Issue 1 – concerns relating to appointments
14. Mrs A complains the Practice failed to book Mr A a face-to-face appointment. She says whenever he would call, a telephone consultation would be booked. She has told us she ‘had to fight for Mr A to be seen in person’. We understand Mrs A’s concerns are that because of this, Mr A’s symptoms were not properly assessed.
15. We are sorry to hear of these concerns and appreciate why Mrs A feels frustrated that Mr A may have not been properly assessed.
16. The Practice has apologised for the difficulties Mrs A has experienced in accessing a face-to-face appointment. In its response dated 22 August 2024 it says, ‘to deal with the large volume of calls we receive at the surgery daily, we operate a Triage system led by our Patient Services Team who either book the patient into an urgent or routine appointment with an appropriate clinician (can be telephone or face to face based on preference)’.
17. From the records we can see that there were two telephone consultations/ contacts to the Practice. The first one was on the 30 October 2023 when Mr A called the Practice to book an appointment. The second was on the 30 April 2024 which we understand is the one Mrs A is referring to when she says she had ‘to fight’ for a face-to-face appointment.
18. In relation to the 30 April 2024 call, we can see that the Practice booked Mr A in for the next available urgent face to face appointment which was 2 May 2024. In light of the above, our consideration has focused on whether it was clinically appropriate, based on Mr A’s presenting symptoms for him to have been assessed over the phone on 30 October 2023.
19. We have noted the Practice’s response is not clear about its position on this and whether it acknowledges failings have occurred. The response starts with an apology and then includes a chronology of which appointments were face to face. In line with NHS England’s Complaint policy, we would expect the response to include a ‘clear explanation of whether or not something went wrong’.
20. We have quoted a newer version of the NHS Complaint Policy which is currently in place. We consider this is still applicable to this complaint. This is because NHS England website confirms the only changes from the previous policy are that ‘Changes take into account that NHS England is no longer commissioner of primary health care services’. Based on this, the guidance we have quoted above from the NHS England Complaint Policy are still the same in both versions.
21. We will inform the Practice of this, however, we are satisfied we have enough evidence to be able to reach a view on this concern.
22. We have obtained clinical advice in relation to this.
23. Our adviser has said there is no national guidance which specifically provides details on circumstances when a telephone consultation or face to face consultation should be done. As such we refer to GMC guidance.
24. GMC is a public body that sets the values, knowledge, skills and behaviours expected of all doctors. GMC guidance ‘Good Medical Practice’ says in section ‘Providing good clinical care’:
‘6. You must provide a good standard of practice and care. In providing clinical care you must:
• adequately assess a patient’s condition(s), taking account of their history, including:
• symptoms • relevant psychological, spiritual, social, economic, and cultural factors • the patient’s views, needs, and values • carry out a physical examination where necessary • promptly provide (or arrange) suitable advice, investigation or treatment where necessary • propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs • propose, provide or prescribe effective treatment based on the best available evidence’
25. Our adviser explains in practice, a cough is a common symptom, and a telephone consultation is appropriate for an initial assessment. Following this, if a patient has other symptoms such as chest pain, then it would be appropriate for a physical examination to be completed.
26. Having reviewed the evidence, we consider there to be no indications to suggest that something went wrong. We can see the 30 October 2023 call was the first contact Mr A had made regarding his symptoms about the cough. We have listened to the recording of this call. During the call, which was between Mr A and the receptionist, he is asked if there are any other symptoms such as a high temperature, chronic obstructive pulmonary disease (COPD) or asthma to which Mr A replies no. He confirms he has tried cough syrups, but nothing is helping. He is then put on hold by the receptionist, whilst she speaks to the on-call GP.
27. We understand the GP advised for a chest X-ray to be completed but advised that if there are any other symptoms, such as shortness of breath or coughing up blood then to be back in contact.
28. Although Mr A did not directly speak to the GP, we can see evidence that the GP took into account his symptoms when considering how best to proceed. This included a consideration of what other symptoms he was suffering which at that time he confirmed was solely the cough. This is in line with paragraph 6.a.i of the above quoted GMC guidelines. It was clinically appropriate for a chest X-ray to be completed to rule out anything further, which we consider to be in line with paragraph 6.c of the above GMC guidelines.
29. Therefore, after considering the available evidence; we consider there to be no indications of failings in a face-to-face appointment not being booked on 30 October 2023. We consider the actions of the GP to be in line with GMC guidelines.
Issue 2- concerns relating to the management of Mr A’s cough
30. Mrs A raises concerns that between October 2023, when Mr A first contacted the Practice regarding the cough and May 2024, the Practice failed to appropriately manage his cough. She raises concerns that he should have been sent for tests earlier than he was. Mrs A says that because of this it failed to adequately identify his cancer.
31. The Practice states in its response that when Mr A first contacted the Practice, he was immediately sent for a chest X-ray. The response goes onto explain the chest X-ray results were clear which was also the case when Mr A was physically examined five months later in March 2024. It states other causes of the cough were considered such as being caused by acid reflux and accordingly medicines were prescribed for this.
32. The Practice goes onto say on 30 April 2024, concerns were raised of weight loss and bowel cancer and so an urgent stool faecal immunochemical test (FIT) test was completed. This is a test that looks for tiny traces of blood in stool that could be signs of cancer.
33. We understand from the records the result of the test was negative. As a result, an urgent appointment was made on 2 May 2024. In this an urgent CT scan was arranged which unfortunately revealed the diagnosis of cancer.
34. We have obtained clinical advice to robustly consider this concern.
35. NICE guidelines ‘Cough’, in section ‘how should I manage someone with acute cough?’ provides guidance on how professionals should manage a cough based on the presenting symptoms. The key parts of the guidelines which are relevant to the complaint have been included below.
36. From the available evidence we understand that on the 30 October 2023, Mr A confirmed his presenting symptom was a cough. He also confirmed there were no other clinical concerns associated with this such as a high fever or shortness of breath. Mr A also confirmed during this call that he had suffered the cough for over three weeks.
37. NICE guidance explains that the ‘management of a cough may necessitate subsequent trials of treatment’, and ‘a number of clinical assessments need to be completed to confirm or refute common causes’. The guidance goes onto consider several possible causes and how professionals should manage these.
38. NICE guidelines ‘how I should assess a person with cough?’ says ‘arrange investigations in primary care if appropriate, such as chest x-ray’. We consider the GP’s actions to firstly carry out a chest X-ray on the 30 October 2023, was in with NICE guidelines. This was clinically appropriate to rule out any chest related concerns. We can see from the evidence that the chest X-ray showed Mr A’s lungs were clear.
39. The NICE guidelines say in section ‘explain that the cough is often self-limiting and usually lasts for no longer than 8 weeks (advise the person to re-attend for assessment if the cough does not improve after 2 months)’. We can see from the records, Mr A was advised that if the cough persisted or further clinical symptoms were noted, then he should contact the Practice again.
40. Following this, we can see Mr A had a face-to-face consultation on 6 March 2024 with concerns of an ongoing cough. The records note that he had a ‘dry cough with no chest pain or breathlessness, he was not coughing up blood’. We can see he was examined and the examination was ‘normal’ which means that no clinical concerns were noted. Mr A was prescribed a steroid nasal spray and a medication to reduce stomach acid.
41. We consider the actions of a nasal spray being prescribed to be in line with the NICE recommendations of ‘the sequential trials of treatment in chronic cough without a specific diagnosis’. The guidelines provide a recommended trial to include ‘post nasal drip- prescribe an antihistamine and a decongestant’.
42. We can also see from the records that during this consultation of 6 March 2024, blood tests and an ECG were arranged.
43. Following this, Mr A had another face-to-face consultation on 11 April where he presented with an ongoing irritant cough. We can see from the records, the GP prescribed metoclopramide. This is a medication to increase stomach mobility (movement). Our adviser tells us that the clinical impression was that Mr A had likely ‘gastro-oesophageal reflux’ as he had raised concerns of bringing up phlegm. This is a condition in which the stomach acid repeatedly flows back into the tube connecting the mouth and stomach, called the oesophagus.
44. The chest X-ray which was completed did show Mr A had a hiatus hernia, which means that part of his stomach had moved up into his chest. NHS England guidance ‘hiatus hernia’ says ‘acid reflux’ is a common symptom of this.
45. Based on this clinical presentation of the acid reflux, we consider the GP’s actions of prescribing metoclopramide to be in line with the NICE guidelines ‘Cough’ which says in section ‘how should I manage someone with acute or chronic cough’ that as part of the clinical trials for the diagnosis of a cough, ‘gastro-oesophageal reflux disease’ should be ruled out.
46. We can see the next consultation was the 2 May 2024 where Mr A raised concerns about weight loss and in the last fortnight he has no appetite, energy and felt sleepy. We can see further blood tests and an urgent CT scan was arranged in which the cancer was sadly identified.
47. We consider the GP’s actions of arranging an urgent CT scan to be in line with section 1.1 of the NICE guidelines ‘Suspected cancer: recognition and referral’. This says:
‘Offer an urgent chest x-ray to assess for lung cancer in people ages 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’
48. We consider the actions of the GP to refer Mr A Mr A on 2 May 2024 for an urgent chest X-ray to be in line with the above NICE guidelines. This is because he raised concerns about weight loss, appetite loss and the persistent cough. Therefore, two or more of the symptoms detailed in the NICE guidelines were present. From the records, we can see no evidence to suggest that Mr A raised concerns of other symptoms other than the cough prior to the 2 May 2024. Therefore, there is no evidence to suggest an urgent CT scan/ X-ray was required prior to the 2 May 2024.
49. We have also reviewed the NICE guidelines ‘the sequential trials of treatment in chronic cough without a specific diagnosis’, which do not provide a requirement for an urgent CT scan to be completed.
50. Based on the evidence we have seen, we have found no indications that the Practice failed to adequately assess Mr A’s cough or that there was a loss of opportunity for the cancer to be identified earlier. It was in line with NICE guidelines ‘Cough’ for the Practice to identify the reason for Mr A’s persistent cough and it was clinically appropriate to use the recommended treatments to rule out the possible causes. It was once other symptoms, particularly the unexplained weight loss came to light that further investigations were warranted.
Conclusion
51. We have decided that there are no indications of failings in how the Practice managed Mr A’s presenting cough symptom. We appreciate why Mrs A has brought these concerns to us and hope that our consideration of this provides her with assurance that nothing went wrong in how Mr A’s condition was managed.
52. We understand that the origin of the cancer appears to have been the kidney and as the Practice says, we understand kidney cancers are hard to detect in early stages. We are sorry that Mr A’s health detoriated so quickly and the sad loss must have affected you and your family.