Referral for recurrent UTIs
39. Mrs T says the Practice did not refer her mother early enough for recurrent urinary tract infections (UTIs). She feels this should have been done sooner as recurrent UTIs can be a sign of cancer.
40. The Practice noted that Mrs O had a history of recurrent urine infections over the years. It said in 2019 she had three presumed urine infections and in August 2019 had an ultrasound of her abdomen and pelvis with normal results.
41. It explained the colorectal team saw abnormalities on a scan in October 2020 which led to urology carrying out further investigations. These investigations had normal results, and the urology team took her off the cancer pathway. The Practice noted there was no evidence of cancer until after a ureteroscopy in January 2021.
42. We obtained clinical advice from our adviser who is a GP. From the advice we understand the following guidance is relevant to explain what should happen, General Medical Council (GMC) guidance on ‘good medical practice’. This says doctors should promptly arrange suitable investigations and treatment. They also referred us to National Institute for Health and Care Excellence (NICE) clinical knowledge summary on ‘Recurrent UTI’ which sets out clinically appropriate treatment for recurrent UTIs. This defines recurrent UTIS as two or more episodes of UTI in six months or three or more episodes in one year.
43. NICE explains that if the woman is aged 60 years and over and has recurrent or persistent unexplained UTI doctors should arrange a non-urgent urological referral.
44. Between 18 June 2019 and 28 September 2020 Mrs O contacted the Practice on nine occasions. During this time her symptoms included pain passing urine, abdominal pain and increased frequency of urination.
45. The Practice prescribed Mrs O antibiotics on eight of these occasions. After our clinical adviser reviewed medical records at the time we are satisfied the prescription of antibiotics for treatment was clinically appropriate.
46. NICE guidance specifically states that doctors should arrange specialist referral or seek specialist advice if the woman is aged over 60 years and over and has recurrent UTI. They should arrange a non-urgent urological referral. As we explain above the guidance defines recurrent UTIs as two or more episodes of UTI in six months or three or more episodes in one year.
47. The records show that Mrs O was indeed experiencing recurrent UTIs in 2019 as doctors prescribed her with antibiotics for UTIs on three occasions between June and November.
48. From clinical advice sought we understand the Practice should have arranged a non-urgent urological referral in November 2019 when it treated Mrs O with antibiotics for a UTI for the third time in five months. This was not done. The Practice did not refer Mrs O to urology until around 11 months later in October 2020.
49. Mrs O experienced an 11-month delay in waiting for her referral to urology which could have occurred sooner, meaning the Practice did not promptly arrange suitable investigations in line with GMC guidance. We have found a failing in this aspect of the complaint. We go on to consider the impact of this in a later section of this report.
Diabetic monitoring
50. Mrs T complains that the Practice did not monitor her mother’s diabetes. She tells us prior to this it regularly monitored her mother’s blood sugars. She says during the period of complaint her mother’s Hba1c levels were consistently elevated and her diabetes was not controlled. She feels the Practice should have referred her mother to a diabetic monitoring clinic.
51. The Practice said that during the period of complaint Mrs O’s diabetic control was very good and her blood sugar levels fell in the pre-diabetic range. It explained that it felt the consultant’s request for a referral to the diabetic team was unnecessary.
52. The relevant guidance for this aspect of the complaint is NICE guideline 28 on ‘Type 2 diabetes in adults: management’. This says for adults with type 2 diabetes doctors should measure their HbA1c (blood sugar) levels every three to six months until levels are stable on unchanging therapy, and then every six months once the HbA1c level and blood glucose lowering therapy are stable.
53. The records show the Practice did monitor Mrs O’s diabetes during the period of complaint as she had the correct HbA1c checks on: 19 April 2019; 27 October 2019; 16 June 2020 and on 1 July 2021.
54. The Practice carried out these checks every six months in 2019 and then yearly in 2020 and 2021. Our adviser confirmed that Mrs O’s diabetes was stable at the beginning of 2019 and results from the period of complaint show her HbA1c levels were well controlled, meaning no increase in monitoring was necessary.
55. Mrs T says in November 2020 a consultant recommended the Practice refer her mother to a diabetes clinic for monitoring as they suspected her diabetes was not controlled.
56. GMC guidance says doctors should promptly arrange suitable investigations and treatment. Our adviser reiterated that Mrs O’s diabetes was well controlled during the period of complaint, meaning there was no need for the Practice to refer her to a diabetes clinic for monitoring.
57. The evidence we have seen in our work shows that the Practice monitored Mrs O’s diabetes in line with NICE guidance during the period of complaint. Whilst we recognise that Mrs T feels strongly that the Practice should have referred her mother to a diabetic monitoring clinic in November 2020, from the clinical advice sought and considered, we have not identified that there was a clinical need for Mrs O with stable managed diabetes to have been referred to the clinic. Therefore, we have found no failing in this aspect of the complaint.
Recommendations from specialists
58. Mrs T complains that the Practice did not follow up on the recommendations urology and respiratory specialists made after her mother’s hospital appointments.
59. The relevant guidance for this aspect of the complaint is General Medical Council’s guidance on ‘good medical practice’. This says doctors must promptly provide or arrange suitable treatment and investigations. They must only prescribe drugs or treatment when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serves the patient’s needs.
60. The clinical records show four occasions where specialists wrote to the Practice with recommendations for further care.
61. In November 2020 a consultant urologist asked the Practice to prescribe three month’s nitrofurantoin (an antibiotic) prophylaxis (medication to prevent infections). Mrs T said the Practice did not provide this.
62. In its response to the complaint the Practice said that whilst the above consultation took place on 1 November, the consultant did not type the letter until 11 December, and it received this on 21 December. It explained that it actioned the consultant’s recommendations shortly after receiving the letter.
63. The records show the urology appointment took place on 1 November 2020, but the urologist did not type the letter to the Practice until 11 December. Our adviser said that whilst it is not clear from the records when the Practice received this, it prescribed the prophylaxis on 17 December.
64. GMC guidance says doctors should promptly provide treatment when they have adequate knowledge of the patient’s health. The purpose of antibiotic prophylaxis is to prevent infections not to treat them. Nowhere in guidance does it recommend specific timeframes for prescribing prophylaxis. From advice sought and within the clinical records we can see the Practice provided this within six days of receiving the consultant’s letter, our adviser noted this was prompt provision of medication, meaning it acted in line with GMC guidance.
65. In July 2021 a respiratory consultant asked the Practice to prescribe two inhalers. The consultant also recommended Mrs O have an annual flu jab, five yearly pneumovax and a rescue course of antibiotics in the community. Mrs T says the Practice only prescribed one inhaler and did not carry out the remaining recommendations.
66. The Practice explained that it received a letter from the respiratory clinic on 6 August 2021 and then issued an inhaler. It said it booked Mrs O to see a lead nurse for a COPD review where the issue of rescue packs and immunisations would have been discussed.
67. The records show the Practice sent a text to Mrs O on 12 August asking her to book an appointment with the lead nurse. Our adviser explained that this was reasonable as the nurse would need to teach her how to use the inhalers and when to take the rescue course of antibiotics.
68. Whilst it is unclear from the records when Mrs O contacted the Practice to arrange this appointment, we can see it booked the appointment for 6 September. Mrs O did not attend this appointment, nor did she contact the Practice to rearrange.
69. The Practice then sent a further text to Mrs O on 20 October asking her to book an appointment for her flu vaccination. The records show she had her previous yearly vaccination in October 2020. We cannot see Mrs O contacted the Practice to arrange this.
70. Nowhere in guidance is it stipulated for the timeframes for doctors acting upon consultant’s recommendations. Again, our adviser noted that the Practice asked Mrs O to book an appointment within six days of receiving the consultant’s letter and asked her to book her yearly flu vaccination when this was due. From the advice sought the evidence shows the Practice promptly acted on the consultant’s recommendations in line with GMC guidance.
71. In September 2021 a consultant asked the Practice to monitor Mrs O’s urea and electrolyte levels. Mrs T says the Practice did not do this.
72. In its response to the complaint the Practice noted that whilst the appointment took place on 24 September, the consultant did not type the letter until 2 November, and it received this on 4 November around six weeks after the appointment. It explained this letter contained no urgent request and it monitored Mrs O’s urea and electrolyte levels regularly due to her diabetes.
73. We were unable to locate a letter dated 24 September 2021 in the clinical records. Our adviser explained doctors use blood tests to monitor urea and electrolyte levels. The records show Mrs O had blood tests in the Practice on: 11 June 2021; 2 July 2021 and 16 July 2021.
74. She also had blood tests via hospital on 24 September 2021 and 7 December 2021.
75. Mrs T says the Practice did not follow the consultant’s recommendation to monitor her mother’s urea and electrolyte levels. The evidence suggests the Practice did monitor Mrs O’s urea and electrolyte levels and was in fact already doing this before the consultant made their recommendation.
76. The evidence suggests the Practice needed to monitor Mrs O’s urea and electrolytes, and we can see it did so. This was in line with GMC guidance which says doctors must provide suitable investigations and treatment.
77. Finally, in December 2021 a consultant asked the Practice to stop Mrs O’s dexamethasone. Mrs T says the Practice did not do this.
78. In its response to the complaint the Practice noted Mrs O was discharged from hospital on 24 December 2021. Her daughter brought in a letter on 29 December, and it actioned the request around dexamethasone the same day.
79. From clinical advice sought and reviewing the records we the Practice received the letter recommending it stop dexamethasone when Mrs O’s daughter brought this in. It stopped Mrs O’s dexamethasone the same day. This was in line with GMC guidance which says doctors should promptly provide suitable treatment.
Conclusion on following up recommendations
80. Mrs T says the Practice did not follow up recommendations from specialists after her mother’s hospital admissions. As we explain in the section above, the evidence shows the Practice promptly carried out the specialist’s recommendations after receiving each letter.
81. The NHS constitution states patients have a responsibility for their own health. It explains patients are responsible for making and keeping appointments and taking ownership for managing their own health through the service.
82. Mrs T tells us the Practice did not provide her mother with vaccinations a consultant prescribed and only provided one inhaler. Whilst we recognise Mrs O did not receive these, the evidence suggests this was because she did not attend or rearrange an appointment with a lead nurse, nor did she book an appointment for her yearly flu vaccination despite the Practice asking her to do so.
83. We understand that Mrs O received a cancer diagnosis in August 2021 and by November 2021 was receiving palliative care. We recognise how distressing this must have been and understand that this may have contributed to her not booking appointments.
84. Our GP adviser confirmed that the Practice promptly followed up on specialist’s recommendations. This was in line with GMC guidance. On balance we consider the Practice would have provided the inhaler and vaccinations had Mrs O arranged the necessary appointments. We have found no failing in this aspect of the complaint.
Wellbeing after cancer diagnosis
85. Mrs T complains that two specific GPs did not telephone or visit Mrs O to enquire after her wellbeing after her cancer diagnosis.
86. In its response to the complaint the Practice explained that its GPs do not have personal patient lists, and several different doctors and health care professionals were responsible for Mrs O’s care.
87. From the clinical advice our GP adviser provided we understand there are no national standards or guidelines on how GPs should support a patient’s mental health following a cancer diagnosis. From work we have done on similar complaints, we understand GPs would not typically contact patients to enquire about their wellbeing, instead providing care when patients make them aware of a health concern or issue.
88. Mrs O received a urethral cancer diagnosis in January 2021 and then bladder cancer in August 2021. Between March 2021 and her death in February 2022 she had 31 interactions with the Practice.
89. Whilst we recognise Mrs O had a history of recurrent depressive disorder and had previously received psychiatric support, we cannot see from her medical records that she reported any decline in mental health to the Practice in January to February 2021. The first time the Practice became aware she was struggling with this after diagnosis was when her daughter spoke to a GP on 24 March 2021.
90. We can see a GP arranged a face-to-face appointment for the following day in response to this. During this appointment the GP discussed Mrs O’s mental health, prescribed medication to help with panic attacks and agreed to review her again in two weeks’ time.
91. The GP reviewed Mrs O’s mental health again on 8 April. The GP discussed ways to distract from anxious thoughts and made a referral to NHS Talking Therapies.
92. On 3 June Mrs O’s daughter contacted the Practice again as her mother’s mood was down and she did not want to eat. A GP made a referral to old age psychiatry to assess her need for further mental health support.
93. Old age psychiatry accepted Mrs O into the community mental health team (CMHT) on 11 June. Mrs O remained under the care of the CMHT until 20 October 2021 when staff discharged her from the service as she was now receiving specialist palliative care. Documentation from the CMHT discharge clearly states Mrs O’s daughter agreed with the discharge and the team would see Mrs O again if she needed this.
94. We were unable to see that Mrs O, or her family contacted the Practice about her mental health again between 20 October and her death in February 2022. Meaning we cannot say the Practice should have provided any further support.
95. We recognise that the support the Practice provided Mrs O with for her mental health did not meet Mrs T’s expectations. The evidence shows Mrs O had 31 interactions with the Practice between her first cancer diagnosis and her death. During this time doctors did: discuss her mental health with her, refer her to NHS Talking Therapies and referred her to old age psychiatry.
96. Between June – October 2021 she was receiving specialist mental health support from the community mental health team.
97. We understand Mrs T feels two specific GPs should have reached out, contacted or visited her mother to enquire about her wellbeing after each cancer diagnosis. From clinical advice we obtained, we understand GPs are not responsible for specific patients and care is usually provided by the wider Practice team.
98. Nowhere in guidance does it stipulate that specific GPs must enquire after patient wellbeing. Meaning we cannot say that a failing occurred. For this reason, we have not found a failing in this aspect of the complaint. We hope the contents of this report reassure Mrs T that the Practice did provide support for Mrs O’s wellbeing when it was made aware she needed this.
Aged care assistance
99. Mrs T complains that the Practice did not arrange an assessment for aged care assistance for things like shopping and cleaning after her mother's health declined in January 2022.
100. We can see the Practice notes a GP had a video call with Mrs O on 24 January 2022. It explained two hours after this call its social prescriber spoke to Mrs O and her family to discuss what support they needed and what was available.
101. The relevant guidance for this aspect of the complaint is GMC’s good medical practice. This says if doctors examine a patient they must promptly arrange and provide care.
102. Mrs O was in hospital between 13 January – 22 January 2022 due to general decline. Our adviser explained it would have been the hospital's responsibility to ensure her needs were met on discharge. The discharge summary says she was to have a four times daily package of care, and that hospital staff had sent a red cross referral to assist with shopping.
103. The records show a community palliative care clinical nurse specialist reviewed Mrs O on 23 January. They nurse specialist referred her to Marie Curie for nighttime support and made a social worker referral to assess what support Mrs O’s husband may need. She began receiving end of life care on 24 January.
104. We understand that Mrs T feels the Practice itself should have arranged an assessment for aged care assistance. The evidence indicates that both hospital and community staff were arranging further support for Mrs O’s needs when her health declined in January 2022. Having reviewed the records we cannot see that Mrs O, or her family asked the Practice to arrange an assessment for aged care assistance.
105. The GMC guidance does not set out that GPs are responsible for providing support with aged care assessments. We recognise that Mrs T feels the Practice should have done more. The evidence we have seen shows that non-practice staff were responsible for providing this support. Meaning we cannot say a failing occurred. For this reason, we have not found a failing in this aspect of the complaint.
Antibiotics for diverticulitis
106. Mrs T says her mother had diverticulitis which at one point was managed with antibiotics. She says during the period of complaint the Practice did not treat her mother's diverticulitis.
107. In its response to the complaint the Practice said that diverticular disease is not the same as diverticulitis. It said it would manage diverticulitis with antibiotics and hospital admission if necessary. It explained that it did not see Mrs O with any episodes of diverticulitis during the period of complaint.
108. The relevant guidance for this aspect of the complaint is GMC’s good medical practice. This says promptly arrange suitable investigations and treatment. Our adviser referred us to NICE clinical knowledge summaries on diverticular disease. This explains that doctors should suspect acute diverticulitis if a person presents with constant abdominal pain with any of the following:
• fever • sudden change in bowel habit and significant rectal bleeding and passage of mucus from the rectum • tenderness in the lower left area of the abdomen, a palpable abdominal mass or distention on abdominal examination, with a previous history of diverticulosis or diverticulitis.
109. NHS.UK webpage explains that diverticulitis can be treated with antibiotics. Meaning it is not always a lifelong condition.
110. We have been unable to identify a diagnosis of diverticulitis during the period of complaint. Whilst Mrs O’s records do show she was previously diagnosed with this, this was in 2012.
111. Having considered our GP adviser’s review of the clinical records, we consider the only time clinicians showed mention or consideration of diverticulitis was during a telephone consultation on 11 March 2021. A GP did a home visit, examined her and did not think she had diverticulitis. Our adviser explained that Mrs O did not report symptoms of diverticulitis on any other occasion during the period of complaint.
112. GMC guidance says doctors should examine patients and promptly provide suitable investigations and treatment. Whilst we recognise that Mrs T feels the Practice did not treat her mother’s diverticulitis, we have not seen any evidence that this was an existing diagnosis during the period of complaint. Our adviser said we would not expect a GP to provide treatment for diverticulitis if a diagnosis was not reached. For this reason, we find no failing in this aspect of the complaint.
Diarrhoea
113. Mrs T says during the period of complaint her mother had frequent and repeated bouts of diarrhoea. She feels the Practice did not do anything to try and resolve this.
The Practice did not specifically address how it managed Mrs O’s diarrhoea in its response to the complaint. It explained it referred her to the colorectal team on several occasions due to loose bowels during the period of complaint.
114. In seeking clinical advice from our adviser who is a GP we understand there are no specific guidance for the management of diarrhoea. This is because it can be a symptom of many different health concerns. The relevant guidance for this aspect of the complaint is GMC’s good medical practice. This says doctors must promptly arrange suitable investigations and treatment.
115. The first time Mrs O contacted the Practice about diarrhoea (during the period of complaint) was 15 January 2019. She told a GP she had experienced a change in her bowels over the last four months, as she was usually constipated but was now experiencing diarrhoea. The GP made a two week wait referral for colorectal cancer investigations.
116. The next time Mrs O reported diarrhoea was 5 June. The GP noted that the colorectal team had recently carried out a colonoscopy with normal results. The GP agreed to review her again in three weeks’ time. We can see Mrs O had a further telephone consultation on 18 June however she did not mention diarrhoea during this.
117. Mrs O did not contact the Practice about diarrhoea again until 19 March 2020. A GP asked her to provide a stool sample, and this showed normal results on 24 March.
118. She reported intermittent diarrhoea again on 1 May. She told a GP this lasts for a few days, resolves, then reoccurs. The GP referred her to gastroenterology for further investigations.
119. She had a further two telephone consultations in May. During the first a GP recommend she continue taking Imodium. During the second she told the GP gastroenterology were not doing anything further as they could not find a sinister cause for her diarrhoea. The GP prescribed Mebeverine (medication to treat irritable bowel syndrome) to see if this helped. She contacted the Practice again on 1 July to confirm her diarrhoea had resolved.
120. Mrs O did not contact the Practice again about diarrhoea until 21 September. The GP explained they would consider doing another cancer referral but asked her to provide a stool sample first. They also prescribed Mebeverine again as this had helped in the past.
121. On 29 September the stool sample results came back as normal, and the GP made a two week wait referral for gastroenterology cancer investigations.
122. The last time Mrs O reported diarrhoea in 2020 was 17 November. The GP saw her face to face and agreed to monitor this on an ongoing basis as she had undergone both colorectal and gastroenterology investigations which had not found a cause for her diarrhoea.
123. On 8 March 2021 Mrs O reported diarrhoea again. The GP felt this could be related to her urinary tract infection. They recommended she increase her fluid intake and agreed to review the antibiotics she was taking.
124. A GP did a home visit on 11 March. Mrs O had recently had an operation and said she had diarrhoea prior to this and felt it had gotten worse since taking antibiotics. The GP recommended take Imodium. Mrs O’s daughter contacted the Practice on 24 March and confirmed the diarrhoea had resolved.
125. On 1 April 2021 Mrs O told a GP she was still having intermittent episodes of diarrhoea. The GP noted she was taking metformin (medication for diabetes) and atorvastatin (medication to lower cholesterol). They recommended Mrs O trialled coming off these medications to see if they were contributing to her diarrhoea.
126. We cannot see Mrs O, or her family reported any further instances of diarrhoea after 1 April 2021. Our adviser explained they would expect doctors to provide care for Mrs O’s diarrhoea when she reported this. The evidence shows that Mrs O reported having diarrhoea on 12 occasions between January 2019 and April 2021, each time doctors prescribed medication and made referrals for further investigations when necessary.
127. Whilst we understand Mrs O received cancer diagnoses in January 2021 and August 2021, we were unable to see that investigations had identified any specific cause for her diarrhoea. Meaning we cannot say the Practice should have provided any specific treatment. Our adviser reviewed the care GPs provided between January 2019 and April 2021and confirmed that this was in line with clinical best practice.
128. GMC guidance says doctors must promptly provide or arrange suitable investigations and treatment if they assess patients. Mrs O began receiving end of life care on 24 January 2022 and sadly died on 6 February 2022. We cannot see Mrs O, or her family reported any further episodes of diarrhoea to the Practice after 1 April 2021. The evidence suggests the Practice was unaware Mrs O was struggling with diarrhoea between 2 April 2021 and her death, meaning we cannot say it should have done anything further to resolve this in the last weeks of her life.
129. The evidence suggests that the Practice was actively trying to resolve Mrs O’s diarrhoea each time she reported this. Our adviser confirmed the treatment the Practice provided was in line with clinical best practice and therefore it acted in line with GMC guidance. Meaning we cannot say a failing in care occurred.
130. Whilst we recognise that Mrs T says her mother was struggling with diarrhoea in the last weeks or her life and acknowledge how distressing this must have been, we have not found a failing in this aspect of the complaint. We hope the contents of this report reassures Mrs T that the Practice did try to resolve Mrs O’s diarrhoea when she reported this.
Impact
131. We will now consider what impact the failings we have identified had on Mrs O and Mrs T. To aid clarity we have split that into two sections. We will first consider whether the Practice’s failings had any physical impact on Mrs O. We will then go on to consider any emotional impacts on Mrs T.
Physical impact
132. We have found a failing in the way the Practice arranged investigations of Mrs O’s recurrent urinary tract infections. Specifically, we have found that it should have referred her to urology for further investigations in November 2019. It did not do this until October 2020 meaning Mrs O experienced an 11-month delay in receiving the care she needed.
133. Mrs T feels the Practice’s actions caused her mother suffering and contributed to her death.
134. To assist us in exploring impact we sought clinical advice from our adviser who is an oncologist. They noted that whilst NICE clinical knowledge summaries on recurrent UTIs says doctors should make a non-urgent referral to urology if the woman is over 60 and has recurrent UTIs, it does not say what tests urology should do. They said this is because the tests will be based on clinical opinion. They explained in a situation like this, the most likely tests a urologist would have done are a cystoscopy (a procedure to investigate the bladder) and/or an abdominal ultrasound.
135. The records show Mrs O’s first cancer was in her ureter not her bladder. Our adviser noted she had an abdominal ultrasound in August 2019 which was normal. They explained if the Practice had referred her to a urologist in November 2019, and she had a cystoscopy done, the results would not have identified ureter cancer as a cystoscopy looks inside the bladder not the ureter.
136. Our adviser explained that had the failings around referral not occurred, and Mrs O had urology investigations sooner, they would not have revealed anything wrong with her abdomen and pelvis. The colorectal team found a tumour in her ureter on a CT scan (a detailed X-ray) in 2021.
137. Our adviser explained that a CT scan would not have formed part of the investigations the urology team would have carried out had the Practice have referred Mrs O to urology in November 2019, meaning earlier referral would not have led to Mrs O’s ureter cancer being identified sooner.
138. We recognise that Mrs T feels failings on the Practice’s part led to her mother’s death. Our adviser explained that the failings around referral did not lead to a delay in ureter cancer diagnosis. They noted that doctors successfully treated Mrs O’s ureter cancer via surgery.
139. Mrs O went on to be diagnosed with bladder cancer in August 2021. From our advice we note this was not a recurrence of existing cancer but a second separate form of cancer, that further cancers of the urinary tract are common in people who have had ureter cancer, meaning Mrs O would still have gone onto develop the second cancer even if the Practice had referred her to urology in November 2019.
140. We recognise that Mrs O deteriorated rapidly after her second cancer diagnosis and sadly died on 6 February 2022. The evidence we have seen suggests this was unavoidable and not because of any failing on the Practice’s part.
141. Mrs T says her mother experienced a lot of suffering due to the Practice’s actions. She says her mother did not leave the house due to her health issues towards the end of her life. We have only identified a failing in the way the Practice arranged investigations of Mrs O’s recurrent urinary tract infections and not in the way it provided treatment.
142. The evidence shows that whilst earlier referral should have occurred, this would not have led to any change in treatment. Meaning we cannot say that any of Mrs O’s symptoms and associated suffering were preventable.
143. We recognise that Mrs O became increasingly frail and unwell towards the end of her life. Mrs T tells us that her mother was bedridden and increasingly incontinent with diarrhoea. Whilst we recognise Mrs O was suffering and understand how distressing this was for her and her family, we have seen no evidence that this was because of any failing on the Practice’s part.
144. Whilst we have found that a failing occurred, we have not been able to link this with any negative physical outcome on Mrs O as sadly her deterioration, incontinence and death would still have occurred had the Practice made an earlier referral. We hope the contents of our report reassure Mrs T that the Practice did not cause her mother suffering or contribute to her death.
Emotional impact
145. We have not been able to establish whether the failing around referral had any emotional impact for Mrs O as she has sadly died. It is not clear from the evidence available whether she felt she needed referring to urology, meaning we cannot say this caused her any distress.
146. Whilst Mrs T’s account of events describes her mother’s distress in detail, this is in relation to her diarrhoea and cancer diagnoses. As we explain in an earlier section of this report, sadly Mrs O’s deterioration, incontinence and death would still have occurred had the Practice made an earlier referral. Meaning we cannot link the failing identified with any distress Mrs O experienced around these.
147. Mrs T feels the Practice should have made an earlier referral to urology. Our work found this was the case. Whilst we recognise that earlier referral would not have prevented Mrs T from experiencing distress, as her mother was very unwell and living in a different country, we consider the Practice missed an opportunity to dial back the level of this distress by making an earlier referral and providing Mrs T, her father and her sister with some reassurance.
148. Whilst cannot quantify the amount of distress Mrs T and her family have experienced, as we recognise much of this will be related to Mrs O’s deterioration and death, we consider the Practice’s actions contributed to this.
149. Whilst we would reasonably expect this distress to diminish over time, it is clear this continued beyond Mrs O’s death on 6 February 2022 and that this formed part of the loss and bereavement experienced. Our view is that the Practice’s actions caused additional worry, distress and emotional upset.