GP care
20. Mr A says GPs at the Practice failed to identify Mrs B’s potential cancer symptoms and refer her to onward services promptly.
21. Our GP adviser says the GMC Good medical practice guidance is applicable in this case. Specifically: -
“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.”
22. Also, NICE guidance on symptoms suggestive of lung and plural cancers and referral for suspected lung or plural cancer. Specifically: -
• When should I refer a person with suspected lung cancer?
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer if they:
Have chest X-ray findings that suggest lung cancer, or Are aged 40 years and over with unexplained haemoptysis.
• Offer an urgent chest X-ray (to be performed within 2 weeks) to assess for lung cancer in people aged 40 years and over if they have two or more of the following unexplained symptoms, or if they have ever smoked and have one or more of the following unexplained symptoms:
Cough.
Fatigue.
Shortness of breath.
Chest pain.
Weight loss.
Appetite loss.
• Unexplained is defined as symptoms or signs that have not led to a diagnosis being made by the healthcare professional in primary care after initial assessment (including history, examination, and any primary care investigations).
• Consider an urgent chest X-ray (to be performed within 2 weeks) to assess for lung cancer in people aged 40 years 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.
23. Mrs B’s GP records indicate that during a consultation on 3 January 2023, she reported a headache and she felt cold and tired. Mrs B had a high temperature and was sweating, as well as having pain in her stomach and no appetite. The GP thought Mrs B had a flu-like illness which our GP adviser says was a reasonable assessment in the circumstances, in accordance with the GMC guidance. Therefore, Mrs B was given Paracetamol, and it is noted that she was feeling better the following day as reported during a telephone consultation.
24. We note that at this stage, Mrs B reported being tired and having no appetite which could be interpreted as two of the unexplained symptoms referred to in the NICE guidance. However, the NICE guidance talks about ’fatigue’ rather than ‘tiredness.’ We consider that fatigue is beyond tiredness, a feeling of exhaustion or burn-out over a long period of time. This was Mrs B’s first consultation with the Practice and there is no indication that she was suffering from longer-term fatigue. It was thought she had flu and her reported symptoms improved the next day, so there was no basis for the GP to refer her.
25. On 10 January 2023, Mrs B reported similar symptoms alongside belching and non-urgent back pain. The GP suggested that Mrs B may have a viral illness such as gastroenteritis and it is documented on the same day that Mrs B was recovering from this during a follow-up telephone consultation. The GP advised Mrs B to contact the Practice again if her symptoms got worse which our GP adviser says was appropriate advice in accordance with the GMC guidance.
26. On 27 January 2023, Mrs B had a temperature with night sweats. She reported tiredness and pains in her abdomen, stomach and back. As a result, after three consultations and some persistent symptoms, Mrs B’s situation was escalated. Therefore, our GP adviser says the GP at the Practice arranged a series of tests which was an appropriate course of action in accordance with the GMC guidance.
27. By 1 February 2023, Mrs B was not feeling any better. She saw a GP at the Practice on 2 February 2023 and her test results were discussed. Apart from slightly raised inflammatory markers and a possible underactive thyroid, our GP adviser says that Mrs B’s test results were ok. The GP thought she had a post-viral illness but would wait for the remaining blood tests to come through. Mrs B was advised to continue Paracetamol and Ibuprofen and return if her symptoms get worse or she is still feeling unwell. It is noted that Mrs B was worried about potential cancer.
28. Mrs B visited the Practice on 8 February 2023 as she was still feeling unwell after two weeks. The Practice offered her a sick note (for work), but she decided to go to hospital. Mrs B got her sick note on 10 January 2023 and saw a GP the same day. She was feeling very tired after walking only short distances and struggling to sleep. She was anxious and explained that a palpitation had triggered her visit to hospital, although the resultant ECG was normal.
29. After Mrs B and her husband contacted the Practice again on 13 February 2023, she was seen by another GP that afternoon. The GP decided to refer Mrs B to hospital for a pelvic CT scan to investigate her ongoing symptoms further which our GP adviser says was an appropriate next step. She was also given antibiotics. Therefore, Mrs B was referred for a scan less than six weeks after her initial GP appointment at the Practice.
30. We note that Mrs B was seen in A&E on 14 February 2023, and she had a CT scan on 15 February 2023. Mrs B contacted the Practice on 17 February 2023 as she was feeling unwell again with ongoing back and stomach pain. Mr A was worried that Mrs B had pancreatic cancer, so the GP referred her to the hospital to be assessed in Same Day Emergency Care (SDEC) where Mrs B was reassessed and had another scan. Unfortunately, the result of this scan on 24 February 2023 showed a tumour in Mrs B’s lung.
31. In summary, we recognise that Mrs B was unwell (on and off) for a few weeks during January and February 2023. This must have been worrying for Mrs B and her husband especially as she visited the Practice on several occasions, but our GP adviser says Mrs B’s symptoms were inconclusive and did not meet the criteria outlined in the NICE guidance for suspected lung cancer referral. We appreciate that Mr A and Mrs B were both concerned that Mrs B may have cancer and in hindsight, their suspicion very sadly proved to be correct. This must have been shocking news for both of them. As above, it was less than six weeks from Mrs B’s first presentation until she was referred for a CT scan due to some persistent symptoms which were identified by GPs at the Practice. Our GP adviser says this was a reasonable time frame in the circumstances and there is no clinical basis for us to say Mrs B should have been referred any sooner.
CT scan
32. Mr A says Mrs B was wrongly told that her CT scan on 15 February 2023 was clear when it showed lesions on her adrenal glands.
33. Firstly, we have considered if a CT scan was appropriate for Mrs B on 15 February 2023. Our consultant adviser says that when Mrs B was triaged on 14 February 2023, an intrabdominal abscess was suspected based on her presenting symptoms. There is no specific guidance that stipulates this, but our consultant adviser says it would be entirely reasonable to perform a CT scan when this type of abscess is suspected. It is the investigation of choice in such circumstances.
34. Our radiology adviser says that Mrs B’s CT scan of her abdomen and pelvis showed multiple nodules in both adrenal glands. An adrenal nodule is when normal tissue grows into a lump. Measuring the density of these nodules, our radiology adviser says this scan is not able to make a diagnosis as to whether they represent a benign adrenal adenoma (a common finding in asymptomatic patients and not usually of concern) or a different, rarer, benign, or malignant lesion of the adrenals.
35. In terms of Mrs B’s management, our radiology adviser says dedicated CT of her adrenals and endocrine referral was correctly instigated by the Trust. It would not have been appropriate to mention potential malignancy based on this scan at this point as more than 50% of incidental adrenal nodules found on CT scans are benign adenomas and only around 20% of incidentally found lesions are metastatic. This is supported by the academic articles on evaluation and management of the incidental adrenal mass and adrenal incidentaloma, highlighted in the evidence section of this report.
36. Having considered Mrs B’s clinical records, there is nothing documented to verify that Mrs B was told her CT scan on 15 February 2023 was clear, but our radiology adviser says that such conversations with patients and relatives are not always recorded. The Trust acknowledged that the findings from this scan were not initially recognised as potentially being related to cancer and clearly explained to Mrs B. It apologised for this.
Chest x-ray and ultrasound
37. Mr A says Mrs B was wrongly told that nodes seen on her chest x-ray dated 17 February 2023 and ultrasound scan dated 23 February 2023 were nothing to worry about when they were potential signs of cancer.
38. Firstly, we have considered if a chest x-ray was appropriate for Mrs B on 17 February 2023. Our consultant adviser says Mrs B had a thorough consultant review following an equally thorough assessment in the SDEC Department at the Trust. A chest x-ray is a simple procedure and looks for infection which can also show other things such as cancers. The CT scan on 15 February 2023 did not find any obvious infection and so a chest x-ray is entirely reasonable to try and identify the reason for Mrs B being unwell. It is combined with 3 sets of blood cultures. This is basic medicine and not covered by any specific guidelines in this instance, rather it is down to the knowledge, skills, and experience of the treating doctor. This investigation would be considered standard practice in this situation.
39. Our radiology adviser says that Mrs B’s chest x-ray showed a right upper zone lung nodule but no other finding of note. Lung nodules are small clumps of cells in the lungs which can be cancerous. As for Mrs B being told that nodes seen on her chest x-ray were nothing to worry about, our radiology adviser says that (lymph) nodes which can be cancerous are not usually visible on a chest x-ray. Therefore, it may be that this refers to the subsequent investigations that Mrs B had including an ultrasound which included an assessment of nodes. If the conversation was about the lung nodule (rather than lymph nodes), our radiology adviser says the medical team certainly knew that the nodule was suspicious for cancer during the same admission due to the chest X ray report on the 20 February 2023 and the CT report from 22 February 2023 as documented in the patient records.
40. Nevertheless, the Trust acknowledges that the lesion on this x-ray is very difficult to see on the images. It apologised that Mr A and Mrs B were initially led to believe the x-ray was normal. We have not seen anything else documented in the clinical records about Mrs B being told there was nothing to worry about from her chest x-ray.
41. We have considered if a thyroid ultrasound scan was appropriate for Mrs B on 23 February 2023. Our consultant adviser says the ultrasound was intended to obtain tissue to give a diagnosis for a potentially enlarged lymph node which could have been related to Mrs B’s suspected cancer. A node may be enlarged for a number of benign reasons, but also because of a cancer which had spread. When obtaining biopsies in someone with a suspected cancer, it is usual to try to get a sample by the easiest method available. This was the easiest method at that time as shown on the earlier CT scan. It would be up to the practitioner as to whether they proceeded to biopsy anything. This is dependent on what they saw and felt was appropriate on the day of the scan. Again, there is no specific guidance, this is standard medical practice.
42. Our radiology adviser says that all the lymph nodes that were visualised on Mrs B’s ultrasound were under 5mm in short axis and demonstrated normal shape and no evidence of metastasis (spread). Ultrasound will not pick up all metastatic node deposits, but it has an extremely high specificity if the node is less than 5mm in size (i.e. if the node is under 5mm in dimension, the chance of a node metastasis in a patient with known cancer is around 2% and as such undertaking a biopsy randomly in such nodes is discouraged. This is supported by the academic article on the accuracy of ultrasound for the diagnosis of cervical lymph node metastasis in esophageal cancer highlighted in the evidence section of this report.
43. It is noted that Mrs B had a Positron Emission Tomography (PET)-CT scan on 14 March 2023. In retrospect, our radiology adviser says only one of the nodes in Mrs B’s lower neck showed any uptake and only at a non-specific level (a lymph node can uptake PET tracer for many reasons and not all of them due to cancer. When uptake is above a certain level, biopsy can be recommended at a location but the single neck node that showed uptake did not reach this level and would not have necessarily been recommended for biopsy with the benefit of the findings of the PET-CT).
44. Therefore, undertaking a biopsy randomly in Mrs B’s neck in a lymph node of normal size at the time of the ultrasound scan would most likely have resulted in a not insignificant risk of injury to vessels or nerves in her neck and a false negative result.
45. We have not seen evidence in the clinical records that Mr A and Mrs B were told the nodes seen on her ultrasound scan were nothing to worry about, but we note that the Trust acknowledges in its complaint response that such a conversation happened with the ultrasound department assistant that was helping with the procedure. The Trust apologised for inappropriate communication by the assistant regarding Mrs B’s ultrasound and any confusion or distress this caused.
46. Paragraph 30 (domain 2) of the GMC Good medical practice guidance states: ‘You must make sure that the information you give patients is clear, accurate, and up to date, and based on the best available evidence’.
47. Overall, we consider there are failings in the Trust’s communication with Mrs B regarding the results of her scans and x-ray contrary to the GMC guidance on communication. This caused some unnecessary confusion for Mr A and Mrs B about her condition which was emotionally distressing for both of them. We have made recommendations about this.
Medication
48. Mr A says Mrs B was given the wrong medication when she was on Ward 2 from 23 May 2023 at hospital. The Trust gave her the medication which she was discharged with from Ward 8 instead of her current medication.
49. Having considered the Trust’s complaint response, a detailed reply has been provided to this point. The Trust’s letter of 29 August 2023 states there is no evidence Mrs B was given any incorrect medication on her admission to ward 2. It also provides assurances that Mrs B received the correct medication throughout her admission from the Emergency Admission Unit (EAU) and Ward 2. In the Trust’s letter of 29 November 2023, it says that following a review of Mrs B’s medication, there were no concerns about her receiving the wrong medication whilst an inpatient. It apologises if Mr A was given any misinformation about his wife’s medication.
50. Given Mr A’s concerns, our consultant adviser has conducted a review of the medication given to Mrs B on Ward 2 from 23 May 2023 and at the point of discharge from Ward 8 on 15 February 2023. Our consultant adviser says the medication taken by the clerking clinician on 23 May 2023 states that Mrs B is taking Propranolol, Marcogol, Dexamethasone, Lansoprazole, Levetiracetam, Sertraline, Diazepam, Docusate, Zomorph, Morphine, Apixaban, Nystatin and Lorazepam. The medications taken from 15 February 2023 shows that Mrs B is on Omeprazole, Co-Amoxiclav, Aspirin, Propranolol, Paracetamol, and Ibuprofen.
51. Therefore, our consultant adviser says it is entirely clear the medications Mrs B was known to be taking when admitted on 23 May 2023 were different from those she was discharged with on 15 February 2023.
52. Getting a patient’s medication right when they are admitted to hospital is important, but it can be complicated and is not always perfect. All relevant patients should go through a process called ‘medical reconciliation’ when any discrepancies are appropriately corrected, but we can never be certain about all the medication that was given to Mrs B by the Trust. Therefore, the key question is, if there were any errors by the Trust, is there any evidence of a significant negative clinical impact on Mrs B.
53. Our consultant adviser says Mrs B had terminal cancer from some time before she had first presented to the Trust. If there was an error with her medication from 23 May 2023, it would be minor, time limited, and of no clinical significance. Mrs B would not have suffered any significant negative impact from it. Therefore, we have not seen any failings regarding the medication given to Mrs B by the Trust. We understand why Mr A is concerned about the medication given to his wife, but we hope our review helps to put his mind at rest about this matter.
Conclusion
54. Mrs B was referred to the Trust with a suspected condition which our consultant adviser says was completely unrelated to cancer. Within a very short time (8 days) the diagnosis of cancer was discovered, and she had had several complex investigations which many people wait at least weeks for. This was rapidly followed by a tissue biopsy and palliative treatment started. There was no curative option as the cancer was too advanced and had spread to multiple different places. Mrs B had terminal metastatic lung cancer. This was diagnosed at a point that it had already spread to multiple sites within her body and was therefore not curable. Very sadly, Mrs B died from this and its immediate consequences.