A practice in the Leicestershire area

4. Mrs I complains about the following aspects of the care and treatment her husband Mr I received from the Practice between 20 March and 6 August 2023.

• The Practice prescribed incorrect medications including clotrimazole (a vaginal pessary for thrush in women) and incorrect dosage of antibiotics.

• It was very difficult to get face to face appointments with the Practice and it ultimately failed to physically examine Mr I’s penile cancer symptoms.

5. Mrs I says the Practice’s failings meant her husband was not prioritised and there were delays in Mr I getting a diagnosis of penile cancer. By the time the hospital diagnosed it in August, it was terminal and incorrect medications only exacerbated the distress they were under. Mrs I has been deeply affected by the failings and the implications this had on her husband’s prognosis and diagnosis.

6. Mrs I is seeking accountability for the failings. She wants to know if earlier diagnosis and treatment would have led to a better prognosis.

7. Mr I contacted his Practice with health concerns in March 2023. Between March and August, he had face to face and telephone appointments. The Practice diagnosed him with various conditions including thrush, e-coli infection, and prostate issues.

8. On 7 August Mrs I called 111. The call taker advised Mr I should go to the emergency department. At the hospital doctors discovered he had penile cancer, and he underwent surgery. Mr I was later told he was terminal and started on palliative care. He died on 22 May 2024.

Incorrectly prescribed medications

12. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so it appears the Practice got things wrong here. But we think it has already done enough to put right the impact this had.

13. Mrs I was frustrated and disappointed with two separate incidents where the Practice provided incorrect prescriptions for her husband. The medical records confirm this happened.

14. The Practice first incorrectly prescribed Mr I a vaginal pessary to treat thrush in women on 27 March 2023. It later prescribed him a three-day course of antibiotics for a bladder infection on 4 April. The shorter prescription of antibiotics is suitable for women but NICE guidance on lower UTI infection in men says men should have a seven-day prescription.

15. So the Practice made medication errors and we understand what this was frustrating for Mr and Mrs I. The records show on 19 April the clinician apologised in person to Mr I for prescribing the wrong pessary and incorrect dosage of antibiotics.

16. One of the outcomes Mrs I is seeking is accountability. The NHS Complaint Standards say an organisation should be accountable for its actions and open and honest when it gets things wrong. It should try and put things right and offer meaningful apologies. In both instances the Practice rectified the prescriptions within a week and the records show it acknowledged its failings and offered an apology to Mr I for the errors.

17. Based on the records we have seen; our view is the Practice has already done enough to put things right when it acknowledged it got something wrong and apologised to Mr I. There is nothing more we would ask the Practice to do if we looked at this part of the complaint further.

Lack of physical assessment or suspicion of cancer

18. When we have looked at the evidence here, we have not seen any indications something has gone wrong.

19. Mrs I says Mr I had a rash on his penis, the Practice failed to physically examine him. She is further frustrated because he was diagnosed with thrush without physical examination and had a physical prostate assessment, but the Practice failed to use either opportunity to examine his penis.

20. The Practice said it was not aware Mr I had a rash on his penis until he went into hospital on 7 August. It said it would not do an examination of such an intimate area unless there was good reason.

21. The NICE guidance on suspected cancer (NG12) says a doctor should consider a suspected cancer pathway referral for penile cancer if the man has a penile mass or ulcerated lesion and there is no indication it is caused by a sexually transmitted infection. So, whether the Practice was aware of the rash on Mr I’s penis is important.

22. Our adviser reviewed Mr I’s medical records between March and August 2023. We asked them whether there was any evidence to indicate the Practice should have physically examined Mr I’s penis.

23. Our adviser explained penile cancer is very rare and from the records there was no evidence Mr I told the Practice about any penile cancer specific symptoms such as lesions, genital growths, or rashes. Based on the symptoms Mr I told them he was presenting with, our adviser said it would not be standard protocol to request a physical genital examination. They highlighted on 17 May and 30 June Mr I told the Practice he was feeling much better. This would have indicated all his issues were in hand since he was getting better from urinary and prostate related treatment alone.

24. We asked the adviser whether there was missed opportunity to for a physical examination when a GP diagnosed Mr I with thrush during a telephone consultation. Our adviser emphasised it is not unusual to diagnose thrush without physical assessment and whether a clinician decides to do so or not depend on the symptoms relayed by the patient. In this case there were no chronic thrush symptoms, repeat prescription requests or abnormal symptoms (such as a rash) recorded which would have indicated a physical assessment was necessary.

25. NICE guidance on how to diagnose a thrush infection in men states swabbing is only recommended where diagnosis is uncertain and further investigation to reach diagnosis is usually not necessary.

26. Mrs I felt the Practice could have done a genital assessment during the prostate examination. Our adviser assured it would not be usual for a clinician doing a prostate examination to assess genitalia without cause to do so, which there was not.

27. We appreciate Mrs I believes her husband would have told the Practice about his rash on his penis. When we weigh up the records, we cannot see evidence to support this. There is no reference to it in the records of any of the appointments. We note that at some of the appointments, the GP asked about unintended weight loss and mentioned red flags. These are things the NICE suspected cancer guidance says doctors should think about. That indicates that had Mr I mentioned all his symptoms that could have indicated cancer, the Practice would have recorded this and been aware there was a need for a referral.

28. Based on the records, guidance, and our clinical advice there does not appear to have been a reason for the Practice to physically examine Mr I’s penis, or to refer him for suspected penile cancer. His documented symptoms did not indicate he needed referral under the cancer guidance or that he needed a physical genital assessment.

29. This means there is no reason for us to take any further action on this part of the complaint. We do not intend our decision to take away from the very difficult time she has had, or the worry she has experienced. We hope how we have reached our view is clear.

Appointments and prioritisation

30. When we look at this part of the complaint, we think the Practice got something wrong and has not yet put right the impact that had for Mrs I. The Practice has agreed to do this now.

31. Mrs I felt it was difficult to get face to face appointments which resulted in her husband not being prioritised properly and potentially missing opportunity for further physical assessment.

32. We told Mrs I that we cannot look at or comment on how an organisation allocates its resource (including human resources). But we can review whether based on Mr I’s symptoms the appointments and care he received was appropriate.

33. Between 20 March and 1 August, the records show the Practice offered a range of appointments including telephone and face to face consultations. As we have explained earlier, we are satisfied there was no indication a GP needed to see him face to face to manage his known symptoms.

34. However, we noted on 1 August the records show Mr I was unable to attend a face-to-face appointment and the Practice offered no further care. The Practice told Mr I to contact it again should his condition worsen. Mrs I emailed the Practice on 3 August asking for help after relaying his worsening symptoms and raising none of the medications were working. But the Practice did not respond to Mrs I. She then had to call 111 on 7 August.

35. The GMC’s Good medical practice says doctors should adequately assess a patient’s condition and promptly provide or arrange suitable advice, investigations, or treatment where necessary.

36. We asked our adviser whether the Practice failed to prioritise Mr I for face-to-face appointment during this period. They said the Practice should have done more as Mr I’s clinical picture shows by this point, he was clearly deteriorating. If the Practice was unable to send out a clinician, it should have facilitated some additional care instead of waiting for the I’s to get in touch.

37. The Practice told Mr I to let it know if he got worse. Mrs I did that, by email two days later. But it failed to pick up on this in time. So, we do not think the Practice acted in line with the GMC guidance and there is an indication of a failing.

38. Mr I was admitted to hospital less than a week after the 1 August telephone appointment with the Practice and was quickly diagnosed with penile cancer. So, we would not be able to say the clinical outcome would have been any different if the Practice had arranged to see him on 1 or 3 August. He would still have needed to go into hospital, possibly as urgently, and would have been diagnosed with cancer. But this was a very worrying few days for them both, when Mr I was getting worse quickly, and they did not have support. If the Practice had arranged to see him, it could have alleviated some of that worry for them.

39. As we set out earlier, the NHS Complaint standards say organisations should be accountable, acknowledge when they make mistakes, and put things right.

40. We do not think we need to investigate this part of the complaint any further to know what happened and what would resolve the impact. So, we as asked if the Practice would be willing to write to Mrs I to acknowledge it could have done more between 1 and 7 August to prioritise or escalate her husband’s care, and to apologise for the worry it caused them because it did not do this. The Practice has agreed to do so and will write to Mrs I within ten working days.

41. We appreciate this will remain a very difficult time for Mrs I and truly want to extend our gratitude to her for bringing her complaint to us. We hope we have been able to assure her about most of the care her husband had from the Practice, and that its further letter will resolve the final part of her complaint for her.

1. We have carefully considered Mrs I’s complaint about a practice in the Leicestershire area (the Practice). Based on the information the Practice had about Mr I’s symptoms, we have not seen any indication the Practice should have referred or physically examined him for further investigations. We recognise it gave him two incorrect prescriptions. We can see it acknowledged and apologised for this and put things right at the time.

2. We think the Practice should have done more when Mr I was very unwell just before his hospital admission, and that because it did not, he and his wife experienced more worry than they should have. The Practice has agreed to write to Mrs I to acknowledge and apologise for this. We think this is enough to put things right.

3. We are sorry to hear about Mrs I and her family’s experience while her husband, Mr I, was under the Practice’s care. We recognise this has been a difficult and deeply distressing time for Mrs I and hope the information below clearly explains how we reached our views.