade.

32. We have considered these symptoms. Mr L was clearly experiencing an increasing level of ongoing pain. We can see the pain reached a level where Mr L felt unable to cope. The symptoms he reported to the Practice were pain and aching in his shoulder and shoulder blade, tingling and pins and needles in his arm.

33. We have found no evidence of Mr L approaching the Practice at any point with any of the symptoms set out in the suspected cancer NICE guidelines. Therefore, we consider there to be no fault with the Practice not referring Mr L for further investigation under the cancer care pathway.

34. The NICE Clinical Knowledge Summaries on shoulder pain says, ‘Refer a person urgently to secondary care if any red flags are identified in the history or examination. These include:

• Trauma, pain and weakness, or sudden loss of ability to actively raise the arm (with or without trauma): suspect acute rotator cuff tear.

• Any shoulder mass or swelling suspect malignancy.

• Red skin, painful joint, fever or the person is systemically unwell: suspect septic arthritis.

• Trauma leading to loss of rotation and abnormal shape: possible shoulder dislocation.

• New symptoms of inflammation in several joints: suspect inflammatory arthritis.

Also consider urgent investigations and/or referral to secondary care if there:

• Are systemic symptoms such as fever, night sweats, weight loss or new respiratory symptoms.

• Is undiagnosed severe shoulder pain or severe restriction of movement.

• Is a history of trauma and the person is being seen acutely’.

35. Given the NICE guidelines on shoulder pain, a Practice should refer a patient to secondary care (a specialist) as he had severe undiagnosed shoulder pain. We can see the Practice did this on 12 May 2020, when it made a referral for Mr L to be seen by an orthopaedic specialist. We therefore do not think the Practice did anything wrong when referring Mr L for an orthopaedic consultation.

36. Our adviser noted Mr L was reviewed by an orthopaedic consultant in December 2020. The consultant made a diagnosis of ‘right (sic) shoulder scapulothoracic pain due to partial thickness tear of the supraspinatus () and fatty atrophy’. This means pain between the scapula and thorax due to a partial tear in a small muscle of the upper back and shrinking or thinning of the muscle. Our adviser said the Practice had no reason to believe the pain was coming from lung cancer as the orthopaedic consultant had made a diagnosis.

37. We can see from Mr L’s medical records he went to the Practice on several occasions. We can clearly see he was suffering from a lot of shoulder pain, and this gradually started to impact his life and daily activities. We understand how hard this must have been for Mr L and his family especially as the medication prescribed was not easing his pain.

38. Based on the symptoms Mr L had, we consider the Practice acted in line with guidelines. We are unable to find any evidence to suggest further scans or tests should have been requested.

39. We appreciate our decision will be disappointing. We hope our response offers Miss L and her family some answers and reassurance that the Practice acted in line with guidance when treating and managing Mr L’s pain and other symptoms.

40. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any signs that something has gone wrong.

Delay with referral

41. Miss L says when the Practice referred Mr L for further testing on 26 February 2021, the Practice delayed processing this referral. Miss L says the Practice did not process the referral until Mr L rang them to ask for it to be processed.

42. The Practice’s response letter dated 13 May 2021 says these requests were made electronically on 3 March 2021.

43. We can see from Mr L’s medical records, the Practice agreed on 26 February 2021 he needed further investigation. These were an MRI of the thoracic (chest) section of his spine and a chest X-ray. His medical records show the Practice did not process this referral until3 March 2021.

44. Our adviser said there is no guidance on how quickly a referral needs to be processed. However, they did say for a referral to be processed within three working days is normal practice.

45. Our Principles of Good Administration say, ‘Public bodies should behave helpfully, dealing with people promptly, within reasonable timescales and within any published time limits’. While there are not any published time limits for processing referrals, we would consider three working days is appropriate given how busy GP practices are. We also consider three working days to not be too much given Mr L had a diagnosed shoulder condition and at this time there were no indications of cancer.

46. We have listened when Miss L says she feels the referral should have been processed sooner. We understand she feels the referral was only processed when it was because Mr L contacted the Practice.

47. We have looked at Mr L’s medical records and at the Practice’s response to this part of the complaint. We are unable to see any evidence Mr L had to contact the Practice to prompt the Practice to process the referral. That is not to say he did not make the phone call as Miss L says.

48. We are unable to say whether the phone call made the Practice do the referral or what would have happened if Mr L did not call. However, as the Practice took three working days to process the referral, we consider there to have been no failing.

49. We can see by this point Mr L had been in pain since early 2020. We therefore understand why both Mr L and his family would have wanted him to be referred as quickly as possible. We appreciate they needed answers about the cause of this significant pain and hopefully some treatment to ease the symptoms. We hope Miss L is reassured the Practice dealt with his referral within normal practice timeframes and there is no evidence the Practice delayed Mr L’s referral.

Face-to-face consultations

50. Miss L raises concerns the Practice did not see Mr L face-to-face and only ever had telephone consultations with him.

51. After his first appointment with the Practice on 2 March 2020, all Mr L’s appointments took place while COVID-19 restrictions were in place.

52. We understand the COVID-19 pandemic changed how many patients were seen by their GP. It was largely a new experience for patients who were used to seeing their GP in person at appointments. GP Practices had to adapt quickly to a different way of providing care and treatment to their patients. We hope our response provides Miss L with some further information on what was expected from GPs during the pandemic and when face-to-face appointments were offered to patients.

53. In response to Miss L’s complaint, the Practice says, ‘due to the COVID pandemic all NHS GP surgeries were instructed to operate a new consultation model of remote triage before making a decision as whether to see a patient face-to-face’. It goes on to say, ‘However, we were always happy to see patients face-to-face when appropriate’.

54. The NHS England guidance, ‘Advice on how to establish a remote ‘total triage’ model in general practice using online consultations’, was used by GP Practices from September 2020. The guidance says during the COVID-19 pandemic a remote consultation should be carried out and then make a clinical decision on whether a face-to-face consultation is needed.

55. Our adviser says before September 2020, GP practices were asked to do telephone consultations and then a make a decision on whether a face-to-face appointment is needed.

56. We understand Miss L feels telephone consultations were not the only option. We agree Mr L could have been seen face-to-face or by video call. However, this would have been at the discretion of the Practice and whether they felt it was right, based on the symptoms. Our adviser said based on Mr L’s symptoms, they did not feel a different type of appointment should have been offered.

57. We therefore consider the Practice were correct to offer telephone appointments to triage the issue, and then decide whether a patient would need to be seen in the Practice.

58. The GMC guidance says, ‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:

1. adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient 2. promptly provide or arrange suitable advice, investigations or treatment where necessary 3. refer a patient to another practitioner when this serves the patient’s needs’.

59. From looking at Mr L’s clinical records we can see Mr L was seen face-to-face on 2 March 2020. Mr L was seen face-to-face three times during July and August 2020 by a doctor, at another clinic, who gave the steroid injections. He was seen face-to-face and examined by an orthopaedic consultant in December 2020.

60. Our adviser said if the clinic who gave Mr L the steroid injections or the orthopaedic specialist had any concerns about Mr L, this would have been reported back to the Practice for it to further investigate. This further investigation may have meant a face-to-face consultation. We have seen no evidence of concerns being raised with the Practice, which it should have followed up on.

61. The Practice were actively trying to treat the pain Mr L was suffering. We can also see from the medical records whenever Mr L reported his pain was not easing, the Practice prescribed new pain relief or increased the dose. He was prescribed an anti-inflammatory gel in March 2020, then co-codamol in April. The Practice arranged steroid injections in July and August, prescribed naproxen in October, tramadol in February 2021 and duloxetine in March.

62. The Practice referred Mr L to be reviewed by an orthopaedic consultant in May 2020. Due to the pandemic, it took some time for the appointment and Mr L was finally seen in December. However, between these dates the Practice tried to get Mr L seen quicker, as they made requests to different clinics and departments.

63. We hope our response offers Miss L reassurance that even though Mr L was not seen in person by the Practice, he was seen by other health professionals. We understand Miss L lost Mr L very suddenly after his diagnosis of lung cancer. This must have been extremely difficult for her and the family, particularly as COVID-19 restrictions were in place at the time. We fully understand her uncertainty around whether things could have been different. We are aware face-to-face GP appointments were standard before the pandemic. We hope our response reassures Miss L as we have not seen that it did anything seriously wrong.

64. The Practice was acting in line with the GMC guidance and was increasing medication and making referrals when needed. Whenever Mr L had an appointment with the Practice, it always tried to ease his pain or refer him.

65. We are grateful to Miss L for bringing her complaint to our attention.

1. We have carefully considered Miss L’s complaint about a GP Practice in the Havering area (the Practice). We have seen no signs that anything went seriously wrong. We understand how hard it has been for Miss L in bringing this complaint to the Parliamentary and Health Service Organisation (our organisation) after her father, Mr L, died so suddenly after being diagnosed with lung cancer.

2. We recognise Mr L experienced significant pain for over a year and appreciate the impact this had on him. We are sorry to hear Miss L feels the pain Mr L suffered and the circumstances in which he died could have been prevented.

3. We have seen no evidence anything went wrong with the Practice not sending Mr L for further investigation before February 2021. This is because Mr L was not showing any symptoms which would make the Practice think he needed a referral for suspected lung cancer.

4. We consider Mr L’s referral for further testing was processed within three working days which is within a reasonable timeframe.

5. We also consider Mr L was seen face-to-face, once by the Practice, three times by another Practice and once by an orthopaedic consultant. Therefore, while the Practice only saw him once, he was seen and reviewed by other doctors and consultants.