A practice in the Stockport area

3. Miss U complains about the care and treatment provided by the Practice between August 2021 and October 2022. She says the Practice failed to assess and refer her appropriately when she presented with body pain, lumps in her neck, pain in her hips and groin, a weakened bladder, stomach pain, reduction in appetite, night-sweats, joint pain and chest pains.

4. Miss U says the Practice’s failure to assess and refer her appropriately led to a delay in her diagnosis of stage 4 Hodgkin’s lymphoma. She says if she was diagnosed earlier she would not have had to endure aggressive chemotherapy. She says this chemotherapy carries a risk of placing her in early menopause. She says the late diagnosis meant this treatment had to be escalated, resulting in a lack of time and opportunity to freeze her eggs. She states the chemotherapy has left her with bone and joint pain, neuropathy and fibromyalgia. She says she has been left with emotional trauma.

5. Miss U seeks an acknowledgement of failings, service improvements and a financial remedy.

6. Miss U attended the Practice on multiple occasions with various symptoms between August 2021 and October 2022.

7. In August and September 2021 Miss U presented to the Practice with lower back pain. The Practice referred her for an MRI scan which revealed a small right paracentral disc protrusion (disc bulge). This is a condition where a small portion of the inner part of a spinal disc has pushed to the right side of the spine, often pressing on a nearby nerve. This can result in the patient experiencing lower back pain.

8. She says she attended in August 2021 with body pain and in March 2022 her symptoms worsened. She says she presented with lumps in her neck, pain in her hips and groin, a weakened bladder, stomach pain, reduction in appetite, night sweats, joint pain and chest pain.

9. Between January 2022 and March 2022, Miss U presented to the Practice with abdominal symptoms and headaches. The Practice provided dietary advice and referred her for a stool test and a blood test.

10. On 17 May 2022, Miss U presented with a lump in her neck. The Practice though it was likely a swollen lymph node.

11. In September 2022, Miss U presented with pain in her flanks. The Practice prescribed antibiotics and referred her for a pelvic scan.

12. On 21 October 2022, the Practice referred Miss U to the Emergency Department (ED). A CT scan revealed she had stage 4 Hodgkins lymphoma. This is a type of cancer that affects the lymphatic system involved in the body’s immunity.

16. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

17. GMC good medical practice guidelines say clinicians should adequately assess patients and provide them with suitable advice and investigations. Our adviser said the Practice acted in line with these guidelines when assessing Miss U for her presentations of lower back pain. Our adviser explained the MRI scan did not show cancer and cancer was not the cause of her lower back pain.

18. Our adviser said the assessment of Miss U’s headaches and abdominal symptoms was also in line with GMC guidelines. The Practice appropriately assessed Miss U and arranged appropriate investigations. Our adviser said Miss U’s headaches and early abdominal symptoms were unlikely to be related to her eventual cancer diagnosis. They also explained it was appropriate for the Practice to refer her for a pelvic scan as her symptoms were consistent with pelvic inflammatory disease. We have not seen failings in how the Practice managed Miss U’s symptoms here. The Practice’s actions were in line with GMC guidance and the advice we have received.

19. On 17 May, Miss U presented with a lump in her neck. The records say it was visible to the eye and the size of a raspberry. It had been present for three days and she was otherwise feeling well with no temperature. It is recorded this was an anterior cervical raised node. This is a swollen lymph node on the side of the neck. The records say the lymph node is likely reactionary. The clinician also noted ‘had bloods last month – all normal’.

20. The NICE guidance on suspected cancer, say clinicians should consider a suspected cancer pathway referral for Hodgkin’s lymphoma in adults presenting with unexplained swollen lymph nodes. It says, when considering referral clinicians should take in to account any associated symptoms, particularly fever, night sweats, shortness of breath, itching, weight loss or alcohol-induced lymph node pain.

21. Our adviser said it is common for swollen lymph nodes to resolve on their own and as Miss U was not experiencing any of the associated symptoms, the Practice acted in line with NICE guidelines by not making an immediate referral.

22. They went on to explain the records show Miss U was advised to observe the lump and attend a review if it was still present in two to three weeks.

23. Our adviser said it is important to note the guidelines do not set out a timeframe for when to refer a patient if the lump does not resolve on its own. They said most clinicians would refer the patient after three to six weeks. Our adviser said the Practice acted appropriately as it safety netted her (provided instructions on when to receive further medical attention) by suggesting a review in an acceptable timeframe.

24. Our adviser said it was acceptable for Miss U to be left to book an appointment for review herself as there were no vulnerabilities preventing her from doing this. Taking into account NICE guidance and the views of our adviser, we found the Practice managed this presentation appropriately.

25. Our adviser said, in hindsight, the swollen lymph node was most likely a symptom of her cancer.

26. On 6 June, Miss U attended a telephone consultation regarding her ongoing lower back pain.

27. Our adviser said there was an opportunity here for the clinician to ask her if the lump was still present. They explained there is no guidance to say what extent a clinician must review previous consultations and therefore we cannot be critical of the Practice for not asking Miss U about this.

28. On 15 June, Miss U presented with a mixture of symptoms. She was still experiencing lower back pain which was not due to cancer. She had also developed a new pain. The new pain was from her lower back to her abdomen and usually only at night, while lying down.

29. The Practice arranged a urine test and prescribed painkillers.

30. Our adviser said this was an appropriate assessment of her symptoms, in line with GMC good medical practice guidelines. They said a urine test was an appropriate medical intervention, in line with these guidelines. They said, in hindsight, this new abdominal pain was due to her cancer.

31. On 24 June, Miss U presented with her ongoing symptoms from 15 June. She was now also presenting with groin pain. The Practice arranged a follow up for within three days. It also arranged a urine test to check for the presence of any ongoing infection. The results revealed Miss U had a urinary tract infection (UTI) and the Practice prescribed antibiotics.

32. Our adviser said the assessment of groin pain was complicated due to the presence of new and old symptoms. They explained the plan to test for the presence of an ongoing infection was a reasonable investigation of the new groin pain, and in line with the GMC guidelines.

33. On 8 September, Miss U presented again with abdominal symptoms.

34. The Practice arranged a stool test which returned as normal on 13 September. Her abdominal symptoms were still present. The Practice arranged a blood test.

35. Our adviser said a blood test was an appropriate investigation at this time.

36. The Practice received the results of the blood test 21 September. The results revealed raised levels of C-reactive protein (CRP). This is a protein found in the blood. High levels indicate inflammation in the body. These abnormalities were not present previously. The Practice arranged a repeat blood test.

37. Our adviser said it was appropriate for the Practice to arrange a repeat blood test. This is usual when the initial results show abnormalities.

38. On 3 and 12 October, the Practice advised Miss U to attend for repeat blood tests to follow up the abnormalities present on 21 September.

39. On 20 October, Miss U attended the Practice for the repeat blood test.

40. The Practice received the results of the blood test. It revealed her CRP had raised further. On 21 October, the Practice advised Miss U to attend ED for further investigations so she could be directed to the appropriate speciality.

41. Our adviser said in hindsight Miss Nuu’s symptoms of cancer began in May 2022 when she presented with a swollen lymph node and when she presented with the new abdominal pain. She was eventually diagnosed October 2022. They said the timeframe between the first presentation of symptoms to the date of diagnosis is fairly normal in cases of Hodgkins lymphoma.

42. We understand why Miss U is concerned the Practice should have recognised sooner her symptoms were related to Hodgkins lymphoma. She has told us she felt her symptoms were dismissed and her numerous presentations to the Practice were not taken seriously. We appreciate why Miss U would feel this way given the amount of health issues she experienced during this period of time.

43. In summary, taking into account the evidence we have seen and the clinical advice, we have not seen indications the lower back pain Miss U experienced throughout 2021 and 2022 was due to cancer. We have not seen the symptoms she presented with in 2021 related to her eventual cancer diagnosis.

44. We have seen the symptoms related to Miss U’s cancer first presented in May 2022. However, through our work we have seen the Practice’s assessment of her swollen lymph node, groin and abdominal pain were in line with the appropriate guidelines and therefore we are not critical of the Practice’s actions. We have seen when Miss U’s blood tests revealed abnormalities, these were repeated. When the blood tests were abnormal again, the Practice referred her to ED immediately. We have found this to be appropriate. We have not seen evidence the Practice did anything wrong and will not be taking further action.

1. We have carefully considered Miss U’s complaint about the Practice. It is clear from what Miss U has told us, she experienced a significant amount of health issues over a number of years. We were sorry to hear she was diagnosed with stage 4 Hodgkins lymphoma and recognise the impact this had and continues to have on her, both physically and emotionally.

2. We have decided not to consider Miss U’s complaint further. We have seen evidence the Practice made appropriate clinical decisions throughout Miss U’s presentations. We hope our explanation helps to show the Practice followed appropriate guidelines and arranged investigations within an acceptable timeframe. We hope this reassures her we have not seen signs her care fell below the expected standard.