A practice in the Lincolnshire area

The Practice

7. Mrs M complains about the care provided to her late sister, Mrs F, by the Practice between December 2023 and February 2024. Specifically, Mrs M complains that her sister’s symptoms of rectal bleeding were not appropriate considered and she was not examined.

Mrs M say her sister’s symptoms were instead thought to be due to endometriosis (where cells similar to those in the lining of the womb (uterus) grow in other parts of the body).

8. Mrs M says this was a missed opportunity to refer her sister on for further tests, which likely would have resulted in an earlier diagnosis of liver cancer. Mrs M says an earlier diagnosis may have meant her sister could have had treatment and potentially extended her life.

9. Mrs M says her sister’s death has had a profound effect on her family. She explains her sister had three young children, and her sister’s husband has not been able to work due to the trauma of these events. This in turn is causing financial concerns on top of the family’s significant grief.

10. Mrs M says the failings in her sister’s care have not been recognised and addressed. She is seeking an apology, acknowledgement of the failings and for the Practice to improve its service. Mrs M is also seeking a consideration of what her sister’s outcome might have been had the failings not occurred, and a financial remedy.

The Trust

11. Mrs M complains about the care and treatment provided to her late sister, Mrs F by the Trust between December 2023 and February 2024. Specifically, Mrs M complains:

• symptoms of rectal bleeding were not appropriately considered even though this information as included on the GP referral information • the urgent care team and A&E did not appropriately consider her sister’s symptoms of increasing pain, and instead dismissed this as due to undiagnosed endometriosis • Mrs F was not told to stop her oramorph before a scheduled colonoscopy (a test to check inside the bowels) and this meant the procedure could not go ahead • there were a number of missed opportunities to discuss Mrs F’s care at multi-disciplinary team (MDT) meetings, which meant there was not opportunity to provide any form of chemotherapy • her sister’s oxygen, pain relief and intravenous (IV) fluids were not appropriately administered • confidential information about her sister’s treatment was shared by staff, meaning others were aware of her diagnosis before the family.

12. Mrs M says an earlier diagnosis may have meant her sister could have had treatment and potentially extended her life. She says the failings in the nursing care and the inappropriate sharing of information has added to her sister’s distress at an already difficult time.

13. Mrs M says her sister’s death has had a profound effect on her family. She explains her sister had three young children, and her sister’s husband has not been able to work due to the trauma of these events. This in turn is causing financial concerns on top of the family’s significant grief.

14. Mrs M says the failings in her sister’s care have not been recognised and addressed. She is seeking an apology, acknowledgement of the failings and for the Trust to improve its service. Mrs M is also seeking a consideration of what her sister’s outcome might have been had the failings not occurred, and a financial remedy.

16. The law says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider this is (or was) unreasonable in the circumstances. We do not consider whether legal action would succeed but whether it would be a reasonable option to look in to.

17. We also cannot look at complaints if someone has the chance to take legal action that would address the issues in their complaint and potentially give them the outcome they are looking for.

Late diagnosis

18. We note Mrs M’s concerns about the missed opportunities to investigate her sister’s symptoms, the delay in the colonoscopy due to incorrect advice, and the delayed MDT meetings. Mrs M feels these failings meant her sister was not able to have treatment which could have potentially extended her life.

19. Mrs M has explained the significant effect these events have had on her late sister’s family, and the financial pressures they are facing. It is therefore understandable that the family are seeking a significant financial remedy.

20. We consider it would be reasonable for Mrs M and her family to gain legal advice in relation to these concerns, to consider the outcomes Mrs M is seeking of an acknowledgement of ay failings and a consideration of compensation.

21. We note Mrs M is also seeking an apology and service improvements in relation to the late diagnosis. These outcomes may not be directly achievable via the courts but may still happen as a result of a successful legal claim.

Nursing care and information sharing

22. Mrs M also complains about the care the Trust provided in relation to her sister’s oxygen, pain relief and IV fluids. She says these were not properly administered and this caused her sister additional pain and distress at what was already a difficult time.

23. Mrs M also raises concerns about staff at the Trust sharing information about your sister’s care with colleagues, and says information was known by others before the family.

24. These aspects may not be part of a potential legal claim. We have therefore considered whether we should look at these now.

25. At the moment, we think it is best to wait for the outcome of any legal advice and the conclusion of any potential legal action, before we consider these concerns. This is because any legal action may draw in other issues as part of its consideration and provide a response or resolution to these.

26. It is for these reasons that we will not look at these aspects further at this time.

Next steps and our time limit

27. If Mrs M and her family are unhappy following legal action or have outstanding issues or outcomes which they could not pursue via the courts, they can return to us. However, we cannot consider issues which have already been examined by the courts.

28. If for some reason, Mrs M and her family are unable to proceed down the legal route and want us to consider their complaint again, they can also contact us. It is important they approach us as soon as possible. This is because we can usually only look at complaints that are raised within 12 months of the individual becoming aware of the issue. We can sometimes put the time limit to one side if we see there are good reasons for the delays in a case reaching us.

29. We recognise this has been a significant and distressing complaint for Mrs M and her family. We cannot underestimate the impact of these events, and we are very sorry for their loss. We hope the above clearly explains the reasons for our decision and the next steps they can take.

1. We have carefully considered Mrs M’s complaint about the Practice and United Lincolnshire Teaching Hospitals NHS Trust (the Trust).

2. Mrs M complains about the care and treatment provided to her late sister, Mrs F. Mrs M says the Practice and Trust missed opportunities to investigate her sister’s symptoms sooner, which led to a delayed diagnosis of cancer. Sadly, Mrs F died in February 2024. Mrs M feels an earlier diagnosis may have meant her sister could have had treatment and potentially extended her life.

3. We recognise the profound impact Mrs F’s death has had on Mrs M and her family, especially as Mrs F was the mother of three young children. We offer our sincere condolences to Mrs M and her family.

4. We consider there is a possible legal remedy available in relation to the delayed diagnosis and clinical concerns. We would therefore not consider these concerns as the law says we cannot investigate a complaint where a person has the option to take legal action.

5. We understand Mrs M has some further concerns around the nursing care and information being inappropriately shared. She also does not feel appropriate learning has been taken from the failings in her sister’s care. We consider it is best to wait for the conclusion of the legal process before we consider these concerns. This is because the legal action may draw in other issues as part of its consideration and provide a response or resolution to these.

6. Overall, it is for these reasons that we have decided not to consider Mrs M’s complaint at this time.