3. Mrs U says between January and April 2022, the Practice did not correctly assess or complete medical tests on her mother before she was admitted to hospital where she died.
4. Mrs U says the impact of her mother dying has affected the whole family as they feel let down by the Practice.
5. Mrs U wants an apology and an acknowledgment that the Practice could have done more medical tests and assessments for her mother.
6. Mrs A was in her eighties and lived independently. She had several chronic conditions including osteoporosis (a condition where the bones weaken and become fragile).
7. In January 2022, she began to report pain in her hip and groin.
8. Mrs A sadly died in May after a short stay in hospital.
12. Mrs U says the Practice did not correctly assess or complete medical tests on her mother before she was admitted to hospital on 25 April.
13. Mrs U told us she thinks the GP should have completed more face-to-face appointments with Mrs A. She believes the deterioration in her health would then have been more obvious and her cancer could have been diagnosed sooner. We do not wish to minimise the emotional impact this has had on Mrs U. We appreciate this has been difficult time for her.
14. The Practice says it offered Mrs A good care and thorough medical assessments, which are noted in her medical records. It acknowledged the tests and examinations did not reveal the diagnosis. The Practice says looking through her records it is clear Mrs A deteriorated in her final days. It says it appreciates how upsetting this must have been for the family.
15. The relevant guidance here is remote consultation guidance that says:
‘Is a remote consultation appropriate
• Remember that patient safety always comes first. You must be confident that assessment via remote means will be adequate. Establish quickly whether the patient may need further review or a face-to-face examination and direct them to the most appropriate service.’
16. Also, relevant is the GMC guidance that says,
‘You must provide a good standard of practice and care. If you assess, diagnose, or treat patients you must:
a.adequately assesses 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 provides or arrange suitable advice, investigations, or treatment where necessary c.refer a patient to another practitioner when this serves the patient’s needs.’
17. Mrs A’s medical records show she had five phone consultations between 21 January and 22 February. She then had an in-person appointment on 28 February, followed by three more phone consultations and a home visit on 19 April. We can see that during each of these phone consultations, the GP had full access to Mrs A’s medical records, in line with the GMC remote consultations guidance.
18. The first of these phone consultations was on 21 January when Mrs A spoke to the Practice because she had ongoing pain in her right hip and groin area. She reported the pain had got worse over a few days but eased when she took paracetamol. She did not report any falls or injuries that may have caused the pain. Our adviser says there were no ‘red flags’ reported like weight loss or changes in bowel or urinary functions.
19. The medical records show Mrs A had an X-ray of her right hip in 2016 which showed mild arthritis with some degeneration (wear and tear) of her lumbar spine. Mrs A also had longstanding peripheral arterial disease (PAD is a condition that causes narrowing of arteries, often in the legs). We can see the GP questioned her about the PAD and Mrs A confirmed this was stable.
20. The Practice referred Mrs A for an X-ray of her pelvis area. On the same day the GP had another phone consultation with Mrs A about the arthritis in her hip. She was offered stronger pain relief (codeine) but she refused, preferring to continue using paracetamol to manage her pain.
21. We think the Practice followed the GMC guidance here when assessing Mrs A’s conditions and considering her medical history. The GP had a working diagnosis of a progression of the arthritis in her hip because it was already known that she had mild osteoarthritis. We also think the GP acted in line when ordering the X-ray as the guidance says doctors must ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’.
22. The GP reviewed the X-ray results on 26 January. The X-ray showed the mild osteoarthritis of Mrs A’s hips was unchanged from 2016. It also showed degenerative changes in her lumbar spine.
23. On 9 February, the GP spoke to Mrs A and discussed her X-ray results, saying they showed mild osteoarthritis of the hips. The GP offered her physiotherapy and stronger pain relief medication which she refused. Offering to refer Mrs A to physiotherapy was in line with GMC guidance which says, ‘refer a patient to another practitioner when this serves the patient’s needs.’
24. Our adviser says the radiologist who reported on the X-ray found no sign of bone changes caused by cancer. Our adviser says treating the arthritis and lumbar spine degeneration as the cause of Mrs A’s pain was appropriate.
25. On 15 February, the GP had a phone consultation with Mrs A where she described she had a cough on and off since December 2021. COVID-19 tests had been negative. The GP noted she coughed up clear liquid at times. Mrs A told the GP she had some breathlessness at times but quickly recovered, she had some loss of appetite and her mood had been flat. She said she had no chest pains or sinus symptoms and had not coughed up any blood. The GP noted Mrs A was an ex-smoker and had some appetite loss at times but had not coughed up any blood.
26. The GP offered to see and examine Mrs A if she went to the Practice, but she declined this and said she would prefer to have blood test and the chest X-ray the GP had suggested. The Practice referred Mrs A for a blood test and chest X-ray.
27. We think the Practice acted in line with GMC guidance by quickly arranging suitable investigations.
28. Also relevant is the NICE guidance that says for an unexplained cough together with fatigue or shortness of breath or chest pain or weight loss or unexplained appetite loss, if the patient is 40 and over doctors should offer an urgent chest X‑ray. This should be done within two weeks.
29. The Practice was right to refer Mrs A under the cancer pathway based on her symptoms.
30. On 22 February the GP had a phone consultation with Mrs A where they discussed her blood test results. The results showed a mildly raised white cell count which can indicate a mild infection. Mrs A’s sodium levels were also slightly low (when sodium levels are low, extra water is kept by the body causing swelling). Mrs A had been prescribed a water tablet, furosemide, in summer 2021. Water tablets can cause sodium levels to drop, so the GP advised her to stop taking the furosemide.
31. The Practice got Mrs A’s chest X-ray (CXR) results on 23 February. The CXR showed changes from the last CXR in 2016 with her COPD (chronic obstructive pulmonary disease), but no sign of cancer.
32. On 28 February Mrs A had a face-to-face appointment at the Practice. It completed a thorough assessment and her ongoing cough was discussed. The GP offered her an inhaler to help with her airways and breathing, but Mrs A refused this. The Practice referred her for more blood tests.
33. The Practice discussed the blood test results with Mrs A during a phone consultation on 21 March. Her sodium levels had returned to normal. Her vitamin D was low. Low vitamin D can weaken a person’s bones. The Practice prescribed a vitamin D supplement. The blood tests did not show any underlying serious health conditions or cancer.
34. On 28 March, Mrs A had a phone consultation where she reported pain in her left side, below her rib cage, and said she was getting out of breath easily. She also reported weight loss, low appetite, loneliness and said her balance was getting worse. Mrs A said she felt ill and was not her normal self. Mrs A reported she was still low in mood, she was lonely because she lived alone and saw her family occasionally but did not like bothering them. The Practice recommended counselling, but she did not want this.
35. The Practice ordered more blood tests and increased her pain medication. Our adviser says this plan was clinically appropriate because her recent CXR was reassuring and her bloods showed minor abnormalities that were being re-checked. We think the Practice acted in line with GMC guidance here, providing suitable advice and arranging further investigations.
36. On 19 April, Mrs A had another phone consultation and reported ongoing and worsening shortness of breath and weight loss over the last few days. Mrs A said she was feeling more breathless around the house but was comfortable when resting. She was offered a face-to-face appointment, but the Practice agreed to do a home visit given her circumstances.
37. The Practice arranged an urgent home visit from the primary care visiting service with an emergency care practitioner (ECP) who assesses the patient and reports back directly to the Practice.
38. Mrs A was seen by the ECP who noted her recent history. Medical records show on examination Mrs A had no chest pain or wheeze and her oxygen saturations were normal. Mrs A explained her breathlessness had been going on for a few months. The ECP examined her by listening to her chest, which was clear with no crackles (crackles can be heard when there is fluid on the lung). The records show Mrs A had slight swelling of her feet but had no breathlessness when laying flat. Mrs A said her feet had begun swelling since stopping the furosemide.
39. Based on the findings of the home visit, the Practice decided to restart Mrs A’s furosemide. Our adviser says this was reasonable because excess fluid could have been the cause of Mrs A’s breathlessness. Restarting the water tablet would reduce the amount of fluid held in the body and ease her symptoms if caused by that.
40. We think the Practice assessed her in line with the GMC guidance that says, ‘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.’
41. On 25 April an ambulance was called to Mrs A’s home. The paramedics called and spoke to the Practice. Mrs A’s oxygen levels had dropped and her blood pressure was also dropping when she stood up. The GP was concerned and documents this in Mrs A’s medical records. The GP had been due to see Mrs A later in the week but decided because of her rapid deterioration over a three-week period, she should go to hospital to be assessed by the medical team.
42. The medical records show scans completed after Mrs A was admitted to hospital showed metastasis lung cancer. Tragically, this meant Mrs A had cancer that had spread from her lungs to her bones.
43. We have not seen there was a missed opportunity for the Practice to diagnose Mrs A’s cancer sooner. We think the Practice arranged appropriate X-rays and blood tests. The pelvis X-ray in January showed arthritic changes that explained her groin and hip pain. The chest X-ray in January showed changes of her COPD which would explain her breathlessness.
44. The pelvic X-ray did not show any changes in the bones to suggest cancer and the chest X-ray did not show lung cancer. By the time Mrs A died her cancer had spread. We appreciate this is why Mrs U believes the Practice could have done more to find the cancer much sooner.
45. Our adviser commented that the X-rays and blood tests gave false reassurance to the Practice because they showed only minor, non-significant findings. Sadly, none of the appropriate investigations showed the lung cancer and its spread to Mrs A’s bones.
46. We do not wish to underestimate the emotional impact this has had on Mrs U. In grieving for her mother, she has also had to deal with the weight of her concerns about the care and treatment her mother received during her final months. We have seen evidence that the Practice did what it should have to care for Mrs A.
47. We understand Mrs U will be disappointed with our decision but thank her for bringing her concerns to us.
1. We have carefully considered Mrs U’s complaint about a GP practice in the Oxfordshire area (the Practice). We have not seen that anything went seriously wrong with the care and treatment the Practice gave to her mother, Mrs A, before she was admitted to hospital.
2. We are sorry to hear about the circumstances of Mrs U’s complaint and her concerns. We do not wish to underestimate Mrs U’s experience and loss. It is clear this has been a difficult time for her.