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A practice in the Lincolnshire area

P-002742 · Report · Decision date: 4 July 2024
Complaint (AI summary)
The Practice allegedly missed opportunities to investigate Mr O's symptoms, delaying cancer diagnosis, and failed to provide face-to-face GP appointments, impacting his health.
Outcome (AI summary)
The complaint was upheld because the Practice did not follow relevant guidelines, missing opportunities for investigation and a chance to improve Mr O's outcome.

Full decision details

The Complaint

5. Mrs O complains the Practice missed opportunities to further investigate her husband, Mr O’s symptoms and diagnose his cancer between 24 March and 30 May 2023. She also complains he did not see a GP face to face during this time.

6. She says the lack of investigations and delayed diagnosis of oesophageal cancer caused her husband to be malnourished, dehydrated, exhausted, and hospitalised. She says it affected him physically and emotionally, which in turn affected her. She said he became dependent on her to care for him which impacted them both and she was concerned about his health. She said this caused them both a great deal of distress. She says an earlier referral and diagnosis would have improved his prognosis and outcome.

7. Mrs O wants service improvements, financial compensation, an acknowledgement, and an apology.

Background

8. This very brief background is only intended to place the key events in context, not to provide a full, chronological account of everything that happened.

9. Mr O was 69 years old at the time of events. His past medical history included bladder cancer, aortic stenosis, and pre-diabetes.

10. He registered with the Practice on 23 March 2023 and contacted it on numerous occasions between 24 March and 30 May. The Practice treated him twice for Helicobacter pylori (H.pylori) during this time. This is a common bacterium that can infect the stomach and cause gastritis, ulcers, and stomach cancer.

11. Mr O asked the Practice to refer him to a gastroenterologist on 11 and 23 May. On 30 May, the Practice referred him on a suspected cancer pathway. He had a gastroscopy on 2 June and an oesophageal mass was found. He then had palliative chemotherapy. Mr O sadly died on 29 December.

Findings

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.

Our Decision

1. Mrs O is understandably concerned that a practice in the Lincolnshire area (the Practice) missed opportunities to investigate the symptoms her husband, Mr O, experienced between 24 March and 30 May 2023. We were sorry to hear that Mr O was eventually diagnosed with oesophageal cancer and how this impacted his health and led to his sad death, which in turn caused Mrs O significant distress. From what she told us, it was clearly a very difficult time for them both and the impact from the experience has been long lasting.

2. We have seen that the Practice did not follow relevant guidelines when it assessed Mrs O’s husband’s symptoms. It missed opportunities to refer her husband for further investigations and therefore a chance to improve his outcome.

3. We have seen that the Practice has explained what happened during Mr O’s appointments, however, we do not consider that is has fully acknowledged what went wrong. We do not consider that it has reflected on or remedied the distress Mrs O experienced, or the missed opportunity for a better outcome for her husband.

4. Therefore, we uphold this complaint and make recommendations at the end of our report. From what Mrs O told us, it is understandable that her experience has been extremely distressing and worrying for her. We hope our report helps to answer her concerns and clarifies any information she was unsure about.

Recommendations

51. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where something has gone wrong and has led to injustice or hardship, the organisation responsible should take steps to put things right.

52. We recommend that the Practice writes to Mrs O to acknowledge the failings we have found in her husband’s care and apologises for the distress this caused her.

53. Our Principles say that public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat what went wrong.

54. In line with this, we recommend the Practice should develop an action plan to address the failings we have identified relating to missed opportunities to refer Mr O for investigations. The action plan should include the action, who is responsible for the action, the timescale for completing the action and how it will be monitored to ensure improvement. A copy of the action plan to be shared with Mrs O, PHSO, Care Quality Commission, and NHS England.

55. Our complaint standards state that public organisations should put things right and, if possible, return the person affected to the position they would have been in if the poor service had not occurred. If that is not possible, they should compensate them appropriately.

56. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. Following this review, we recommend that the organisation should pay Mrs O £2500 in recognition of the distress she experienced not knowing if her husband’s outcome could have been improved with an earlier referral for investigations.

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