The Practice
17. Mrs R believes the Practice could have done more to diagnose Mrs K’s condition from March to June 2020, when she saw a GP.
18. We have reviewed Mrs K’s GP medical records for this period to understand her contact with the Practice. In March Mrs K went to the Practice for a review of her chronic obstructive lung disease and her inhaler medication. She then had a telephone consultation in April related to her chronic obstructive disease and a sick note was issued. A further telephone consultation took place in May for her chronic obstructive lung disease annual review and no changes to her ongoing treatment were made.
19. On 17 June Mrs K spoke with her GP again for a telephone consultation. During this telephone call the GP recorded that Mrs K described having difficulty eating and felt full with small amounts of food. She also described her clothes as feeling looser.
20. On the same day the GP made an urgent referral to the Trust requesting that Mrs K be seen within two weeks for further investigations.
21. Before the telephone consultation on 17 June there is no record that Mrs K raised concerns about these symptoms. The reviews in March, April and May were all related to Mrs K’s chronic obstructive lung disease.
22. GMC Good Medical Practice explains what a doctor should do. It says:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
a) 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
b) promptly provide or arrange suitable advice, investigations or treatment where necessary
c) refer a patient to another practitioner when this serves the patient’s needs’.
23. Our GP adviser reviewed the consultations from March, April and May. We are satisfied Mrs K received appropriate advice and treatment for her ongoing condition, in line with the GMC guidance. Mrs K did not mention her swallowing problems at these consultations so the GP could not have been expected to provide any advice or treatment for them. None of the issues raised in March, April or May suggested an urgent cancer referral.
24. When Mrs K was seen on 17 June and described swallowing and eating problems, the urgent referral was made on the same day.
25. NICE NG12 guidance explains what should happen when patients present with potential cancer symptoms.
In the case of upper gastrointestinal tract cancers, this guidance says:
‘Offer urgent, direct access upper gastrointestinal endoscopy (to be done within 2 weeks) to assess for oesophageal cancer in people:
-with dysphagia or -aged 55 and over with weight loss and any of the following: upper abdominal pain, reflux, dyspepsia’.
26. Mrs K has dysphagia (difficulty swallowing) and was over 55 with weight loss. At the 17 June telephone consultation Mrs K met the criteria for an urgent two-week referral. The GP referred her on the same day.
27. The Practice recorded that Mrs K was not keen to have an endoscopy, but we are satisfied the Practice acted appropriately by referring Mrs K without delay. We have not seen any evidence to suggest such a referral could have been made any earlier. Mrs K had not mentioned any of the relevant symptoms before 17 June. Our decision is the Practice acted in line with the relevant guidance.
28. We appreciate Mrs R’s concerns and hope she can take some reassurance from our decision. It must be very difficult and upsetting to feel that earlier action could have been taken.
The Trust
29. Mrs R is unhappy that when the Practice made the urgent referral on 17 June, it was downgraded to routine, after a telephone triage with the Trust.
30. In June 2020 all NHS hospitals were in the early stages of the COVID-19 pandemic. This meant that any patient attending hospital would have been entering a high-risk environment. At this time there was also limited access to facilities, staff and personal protective equipment. The BSG published guidance to try and deal with the problems.
31. This recommended that:
‘two week referrals are risk assessed on a case-by-case basis before tests such as upper endoscopy are organised, to prioritise those felt clinically to be at greatest need and to take account of limited availability of facilities, staff and appropriate PPE’.
32. Based on this guidance, we are satisfied it was appropriate for Mrs K to have had a triage telephone call on 19 June after the Trust received the referral from the Practice.
33. The BSG guidance on the criteria for an urgent endoscopy was designed to try and make sure the most urgent cases had access to the limited endoscopy investigations available at the time, and to try and minimise the number of patients entering high-risk hospitals.
34. The record of the telephone triage Mrs K had on 19 June shows that she explained she had reflux and dyspepsia (indigestion), but not dysphagia or weight loss. These symptoms did not meet the criteria set out in the guidance, meaning Mrs K was not considered as needing urgent review.
35. After the telephone triage Mrs K was downgraded to a routine endoscopy, rather than an urgent two-week referral. In July, Mrs K was referred again by her GP and this led to her having an endoscopy on 17 July which showed a malignant tumour.
36. With this in mind, we can appreciate how distressing Mrs R found the decision to downgrade the referral to routine. The period in question was very challenging for the NHS because of the COVID-19 pandemic and resources had to be distributed to try and meet the needs of the most urgent patients first, which is why new guidance was introduced as explained above. There were also greater risks for patients attending hospital and the new guidance tried to reduce this risk.
37. It is extremely sad that in this example the limited endoscopy facilities and greater risk posed by hospital attendances meant Mrs K’s case was downgraded to a routine procedure. Before the pandemic, the additional telephone triage may not have been needed.
38. In this case, the Trust’s actions were in line with the guidance that had been produced to manage the difficulties the Trust was facing. The symptoms recorded from Mrs K’s telephone triage on 19 June meant she did not meet the criteria for an urgent referral, and we are satisfied the guidance was followed appropriately. Our gastroenterology adviser shares this view and we are not upholding the complaint about the Trust.