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 we cannot link the events complained about with the negative impact Miss A has claimed.
GP care
13. Miss A is concerned that GPs at the Practice missed signs of Mrs B’s potential cancer such as her chesty cough symptoms during her consultations between June 2021 and July 2022.
14. Paragraph 7 of the GMC Good medical practice guidance states:
“You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must: • 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 • promptly provide or arrange suitable advice, investigations, or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.”
15. During a telephone consultation on 24 June 2021, our adviser says Mrs B reported back pain that ‘comes and goes’. She was also concerned about potential cancer due to her history of breast cancer and because she felt that her known COPD was getting worse. Five days later on 29 June 2021, Mrs B had a face-to-face consultation where her back pain was reviewed. Our adviser says that a thorough examination is documented in the records and Mrs B was noted to have new onset back pain which is a red flag symptom for a patient of her age group. Therefore, the GP took appropriate action (safety netting) by arranging urgent imaging/myeloma screen and blood tests. The results of these investigations did not show any significant concerns.
16. It is noted that Mrs B had been diagnosed with COVID-19 at her telephone consultation on 16 August 2021, and she had a COPD review by telephone on 25 August 2021. It was also noted that Mrs B had a suspected Urinary Tract Infection (UTI) at this time which had been treated by the time her UTI was reviewed during another telephone consultation on 2 September 2021.
17. Our adviser says there were no further consultations until February 2022 when the Practice contacted Mrs B about a COPD review. She had a telephone consultation on 23 February 2022 where it is reported that there were no major changes since summer 2021.
18. On 27 April 2022, Mrs B had a telephone consultation due to a worsening of her COPD symptoms over the past two weeks. She reported a dry cough, tight chest, wheezing and her breathing being heavier. Mrs B thought she may have a chest infection. Our adviser says the GP dealt with these symptoms appropriately by prescribing a course of steroids and Amoxicillin which is an antibiotic used to treat infections.
19. Mrs B spoke to the Practice on 18 May 2022 as she felt her COPD was worsening again. This resulted in a telephone consultation on 19 May and a face-to-face consultation on 23 May 2022. Mrs B’s medication was reviewed and her blood pressure, pulse rate and oxygen saturation were taken. She was given a vaccine (Pneumovax) to protect against serious illness such as pneumonia. Our adviser says there were no significant concerns from this due to Mrs B’s history of COPD and she reported ‘feeling well’ by the end of the consultation on 23 May 2022.
20. Mrs B was seen in A&E on 10 June 2022 due to shoulder/chest pain, leg swelling and a cough. This resulted in telephone and face-to-face consultations with the Practice on the same day. Two-day history of pain in right side of her chest was reported, but no coughing up any blood or new shortness of breath which she had problems with anyway due to COPD. Due to Mrs B’s pleuritic chest pain and a calf discrepancy, the GP decided that they needed to rule out the possibility of pulmonary embolism (PE), so she was referred to an ambulatory care consultant. Our adviser says this was an appropriate course of action in the circumstances and overall, there are indications in the records that all Miss A’s GP consultations were in accordance with the relevant GMC guidance highlighted in paragraph 14 of this statement.
21. Mrs B had chest x-rays on 10 and 24 June 2022. The first x-ray showed some inconclusive haziness across Mrs B’s left lower zone, but the second x-ray showed abnormalities with a lesion present. Therefore, Mrs B was referred to the fast-track lung cancer clinic on 28 June 2022 where she was seen on 6 July 2022. This was in accordance with the relevant NICE guidance (1.1.1-1.1.3) which states:
Refer people using a suspected cancer pathway referral for lung cancer if they: • have chest X‑ray findings that suggest lung cancer or • are aged 40 and over with unexplained haemoptysis. [2015]
Offer an urgent chest X‑ray (to be done within 2 weeks) to assess for lung cancer in people aged 40 and over if they have 2 or more of the following unexplained symptoms, or if they have ever smoked and have 1 or more of the following unexplained symptoms: • cough • fatigue • shortness of breath • chest pain • weight loss • appetite loss. [2015]
Consider an urgent chest X‑ray (to be done within 2 weeks) to assess for lung cancer in people aged 40 and over with any of the following: • persistent or recurrent chest infection • finger clubbing • supraclavicular lymphadenopathy or persistent cervical lymphadenopathy • chest signs consistent with lung cancer • thrombocytosis. [2015]
Communication
22. Miss A complains about inadequate communication by GPs at the Practice during Mrs B’s telephone and face-to-face consultations, some of which she attended.
23. The MPS guidance for GPs on managing telephone consultations states: ‘It must be acknowledged that telephone consultations lack the nuances and richness of the face-to-face consultation. The doctor is deprived of the non-verbal cues that become apparent the moment the patient enters the consulting room. A full clinical assessment is therefore not possible, but if the limitations of the telephone consultation are recognised and a careful history taken and documented, patients can be managed in a reasonable, appropriate, and safe way. It is important to remember that you must put yourself in a position to justify the diagnosis and management plan you make in the context of a telephone consultation, and if there is any doubt then a face-to-face consultation should be arranged.’
24. GMC guidance on when remote consultations may be appropriate states:
• The patient’s clinical need or treatment request is straightforward • You have access to the patient’s medical records • You can give patients all the information they want and need about treatment options by phone, internet, or video link • You don’t need to examine the patient • You have a safe system in place to prescribe • The patient has capacity to decide about treatment.
25. We have noted the telephone and face-to-face consultations that Mrs B had with GPs at the Practice from June 2021 to July 2022, as highlighted in the previous section of this statement. Our adviser concurs that telephone consultations with a GP are not always appropriate, as highlighted by the MPS and GMC guidance. However, the type of consultation offered is dependent on clinical need and the concerns raised. In Mrs B’s case, our adviser says there was not always a clinical need, or significant concerns raised for her to be seen face-to-face during this episode of care. When there was, she did see a GP face-to-face such as on 29 June 2021 and 10 June 2022.
26. As for the GPs communication with Mrs B and her family during these consultations, the GMC guidance for GPs communicating with patients’ states:
“The exchange of information between medical professionals and patients is central to good decision making. You must give patients the information they want or need in a way they can understand. This includes information about:
their condition(s), likely progression, and any uncertainties about diagnosis and prognosis.”
27. We have not seen any concerns about Mrs B’s capacity to understand information being provided in her records, so the GPs would have dealt with her firstly as the patient rather than her family members. We note Miss A’s recollections that sometimes there was inadequate communication from GPs at the Practice regarding the investigation of Mrs B’s symptoms and how these would be treated. We were not present at these consultations so it is more difficult to verify everything that was said, but our adviser says Mrs B’s records document sufficient and appropriate detail of her reported symptoms and how these would be treated. There is no documented indication that Mrs B did not understand. There are also specific examples that the investigation of her symptoms and appropriate treatment were explained to Mrs B, and she understood this, such as at the consultations on 29 June 2021 and 23 May 2022. This is in accordance with the GMC communication guidance.
Complaint response
28. Miss A is concerned about delays in the Practice’s response to her complaint about Mrs B’s care.
29. According to the information we have seen, Miss A made a complaint to the Practice on 21 October 2022. Unfortunately, the Practice did not reply promptly, so Miss A contacted an NHS ICB on 8 March 2023 to try and expediate matters. Meanwhile, the Practice was preparing a written response which is dated 6 April 2023. However, Miss A did not see the Practice’s response until December 2023 as it was not shared with her until the ICB wrote to her with its response on 4 December 2023.
30. The NHS Complaints Regulations 2009 state at paragraph 14(3): ‘in paragraph (4), “relevant period” means the period of 6 months commencing on the day on which the complaint was received, or such longer period as may be agreed before the expiry of that period by the complainant and the responsible body’.
31. This means that the Practice should have provided Miss A with a response to her complaint within 6 months. In hindsight, the Practice’s letter dated 6 April 2023 fell within this period, but it was not sent at the time. According to the letter Miss A received from the ICB dated 4 December 2023, this was because the ICB took responsibility for her complaint after Miss A contacted it in March 2023. As we understand it, the Practice sent its complaint response letter to the ICB, and it carried out a review of Miss A’s complaint over the next few months.
32. The ICB apologised for the delay in its review which was caused by extreme pressures across the NHS at the time. It is unfortunate that it took approximately 14 months for Miss A to see a response to her complaint, but this is not wholly due to delays on the part of the Practice. It had a response ready in April 2023 which, if sent then, would likely have reached Miss A before the 6-month period under the NHS Complaints Regulations had elapsed.
33. However, the Practice was asked to send its reply to the ICB rather than send it to Miss A directly. It did this promptly and therefore we cannot attribute subsequent delays to the Practice or say it has likely contravened the NHS Complaints Regulations. Miss A’s complaint to the Ombudsman is about the Practice. It is not about the ICB, so we cannot consider how it handled her complaint including any delays.
Conclusion
34. In summary, we consider the records indicate that GPs at the Practice thoroughly investigated Mrs B’s presenting symptoms from June 2021 until July 2022, and treated them in accordance with relevant guidance. Our adviser says Mrs B had breast cancer in the 1990s and was a former smoker. She also had a long-term background of COPD which was regularly reviewed. Although she did have some shortness of breath and chest pain which can be accounted for by her COPD, there were no other typical signs of lung cancer such as coughing up blood or unexplained weight loss. Mrs B had other symptoms such as UTI, but these were unrelated.
35. We appreciate this is a tragic situation for Miss A and her family, as they all try to process the sad and unexpected death of Mrs B. We understand that this is difficult to deal with, but our consideration of Miss A’s complaint has not seen any clinical basis for Mrs B to be referred to the fast-track cancer clinic until abnormalities were seen on her chest x-ray in June 2022.
36. Unfortunately, our adviser says Mrs B ultimately presented with signs of lung cancer at a late stage in this episode of care, but even the first chest x-ray she had on 10 June 2022 was inconclusive. She had some haziness on her lungs, but it was not until the second x-ray (24 June 2022) that abnormalities were identified. Overall, we have not seen any indication of failings in Mrs B’s GP care, in the Practice’s communication, or in the way the Practice responded to Miss A’s complaint. Therefore, we consider there is no further action for us to take.