21. When we look at a complaint, we first establish what should happen by using relevant guidance, standards, the law or policies and procedures. We then consider all the available evidence to understand what did happen and if this fell so far short of what should happen to be a failing. We often refer to this as ‘maladministration’.
22. We then go on to consider the injustice claimed and the impact on a person and if we can link this to the failing. We then consider what the organisation has done to recognise those failings and put matters right. We call this the ‘remedy’. If we consider (against our own complaint handling and remedy principles) the organisation has not done enough, then we may make further recommendations for remedy.
Complaint GP did not follow up Miss I’s attendance at A&E on 27 November 2021
23. Miss I tells us she was experiencing stomach pains for a few weeks, and they were becoming more severe. She says she fainted on 27 November because the pain was so bad and this caused injuries to her face and head, so she attended the A&E at her local hospital for assessment and treatment for her injuries. Miss I says her GP should then have contacted her to arrange follow up treatment after her attendance at the A&E.
24. The Practice says the electronic notification letter it received from A&E about Miss I’s attendance did not mention abdominal pain. It says the letter it received contained Miss I’s admission notes, discharge notes, copies of in-patient blood test results, CT scan report and the result of Miss I’s COVID-19 swab.
25. We have reviewed the discharge notes from A&E, and they show no action for the GP to act upon.
26. From clinical advice sought, we understand there are no guidelines for follow on care by a GP after a patient had attended A&E and is discharged. They say generally there would be a comment on the A&E discharge letter to the GP for follow up action if this was necessary (thus to alert a GP that further specific action is documented as needing to be taken). It is up to the patient to contact the GP to report health problems unless anything otherwise is stated on the discharge letter.
27. From the medical records provided by the Practice we can see the discharge letter from the A&E on 27 November does not say any specific GP follow up action should occur.
28. In conducting our work, we became aware the information Miss I provided to us included a different format of the discharge form from the A&E. We have seen the form and compared these and note the form says Miss I was admitted to A&E on Saturday 27 November 2021 at 9.11am, it says Miss I reported she had been experiencing stomach pains and fainted when going to the bathroom and she had lost consciousness and banged her forehead.
29. The form says Miss I’s stomach was examined, and her observations, blood tests and urine samples were normal so the doctors could not find the cause of her abdominal pain. Miss I also had a CT scan of her head to rule out any internal bleeding as she had swelling and bruising to her forehead because of her fall and losing consciousness. Miss I was clinically stable, so she was discharged home from A&E the same day at 3.27pm. This discharge form provided information for the GP about what had occurred and said GP to follow up, but there was no specific action for the GP to take .
30. We asked Miss I where she had got the copy of the discharge letter from her A&E visit. Miss I said she downloaded her medical records from her NHS App (the NHS online digital application for patients) and there was a link which said attachments and it was in that section.
31. We also asked the Practice about this discharge letter from the A&E Department that Miss I had, and it said it did not have the form which says GP to follow up.
32. We have carefully considered this as we can see the form Miss I provided and the records from the Practice are not the same. We recognise the form from A&E is sent electronically to the Practice, which we have seen, and it appears a different form was uploaded onto Miss I’s NHS App. We cannot be critical of the Practice in not following up Miss I’s attendance at A&E on 27 November as we accept it did not receive a notification from A&E to do so and was acting on information provided to it as part of the discharge which stated no further follow up action.
33. We understand Miss I was concerned about her health, and we can see she contacted the Practice less than two weeks after her visit to A&E to report her symptoms and ongoing concerns.
34. An error administratively regarding two conflicting discharge forms being in circulation and originating form A&E is a matter that we have concluded in our investigation that either resides with the hospital or the electronic NHS application – neither of which are contained within the scope of this investigation nor relate to the actions of the Practice.
35. Thus. based on the evidence seen, we have not identified failings by the Practice regarding a follow up after Miss I’s attendance at the A&E on 27 November 2021, as the Practice was acting on available evidence which was provided to it as part of the discharge and was not in receipt of the document Miss I identifies.
Misdiagnosis with IBS on 10 December 2021
36. We have considered two relevant guidelines here. Firstly, the National Institute of Health and Care Excellence (NICE), Irritable bowel syndrome in adults: diagnosis and management Clinical guideline (CG61), this says: healthcare professionals should consider assessment for IBS if the person reports having had any of the following symptoms for at least six months: abdominal pain or discomfort, bloating and change in bowel habit.
37. Further, all people presenting with possible IBS symptoms should be assessed and clinically examined for the following 'red flag' (warning) indicators and should be referred to secondary care for further investigation if any are present. The ‘red flags’ specify signs and symptoms of cancer in line with the NICE guideline on suspected cancer: recognition and referral inflammatory markers for inflammatory bowel disease.
38. Secondly, the National Institute of Health and Care Excellence guideline on suspected cancer: recognition and referral of colorectal cancer says: there should be an offer of quantitative faecal immunochemical testing (FIT) to guide referral for suspected colorectal cancer in adults. This is for those with an abdominal mass, or with a change in bowel habit, or with iron-deficiency anaemia, or if the patient is aged 40 and over with unexplained weight loss and abdominal pain or aged under 50 with rectal bleeding and either of the following unexplained symptoms of abdominal pain or weight loss.
39. For those patients over 50, this should be offered where there are unexplained symptoms that includes rectal bleeding, abdominal pain, weight loss. For patients over 60 with anaemia this should also be offered even in the absence of iron deficiency.
40. A faecal immunochemical test (FIT) is a test that looks for blood in a sample of faeces. It looks for tiny traces of blood that might not be seen and which could be a sign of cancer. FIT should be offered even if the person has previously had a negative FIT result through the NHS bowel cancer screening programme. People with a rectal mass, an unexplained anal mass or unexplained anal ulceration do not need to be offered FIT before referral is considered.
41. Miss I continued to experience pain in her abdomen, so she contacted the Practice on 10 December and had a telephone consultation then followed by a face-to-face appointment on the same day.
42. During the call initially she explained to the GP about her abdominal pain lasting for a few hours every two to three days and her recent attendance at A&E where she had fainted due to the pain. The GP then arranged for a face-to-face appointment for later in the day and asked Miss I to attend early for a urine sample.
43. At the face-to-face appointment Miss I explained about her abdominal pain and was prescribed with mebeverine, this is a type of medicine known as an antispasmodic. It helps with muscle spasms and can be used to ease painful stomach cramps in patients with IBS.
44. From the clinical advice sought, we understand this was the first report to the GP of abdominal pain, and it is clearly documented in Miss I’s notes. The report was of pain and slightly off food – no weight loss, no change of bowel habit and no rectal bleeding. The record mentions Miss I had a colonoscopy (a procedure in which a flexible fibre-optic instrument is inserted through the anus to examine the colon) in 2019 and a faecal occult blood (FOB) test in February 2021 which was normal. The FOB test is used to check stool samples for hidden (occult) blood.
45. A FOB test uses a chemical indicator that shows a colour change in the presence of blood, whereas a FIT uses antibodies directed against human haemoglobin to detect blood in the stool. FIT is considered a more accurate way to screen for blood in the stools as it only detects human blood from the lower intestines.
46. The treatment plan was a trial of medication along with a bland diet and for Miss I to come back if the symptoms persisted. We understand from clinical advice, as there were no indications of red flags reported then it was not appropriate to suggest a two-week referral at this time.
47. The records for the telephone consultation and the face-to-face consultation show a detailed recording of Miss I’s symptoms of two weeks abdominal pain, her past medical history and referenced she had syncope and attended the A&E on 27 November. Syncope is the medical term for fainting or passing out. It is caused by a temporary drop in the amount of blood that flows to the brain. This leads to loss of consciousness and muscle control.
48. The records show there were no red flag symptoms, and Miss I had a colonoscopy in 2019 which was normal, and the blood sample taken on 27 November at the A&E was normal.
49. We can see the record shows that IBS may have been a possible diagnosis, but no formal diagnosis was made at this consultation. This is in line with the NICE clinical guidance on diagnosis and management of IBS, as Miss I did not report having her symptoms of abdominal pain for at least six months. Therefore, we have not identified any failings with this part of the complaint being a misdiagnosis.
Telephone consultation on 6 January 2022
50. The National Institute of Health and Care Excellence guideline on suspected cancer: recognition and referral of colorectal cancer, are relevant to this consultation and the following consultations on 7 and 21 February 2022.
51. Miss I contacted the Practice on 6 January 2022 and had a telephone consultation. She reported constipation and abdominal pain to the GP and was advised to take senna and Fybogel for a week. Senna and Fybogel are laxative medications to relieve constipation.
52. In its complaint response letter to Miss I, the Practice said the correct clinical care was provided based on the symptoms Miss I reported during this consultation.
53. From clinical advice we understand as Miss I now was reporting a change in bowel habit (constipation) as well as abdominal pain a FIT test could have been arranged at this time. The plan was for Senna and Fybogel medicines for a week to deal with constipation, but no follow up action was recommended.
54. As this was the third time Miss I had sought medical assistance since 27 November 2021 and no plan for further investigations or treatment was made, we consider there is a failing here against NICE guidelines on suspected colorectal cancer in adults. This is because a FIT test was not offered at this time and no follow up was subsequently arranged.
55. As we have decided to uphold this part of the complaint, we will go on to make recommendations at the end of this report.
Telephone consultation on 7 February 2022
56. On 7 February Miss I contacted the Practice and had a telephone consultation. She now reported severe abdominal pain which was causing her to faint. Miss I requested a scan and said the mebeverine medication was not helping. Miss I tells us she was distressed during the call; she did not know who she was talking to and when she obtained her medical records she saw it was documented that during the call she was annoyed and had demanded a scan.
57. The Practice apologised to Miss I about her consultation on 7 February. It said a trainee GP had dealt with her and it apologised they had not introduced themselves and for the comments made on her medical record. It said the trainee GP had discussed Miss I’s concerns with another GP stating that Miss I would like a scan performed, but there was no indication of the type of scan that was suggested.
58. The Practice said a GP can only order an ultrasound scan from the surgery setting, and a CT scan which was most appropriate in Miss I’s case can only be organised within a secondary care setting.
59. Based on the clinical advice sought the Practice did not comply with the NICE guidance on suspected colorectal cancer to arrange a FIT test at this time. Miss I had explained to the GP she was passing out with the severity of her abdominal pain; she requested a scan as the medication was not helping. She reported she had been to hospital and was advised to see her GP to arrange a referral. There was no action taken at this appointment and the records say the plan was for the doctor to discuss with another doctor.
60. From the audio recording of the telephone consultation we heard Miss I advised the GP she was suffering in constant pain in her lower stomach, and she was being sick. She explained pain relief was not helping her at all and she had been to hospital as she was fainting due to the severe pain she was in. She explained the hospital had referred her back to her GP to arrange a scan. The GP explained to Miss I they would discuss her request for a scan with another GP and would call her back.
61. The GP called Miss I back and said they had discussed her request for a scan with another GP and they had a couple of questions. The GP asked Miss I if she had diarrhoea or loose stools and if she was passing blood. Miss I said her bowel moments were normal at that time as she was taking Senna and she was not aware she was passing any blood. She said she felt there was something wrong and she would like a scan as suggested by the hospital to rule anything out.
62. The GP said they would not request a scan as they must have a suspicion of what they are looking for, and a scan would not help with their suspicion that she had IBS.
63. The GP suggested Miss I continue taking the mebeverine medication for IBS. Miss I explained she had tried that previously and no medication was helping her at all, and she felt there was something wrong and she did not feel she had IBS. The GP said they did not have enough clinical information to arrange a scan and they felt Miss I had not given the mebeverine medicine enough time, the GP told Miss I that fainting can be a symptom of pain.
64. Miss I said she needed a scan to find out what was wrong, and nothing was helping her. During the call she became upset and said she would need a second opinion or to go private as she knew something was wrong and the Practice was not helping her.
65. Having considered the evidence available, the records, responses and the clinical advice sought, we consider there is a failing here against the NICE guidance on suspected colorectal cancer in adults, which says there should be an offer of a FIT to guide referral for suspected colorectal cancer in adults. At the time of this telephone consultation Miss I had already been to A&E due to her abdominal pain and fainting and had two previous consultations with the Practice, reporting abdominal pain and constipation, where no plan for further investigations was made.
66. We uphold this part of the complaint and will make recommendations at the end of this report.
Consultation 21 February 2022
67. Miss I went to the A&E Department on 19 February 2022 after she had fainted at home again due to her severe abdominal pain. She explained her abdominal pain and her IBS diagnosis from her GP. Miss I was discharged from the A&E and referred to her GP.
68. On 21 February Miss I had a telephone consultation with a GP at the Practice where she explained her ongoing abdominal pain and that she had been to A&E after fainting. The GP said they would arrange for an ultrasound scan of her abdomen.
69. The Practice says the clinical team performed all clinical investigations that were available to them within the GP surgery setting. It says the investigations ordered were found to be in line with secondary care referring criteria and protocols.
70. From clinical advice we understand the correct test was not ordered as an ultrasound scan may not have been the correct diagnostic test. This is because the NICE guidance says a FIT should be offered as this test detects small amounts of blood in faeces, which is a sign of possible colorectal cancer. Miss I’s recent medical history should have been considered, the discharge report from the A&E attendance on 19 February says 66-year-old female with five-month history of bowel/lower abdominal pain and 11lb weight loss. A comment on the discharge form is rule out UTI/renal stone and query’s malignancy.
71. We can see from the medical record the GP noted Miss I had still been in pain and had attended A&E, the record said will send for an ultrasound of abdomen but not sure this will be done and advised Miss I to stop taking ibuprofen and just stick to paracetamol.
72. We have carefully considered all the evidence available and have found there is a failing against the NICE guidelines on suspected colorectal cancer. This is because the NICE guidance says a FIT should be offered to screen for blood in the faeces and this did not happen.
73. At the time of this telephone consultation Miss I had attended A&E on two occasions reporting stomach pain and fainting and she had also had three previous consultations at the Practice reporting the same symptoms of pain, fainting and constipation. She had explained the mebeverine medication and other pain relief medication was not helping her and she had requested further investigations.
74. As we have identified a failing here, we uphold this part of the complaint.
75. We will now go on to consider the impact of the failings we have identified in the care and treatment provided to Miss I at her consultations on 6 January, 7 February and 21 February 2022.
Impact of failings
76. As a FIT was not arranged following the consultation on 6 January, it is difficult to say what the impact of this delay is, as a FIT could have come back negative or positive and we are unable to say with certainty what the outcome may have been. If it was positive this should have led to a two-week referral to the local colorectal team in secondary care, therefore, if positive, would likely have contributed to a reduction in delay of a diagnosis. A negative diagnosis, which is possible even with someone with cancer, may have led to a delay in referring for a two-week wait. However, we recognise Miss I remained in pain, and this was a missed opportunity for her cancer diagnosis being made sooner.
77. Regarding the telephone consultation on 7 February, we consider the failing to arrange a FIT or referral for a scan into secondary care led to a further delay in diagnosing Miss I’s bowel cancer. It also caused distress and despair for Miss I as she was experiencing severe pain and was naturally very concerned and worried about her health and the Practice refused her request for a scan and told her she had IBS.
78. We consider the failing to offer a FIT or make a two-week referral to the local colorectal team in secondary care at the consultation on 21 February was a failing. At this time the GP requested an ultrasound scan and we do not know how long Miss I would have waited for an appointment for this. The impact is that Miss I would have continued to experience pain and anxiety about her health until she had the scan.
79. However, Miss I was in extreme pain and her symptoms worsened so she attended a local Urgent Treatment Centre (UTC) on 2 March which showed she had a blocked bowel, and she underwent emergency surgery for this. Miss I had this treatment within two weeks of her previous consultation at the Practice on 21 February.
80. Overall we can see Miss I was in pain from November 2021, and she initially contacted the Practice about this on 10 December. She was given a prescription for medication to treat IBS although this was not a formal diagnosis. Miss I then had three telephone consultations as well as a further attendance at A&E before she was seen in the UTC on 2 March 2022 and admitted to hospital for treatment.
81. We understand Miss I was diagnosed with a blocked bowel which required emergency surgery. She then had to have further surgery on 26 April to remove the tumour in her bowel and then had a course of chemotherapy.
82. In summary we can see the combination of missed opportunities for a better clinical outcome on 6 January, 7 February and 21 February 2022 caused eight weeks of delay.