A practice in the Hertfordshire area

3. Mr H complains that between February and June 2021, the Practice:

• misdiagnosed Mr O with gallstones, which was later found to be stage four cancer • did not refer Mr O to a specialist under the two-week cancer pathway after an ultrasound scan showed his gallbladder wall looked unusual, and • did not contact Mr O or put a care plan in place following his cancer diagnosis.

4. Mr H says he had to watch his father in pain and deteriorate over several months. He says he will never overcome the trauma of watching his father in agony and helpless and unsupported by the Practice. Mr H says if his father had got the cancer diagnosis sooner, although it would not have changed the outcome or prolonged his father’s life, Mr O would not have had to cope without adequate pain relief.

5. Mr H would like compensation and for the Practice to accept it got something wrong.

6. Mr O spoke to the Practice eight times between February and May 2021. In his first telephone consultation on 22 February 2021 he described symptoms of excess wind and discomfort. He said he also had pain in his right shoulder and his right side. The GP provisionally diagnosed reflux (chest pain caused by stomach acid) and suggested Mr O tried omeprazole (a medication to treat reflux) to see if it would settle.

7. Mr O had another telephone consultation on 12 March when he told the GP his right shoulder and upper right part of his abdomen (stomach) were painful and he felt feverish. Mr O’s daughter had taken his blood pressure, oxygen levels, temperature and pulse at home, and reported these were normal.

8. The GP diagnosed either acute cholecystitis (a gallbladder infection) or biliary colic (sudden intense stomach pain). The GP arranged tests of Mr O’s blood, including for C-reactive protein (CRP) to check for inflammation, his kidneys and liver, and referred him for an ultrasound scan (which uses high-frequency sound waves to assess organs and structures in the body).

9. On 18 March Mr O had a telephone consultation with a GP who explained the initial blood tests showed a raised CRP they felt would fit with a recent infection. Mr O told the GP he was feeling better and in less pain, but he had been watching what he ate. The agreed plan was to wait for the ultrasound scan for further information.

10. Mr O had a GP telephone consultation on 26 March and reported joint pains. The GP thought this was unlikely to be directly linked to Mr O’s abdominal pain because Mr O said the pain seemed better with movement and worse after rest.

11. The GP wondered if the pains were linked to a flare-up of his osteoarthritis (joint inflammation) and decided to repeat CRP bloods to confirm Mr O’s symptoms were getting better, and these did show improvement. The GP felt this indicated an infection, such as cholecystitis, which was getting better.

12. Mr O had an ultrasound on 9 April and discussed the results with a GP in a telephone consultation on 15 April. The results showed some gallstones and a thickened gallbladder, indicative of chronic cholecystitis. The GP advised urgent referral to a specialist and wrote to request this the same day.

13. On 22 April Mr O had a telephone consultation with the GP and said he had received a letter from the hospital. Mr O asked for pain relief, so the GP agreed to try him on co-codamol (a painkiller containing paracetamol and codeine). Mr O said he was still in pain in another telephone consultation on 28 April. A GP prescribed more co-codamol.

14. On 4 May Mr O had both a telephone consultation and saw a GP in person. The GP’s examination of his abdomen, neck and shoulder found they were normal. The GP suggested antibiotics for cholecystitis but to contact them or A&E if his symptoms got worse.

15. Mr O was admitted to hospital on 29 May with abdominal pain. A CT scan (computerised tomography scan – a form of X-ray examination) and further tests confirmed Mr O had gallbladder cancer. He received palliative radiotherapy on 31 May before discharge from hospital.

16. Mr O saw a consultant oncologist (a cancer specialist) on 16 June and discussed treatments available to improve his quality of life. The consultant said they would refer Mr O to the community palliative care team and community dieticians, and would see him again when he started his chemotherapy.

17. Mr O’s daughter made the Practice aware of his diagnosis on 10 June. The Practice contacted Mr O by telephone on 11 and 14 June. The Practice got letters about Mr O’s diagnosis from the hospital and hospice care on 15, 16 17 and 19 June.

18. Shortly afterwards a nurse from the hospice care team called the Practice to say they had visited Mr O and he was anxious and had constipation. The Practice made a home visit that afternoon but found Mr O had been taken to hospital. Mr O sadly died later that day from a pulmonary embolism (blood clot in the lungs).

22. Before we decide if we should investigate 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 we have not found any signs something has gone wrong.

Diagnosis and referral

23. Mr H is unhappy with the treatment his father received from the Practice. He feels his father should have been referred to a specialist using the two-week wait cancer referral pathway (which aims to get anyone with possible signs of cancer seen quickly). Mr H told us the consultant he visited for a private consultation was able to diagnose and refer Mr O for further investigation much sooner. Mr H feels if his father’s cancer was diagnosed sooner he may have had more time to spend with his family or at least been more comfortable in his final months. We recognise it has been difficult for Mr H to see his father go through this experience.

24. Following Mr O’s appointment on 12 March 2021, the Practice arranged an ultrasound scan, full blood count, kidney and liver functions tests and a CRP test. The Practice contacted Mr O on 18 March to tell him his blood tests showed raised CRP levels indicating a recent infection. The Practice said it would wait to see what the ultrasound showed.

25. The ultrasound was performed on 9 April and the results showed the presence of a large calculus (gallstone) measuring 2.4cm and another of 1.6cm, suggesting Mr O had gallstones. After they got these results the GP wrote to the hospital on 15 April for an urgent referral.

26. The Practice arranged further investigations into Mr O’s pain (full blood count, CRP test, liver and kidney function tests and ultrasound) and the urgent hospital referral. Having discussed this case with our adviser, we understand the investigations the Practice carried out were suitable and necessary for Mr O.

27. The evidence indicates the Practice acted in line with the GMC guidelines on good medical practice. Section 15 states medical practitioners must promptly provide or arrange suitable investigations where necessary, having adequately assessed a patient’s condition.

28. NICE guideline NG12 (section 1.2.10) suggests a patient with an upper abdominal mass consistent with an enlarged gallbladder should be considered for an urgent direct access ultrasound scan within two weeks. Mr O’s symptoms and subsequent tests did not suggest gallbladder cancer, so the urgent referral for gallstone treatment, not for cancer, was in line with the guidelines.

29. Although Mr O’s symptoms did not indicate gallbladder cancer, he received the appropriate care to diagnose this through an ultrasound and then an urgent referral to a specialist.

30. Our adviser told us the ultrasound results showing a thickened gallbladder wall and one calculus measuring 2.4cm and another of 1.6cm would suggest gallstones, and our adviser would expect the Practice to then make a referral to a specialist.

31. The Practice referred Mr O for an ultrasound and when it got the results it made an urgent referral to a specialist. At this point the ultrasound results suggested gallstones, so Mr O did not meet the criteria for the two-week wait pathway as cancer was not suspected. This is in line with the suspected cancer NICE guideline NG12.

32. We understand Mr H believes his father should have been referred to a specialist using the two-week wait pathway. We are sorry Mr H has been left with this concern. Having looked at the relevant evidence and guidance, we consider the Practice has acted in line with the relevant NICE guidance.

33. We have not seen any signs something has gone wrong so will not consider this complaint further.

34. We realise how difficult and upsetting this matter has been for Mr H and his family and we thank Mr H for bringing his complaint to us.

End of life care plan

35. Mr H feels his father was let down by the Practice as it did not put a care plan in place for him or keep in touch after his diagnosis. He feels if the Practice had been more involved his father may have been able to stay at home, as he wanted, rather than being transferred to hospital, where he sadly passed away.

36. The Practice became aware of Mr O’s diagnosis when his daughter spoke to staff on 10 June 2021. On 11 June the Practice discussed Mr O’s diagnosis with him, the radiotherapy and chemotherapy he was going to have and if he needed further support. The Practice saw Mr O again on 14 and 17 June to help him with his pain and liaised with care workers who were visiting him at home.

37. Following a call from care worker soon after this, a GP visited Mr O at home, but he had already been taken to hospital. Mr O sadly passed away later that day.

38. When Mr O was diagnosed chemotherapy and radiotherapy were arranged in secondary care (hospital) and healthcare at home put in place. Our adviser told us there is no specific criteria for how a Practice should manage end of life care but there is GMC guidance on managing patients who need end of life care.

39. Paragraph 50 of the GMC’s ‘Treatment and care towards the end of life: good practice in decision making’ guidance says: ‘As treatment and care towards the end of life are delivered by multi-disciplinary teams often working across local health, social care, and voluntary sector services, you must plan ahead as much as possible to ensure timely access to safe, effective care and continuity in its delivery to meet the patient’s needs.’

40. Care at home was already arranged when the family contacted the Practice about Mr O’s diagnosis. There was limited time for the Practice to put any further care plans in place between the date it received the information from the hospital on 15 June 2021 and when Mr O was admitted to hospital.

41. The Practice helped with Mr O’s pain management through telephone consultations and arranged a home visit. But the end-of-life care plan was made in secondary care as the hospital had taken over his care when he was referred there. In this situation the Practice works as part of the multidisciplinary team, giving the pain relief suggested and needed and any other support it is asked to.

42. After reviewing the information and what our adviser said, we consider the Practice met the GMC guidance. The Practice did provide care following Mr O’s diagnosis in the form of telephone consultations and managing his pain. We believe the evidence indicates the Practice did what it reasonably could to make sure Mr O got effective and continuous care within a short period of time and performed its role in helping Mr O receive the end of life care he needed.

43. We understand Mr H’s concerns about the care his father got from the Practice when he returned home after his diagnosis. But we have not seen any signs something went wrong, so we will not investigate this matter further.

44. We thank Mr H for bringing his complaint to us and we hope he will find our decision useful in confirming we have not seen any signs something went wrong with his father’s care.

1. The Parliamentary and Health Service Ombudsman has carefully considered Mr H’s complaint about the care and treatment his father, Mr O, received from a practice in the Hertfordshire area (the Practice). We were sorry to hear about the circumstances that led Mr H to approach us. We appreciate Mr H and his family have been through a difficult time following their loss.

2. We have looked at what Mr H has told us and sought advice from an independent clinical adviser. Having considered all the evidence, we have seen no signs the Practice has done anything wrong. We have decided not to consider Mr H’s complaint further and we fully explain our reasons in this statement.