Issue one – First GP’s alleged reluctance to refer Miss T
20. 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 indications the first GP did anything wrong.
21. The NICE clinical knowledge summary of breast cancer symptoms recommends clinicians should ‘consider non-urgent referral’ in patients with ‘breast lump (unexplained) with or without pain, under age 30 years’.
22. The GMC’s ‘Good Medical Practice’ states doctors must consult colleagues where appropriate (16d) and only provide care when they have adequate knowledge of the patient’s health (16a).
23. Miss T explained she had a consultation on 29 April 2020 due to finding lumps on her breasts. She said the GP examined her during the consultation and felt two lumps, one on each breast. Miss T stated the GP said it was probably due to a blocked duct and if Miss T were their patient, they would not refer her to a specialist. Miss T said that she had to fight to be referred to a specialist.
24. As part of the Practice’s response, the GP who examined Miss T wrote to her to explain they had tried to reassure her that the lumps were most likely non-cancerous.
25. The GP explained they then passed on the findings of the consultation to the Practice and communicated Miss T’s wish for a referral. The GP reflected they could have communicated their conclusions to Miss T in a clearer manner during the consultation.
26. The notes on the system show Miss T called the Practice after the face-to-face consultation and advised the GP she saw ‘wanted [her] referred’.
27. The notes indicate Miss T’s regular GP intended to refer her after the GP who examined Miss T provided their notes from the consultation. The GP who did the examination communicated the symptoms, history and findings to the Practice in notes added on 30 April 2020.
28. The notes show the GP tried to assure the patient the lumps they found were most likely benign but said that the patient still wanted to be referred.
29. Miss T’s regular GP acted on this information and made the referral on 1 May 2020. Based on Miss T’s age (under 30) and symptoms at the time of her consultation, this appears to be in line with the NICE clinical knowledge summary. We can see no indication in the records that the first GP refused to refer her because of her age.
30. We have considered Miss T’s account of her conversation with the GP. We can understand how she may have felt she was not taken seriously, especially as she would have been really worried about her health.
31. We can see the GP tried to reassure Miss T that it was most likely not a serious issue, given that Miss T was ‘worried’. From the records, we can also see the GP planned to communicate Miss T’s wish for a referral to her own GP and did so quickly. We consider this is likely in line with GMC guidance as Miss T’s regular GP would have had the best knowledge of her medical history and was well placed to make the referral.
32. The GP wrote to Miss T, stating that they could have communicated with her better and apologising for any distress caused. We consider this to be a positive, proactive attempt by the GP to improve their service.
33. In summary, we can see the examining GP considered a non-urgent referral and passed on the necessary information to the Practice and Miss T’s regular GP.
34. This is in line with NHS standards based on Miss T’s examination. We do not feel that there is any clear indication the GP gave Miss T any incorrect information or refused to consider a referral. As such, we have decided to take no further action on this point.
Issue two – Failure to refer within two weeks
35. Before we decide if we should conduct a detailed investigation of a complaint, we also look at whether there are signs the event(s) complained about had a negative effect which the organisation has not put right.
36. Our ‘Principles of Good Administration’ state organisations should keep to commitments they make.
37. The NICE clinical knowledge summary for breast cancer symptoms says clinicians should consider a non-urgent referral for someone with Miss T’s symptoms. The NHS targets say a patient should wait no more than two months (62 days) between the date the hospital receives an urgent referral for suspected cancer and the start of treatment (Cancer Research UK).
38. Our ‘Principles for Remedy’ list a range of outcomes in response to a mistake, which include ‘an apology, explanation and acknowledgement of responsibility’. Our ‘Principles for Remedy’ also say to seek continuous improvement, the organisation may make changes, including staff training, to ensure poor service is not repeated.
39. Miss T is unhappy there was a delay in referral after her initial appointment. She said she was told she would receive a referral within two weeks. She chased the Practice after this time but it had not made the onward referral correctly.
40. Miss T explained she took it upon herself to contact two alternative hospitals and was able to get an appointment for 26 May 2020. She said her referral was therefore delayed by 11 days. We were sorry to hear of the additional problems Miss T experienced at what must have already been a stressful and worrying time for her.
41. The Practice explained it tried to make a non-urgent referral to the hospital on 1 May, but sent it to the wrong clinic on the referral system. When Miss T highlighted the problem on 15 May, the Practice resent the referral. It then cancelled this referral and sent another referral to a different hospital on 18 May to get Miss T an earlier appointment.
42. We can see the NICE clinical knowledge summary indicates that Miss T should have had a non-urgent referral, which the Practice attempted on 1 May. Miss T says she was told she would receive a referral within two weeks, which would have meant she would receive an appointment by 15 May.
43. The Practice notes indicate the GP who examined Miss T may have incorrectly advised a two-week referral was necessary and Miss T chased her appointment after two weeks. On balance, we think the Practice led Miss T to believe it would refer her within two weeks and this is what she was expecting.
44. Due to the Practice sending the referral incorrectly, Miss T did not see a specialist until 26 May 2020. This represents a delay of 11 days, which would have been avoided if the Practice had sent the agreed two-week referral correctly. This indicates the Practice failed to act in line with our ‘Principles of Good Administration’.
45. Our oncology adviser considered the impact the 11-day delay in referral would have had. In their view, it did not make a difference to Miss T’s diagnosis or treatment.
46. Our oncology adviser explained when the surgeon removed Miss T’s tumour, it was 14mm, which is considered early-stage cancer. We can see Cancer Research UK’s information explains that stages one and two are early-stage cancer and, in stages 1a, 1b and 2a, the tumours are 20mm or smaller.
47. Our oncology adviser also confirmed Miss T would still have required chemotherapy following her surgery due to the HER2+ (a protein that causes cancer to grow and spread) nature of the cancer. We know from Cancer Research UK’s ‘TNM staging’, HER2+ cancer generally grows more quickly. The same organisation’s ‘Stage 1 breast cancer’ also explains that if HER2 protein is present, the patient will receive chemotherapy alongside a drug called trastuzumab (a targeted cancer drug).
48. Miss T began receiving treatment within 62 days of the urgent referral. We cannot see the Practice's delay caused her to receive treatment outside the NHS target waiting time.
49. As the cancer was still early stage and Miss T would have had the same treatment and within the correct timeframe, we consider it likely that the 11-day delay did not have a negative impact on her illness or treatment.
50. We accept the worry the delay would have caused Miss T, alongside the stress of having to chase up the appointment herself. We understand she is concerned this could happen to someone else.
51. In its complaint response of 24 March 2021, the Practice apologised for what happened and accepted it had contributed to Miss T’s distress. It provided a detailed explanation of what went wrong and accepted that it made mistakes. The Practice also explained it had made several improvements to make sure future referrals were dealt with properly and similar issues did not arise. These new procedures are:
• dedicated ‘referral care navigator’ / secretary to handle referrals • dedicated time for care navigators to process, check and track referrals • spreadsheet created to record and track referrals, and • training for care navigators on how to do all referrals.
52. Our GP adviser reviewed these actions and felt the Practice had analysed the incident and taken measures to reduce, or even prevent, a similar issue. We feel the evidence shows the Practice has learned from the incident and made robust improvements to stop this happening again. It has also apologised, taken responsibility and explained what happened in its response to Miss T. We think this is in line with our ‘Principles for Remedy’.
53. Our view is that the Practice likely caused a short delay in Miss T’s referral (although NICE information suggests urgent referral was not needed, the Practice agreed to submit a ‘non-urgent two-week referral’).
54. We consider that this delay did not negatively affect Miss T’s treatment or outcome and we hope this provides some reassurance to her. We think the Practice has already done enough to put things right for the distress it caused, in line with our ‘Principles for Remedy’. We have therefore decided to take no further action.
Issue three – Complaint response
55. Our ‘Principles for Remedy’ explain outcomes include ‘an apology, explanation and acknowledgement of responsibility’. They also say to seek continuous improvement, the organisation may make changes, including staff training, to make sure poor service is not repeated.
56. Miss T said she was ‘lied to on multiple occasions to cover up [the Practice’s] mistakes’. She feels this was unacceptable and the Practice lacked accountability and tried to conceal its mistakes instead of putting things right. Miss T complained the first response did not correctly explain the error with the referral or how many times she was then referred to correct this.
57. The Practice explained the reception team lead believed she was booking Miss T into a triage clinic at the time of booking. In its first response, the Practice agreed it needed to urgently remove the clinic that sends supporting documentation from the booking system to avoid this happening again.
58. The Practice has since accepted it failed to notice, at the time of booking, there was already a note on the booking system explaining this clinic should not be used for referrals. The Practice made three referrals between 15 and 18 May to correct this error and Miss T quickly got an appointment.
59. We understand Miss T feels there were deliberate attempts by the Practice to cover up its actions. We can see that, after Miss T questioned the first response, the Practice looked again at what had happened and provided clarification and an apology.
60. The Practice also completed a significant event analysis (a way of formally analysing incidents to improve patient care) to identify what went wrong and make improvements to prevent this happening again. We can see it has analysed its errors and put things in place to ensure the same thing does not happen again.
61. Given this, we do not think there are indications the Practice’s responses were deliberately misleading. We are satisfied the Practice has provided a robust explanation for each aspect of potential fault we identified and indicated how it is putting things right. It also gave its apologies for any distress caused.
62. We have not found any impact on Miss T that has not been put right. We can also see the Practice appears to have acted in line with our ‘Principles for Remedy’ by apologising and making service improvements. We will therefore take no further action on this point.
63. We thank Miss T for bringing her complaint to us. We understand this was a very difficult time for her. We are glad to see the Practice has put measures in place to prevent the same issue happening again as a result of her complaint.
64. While we know this may not be the decision Miss T wished for, we hope this report clearly shows how we have reached our decision and reassures that her complaint has led to improvements in the Practice’s breast cancer referral service.