14. Mrs O complains the Practice missed opportunities to further investigate her husband’s symptoms and diagnose oesophageal cancer between 24 March and 30 May 2023. She says he did not see a GP face to face during this time and she thinks this also delayed his diagnosis.
15. She says the lack of investigations and delayed diagnosis meant her husband was malnourished and he had to be admitted to hospital for a week. She says an earlier referral and diagnosis would have improved his prognosis and outcome. She says the experience impacted her husband physically and mentally, he became dependant on her, and this caused them both a great deal of distress.
16. We recognise how difficult this has been for Mrs O. It must be incredibly worrying to have concerns about the care her husband received and experience the distress of not knowing if a sooner diagnosis would have altered his condition and outcome.
17. Mr O had eight telephone appointments with a nurse practitioner, two face to face appointments with a nurse practitioner, and one telephone appointment with a GP between 24 March and 30 May. During at least seven of these appointments, he reported symptoms such as food getting stuck in his throat, bringing up specks of blood, weight loss, fatigue, and feeling generally unwell.
18. NICE gives guidance for clinicians on how to recognise suspected upper gastrointestinal tract cancers and when to refer patients for investigations. It says patients who have dysphagia (difficulty swallowing) or people who are aged 55 and over with either upper abdominal pain, reflux, or dyspepsia (indigestion) should be referred urgently (within two weeks) for a gastrointestinal endoscopy to assess for oesophageal cancer.
19. NMC the Code says nurses should communicate clearly and always practise in line with the best available evidence by making sure any information or advice given is evidence based including information relating to using any health and care products or services. They should maintain the knowledge and skills needs for safe and effective practice.
20. It goes on to say that nurses should recognise and work within the limits of their competence by accurately assessing signs of worsening physical health in patients. They should make a timely referral to another practitioner if needed, and they should ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of their competence.
21. GMC guidance says doctors must provide a good standard of practice and care. It says they must adequately assess the patient’s conditions, take account of their history, and promptly provide or arrange suitable advice, investigations, or treatment where necessary.
22. Mr O first reported symptoms of food getting stuck in his throat during a telephone appointment with the Practice on 24 March. He told the nurse practitioner that he had been experiencing this symptom for four weeks. This is a key symptom to prompt an urgent referral for an endoscopy in line with the above NICE guidelines. This means the Practice should have discussed and offered a referral with him at this appointment but did not.
23. The medical records show that the nurse practitioner did mention a gastroscopy to Mr O at this appointment. However, we cannot see that they informed him how serious his symptom was or that it could be a sign of cancer. Our GP adviser said the Practice should have told Mr O that his symptom had the potential to be serious and that it could indicate cancer.
24. Our GP adviser explained at this appointment the Practice missed an opportunity to discuss his symptoms further and be more direct about the potential of cancer. They said if the Practice had discussed this with Mr O, he could have then made his own, informed decision about if he wanted to pursue further endoscopic investigations on the two-week cancer pathway.
25. The Practice gave him advice about H.pylori, a common bacterium that can infect the stomach and cause gastritis, ulcers, and stomach cancer. It also advised him to restart his protein pump inhibitor which is a medication that is commonly used to treat acid reflux and ulcers of the stomach.
26. The Practice missed an opportunity here to follow NICE guidelines and refer Mr O for an endoscopy to investigate his symptom of food getting stuck in his throat. Its actions fell short of NMC guidance on communicating clearly and this is a failing.
27. Although the Practice missed an opportunity here to refer Mr O for investigations, this is compounded by the fact it then missed further opportunities to refer him. In particular, when he attended a face-to-face appointment with a nurse practitioner on 20 April and reported new symptoms. The records show that he reported having problems with his limbs and feeling generally unwell at this appointment. The Practice advised him to continue with his pain medication.
28. Our GP adviser said limb problems are not symptoms you would usually expect with H.plylori or reflux, which are conditions the Practice was treating him for. It did not consider any other reasons for Mr O’s symptoms during this appointment in line with NMC guidance on accurately assessing signs of worsening physical health in the person receiving care.
29. On 2 May, Mr O had a first telephone consultation with a GP. This is the only time he spoke to a GP between 24 March and 30 May. He reported feeling very tired and said he was bringing up specks of blood. These new symptoms again did not trigger the Practice to explore and ask about other potential symptoms such as weight loss or dysphagia, which are further signs of possible cancer that should be investigated on the two-week cancer pathway in line with NICE guidance.
30. After a discussion with Mr O, the GP decided that the specks of blood he was experiencing were coming from his chest rather than his stomach. It told him to see if his symptoms settled with a medication to treat conditions such as stomach ulcers and reflux and said he may need a chest X-ray if there were any further episodes of blood. The Practice missed a further significant opportunity here to assess and investigate his symptoms further in line with NICE and GMC guidance.
31. The Practice then missed an opportunity to escalate Mr O’s care to a GP in line with NMC guidance on 11 and 23 May. During these telephone appointments, he reported feeling very unwell and unable to tolerate food as it was still getting stuck in his throat. On 11 May, his wife explained to the Practice that he was very ill, losing weight, very fatigued, and had no strength. She explained how worried she was about him and asked the Practice to take his condition seriously. Mr O also asked to be referred to a specialist on both dates, but we cannot see any evidence in the records that suggests his request was actioned.
32. As Mr O’s symptoms were not improving, our GP adviser said that he really should have been seen face to face at these points and the Practice missed an opportunity to see him. They said the nurse practitioner should also have escalated his care to a GP in line with NMC guidelines on asking for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of their competence.
33. The Practice did not make an urgent two-week cancer pathway referral until his appointment on 30 May. By this time Mr O was worried he had throat cancer, had a sore throat for six weeks, and had not eaten for two days. Although it made the referral, it did not appear to tell him that it was a referral for suspected cancer.
34. Having seen failings in the Practice’s actions, we have gone on to consider how this impacted Mr O, and in turn, Mrs O.
35. Mrs O told us that Mr O lost so much weight with his symptoms as he was not able to eat or even drink water. He became malnourished and he had to be admitted to hospital when he had a gastroscopy. She said it was extremely distressing as she was so concerned about his health. She said it affected him physically and mentally as he became very weak and needed a feeding tube. It also affected his mobility, so he had to buy a mobility scooter.
36. She told us she was also recovering from major surgery herself and he became dependent on her to support his everyday living during this time which was distressing for them both. It is clear from the Practice phone consultation recordings and our conversations, that Mrs O was very concerned about her husband’s health.
37. There is a nine-week gap between 24 March, when Mr O first contacted the Practice with symptoms that should have triggered an urgent referral, and 30 May when the Practice referred him. Therefore, there is a nine-week delay in the Practice referring Mr O for further investigation and potentially diagnosing his cancer.
38. We sought impact advice from our oncologist adviser to find out how the nine-week delay may have impacted Mr O’s cancer diagnosis and outcome. They explained that his cancer was very extensive and metastatic (spreading) when he had the gastroscopy on 1 June. It is impossible to say whether it had spread before 24 March.
39. However, our oncologist adviser explained as he had a rare tumour that can develop in many different organs in the body, his cancer would have progressed quickly between 24 March and 30 May. They said this means the tumours ability to respond to treatment would have been poorer due to the delay in diagnosis.
40. They said that if the cancer had spread between 24 March and 30 May, his prognosis would have been significantly different than if the Practice had referred him earlier. If the cancer had been diagnosed earlier, the possible treatment may have been radical and included chemotherapy and consolidation radiotherapy with or without surgery. Instead, Mr O was only able to have palliative chemotherapy.
41. Mr O was admitted to hospital following his gastroscopy as he was so malnourished, and our oncologist adviser explained that this could have been avoided if the Practice had referred him on 24 March.
42. Our oncologist adviser said an earlier referral would have improved the weight loss and fatigue he experienced before his diagnosis, and his ability to undertake his treatment would have been improved. Unfortunately, due the malnourishment he experienced, Mr O’s physical ability to tolerate treatment would have been poorer which compromised the likely outcome of any treatment.
43. Overall, we cannot say for certain that Mr O’s eventual outcome would have been different with an earlier diagnosis. We can say that the delay in diagnosis meant he experienced malnourishment and therefore a hospital admission which could have been avoided. An opportunity for a better outcome from treatment was also missed, and, on the balance of probability, Mr O might have lived longer than he did.
44. We recognise how distressing this situation would have been for Mrs O. She was recovering from major surgery herself and caring for her husband would have added to an already stressful situation. She told us about the distress she continues to experience not knowing if he could have had a better outcome with an earlier referral.
45. Our Principles of Remedy say that to put things right, organisations should provide an apology, explanation, and an acknowledgement of responsibility.
46. In its response, the Practice explained what happened during Mr O’s appointments. It gave a timeline of events and expressed its sympathy that a tumour was found during his gastroscopy. However, it has not apologised for what happened or acknowledged responsibility. It also has not acknowledged or remedied the distress this caused Mr and Mrs O, in line with our Principles, and what she told us she wants to achieve.
47. We found that the Practice’s actions fell short of NHS guidance when it missed opportunities to refer Mr O for further investigations due to his symptoms. We do not consider it has acknowledged what went wrong, apologised for it, or said what it has done to improve it service.
48. We do not consider that it has fully reflected on or remedied the impact this failing had on Mrs O. Therefore, we uphold this complaint and make recommendations at the end of our report.
49. Overall, based on what we have seen, we consider the Practice’s actions fell short of NHS guidance when it managed and investigated Mrs O’s husband’s condition. We consider it missed opportunities to refer Mr O for further investigations which delayed his cancer diagnosis and led to his hospital admission for malnourishment which could have been avoided. We also consider an opportunity for a better outcome from treatment was missed and its actions caused Mrs O the distress she experienced when her husband deteriorated and sadly died.
50. From what Mrs O told us, she has clearly been through an upsetting and distressing time with her concerns about how the Practice managed and investigated her husband’s symptoms and we are sorry for this. We hope that our report helps to answer her concerns.