County Durham and Darlington NHS Foundation Trust

Claimed failings - The Trust

4. Mrs H complains the Trust failed to carry out proper investigations between September and October 2022 into the causes of her stomach pain, weight loss, and loss of appetite. She complains it instead referred her back to her GP.

Claimed failings - the Surgery

5. Mrs H also complains the Surgery failed to refer her for investigations to find the cause of her stomach pain, weight loss, and loss of appetite between August and October 2022. She says the Surgery incorrectly attributed her symptoms to irritable bowel syndrome (IBS).

Claimed impact – both organisations

6. Mrs H says both organisations failure to refer her meant her condition and cancer were not identified as soon as they could have been. She explained this meant she experienced pain longer than necessary. She also says she had to have surgery which would have been avoidable or less intrusive.

7. Mrs H feels both organisations treated her as a hypochondriac, which has led to a loss of trust, and that she experienced shock and distress when she learned of her actual diagnosis.

Desired outcome – both organisations

8. Mrs H would like both organisations to acknowledge they did not refer her for investigations in a timely manner. She also wants service improvements to reassure her there is a low risk of this happening to others.

9. Mrs H is a 46-year-old lady who experienced severe abdominal pain. She initially attended her GP in August 2022. She says the GP put her symptoms down to IBS.

10. Mrs H had been under the care of Gynaecology at the Trust from January 2022. An ultrasound scan showed she had an ovarian cyst (a fluid filled sac that develops on the ovary). She also had a colonoscopy (an imaging test of the colon) which came back as normal.

11. In April 2022, Mrs H was admitted to to the Trust with abdominal pain. Whilst in hospital, investigations started to find whether the symptoms were due to IBS or diverticular disease. A CT scan (a scan to get internal images of the body) was clear, and the discharge records said her GP should treat the symptoms as IBS.

12. On 2 May, Mrs H had an appointment at the Surgery where a nurse examined her. They recorded she had left-sided lower abdominal pain, and a two-week history of cramps.

13. On 11 September, Mrs H attended the Urgent Treatment Centre at the Trust. Records show she was concerned about her IBS symptoms, and the abdominal cramps she had been experiencing for two weeks. She was advised to attend the emergency department if she had any ‘red flag’ symptoms, or to contact her GP if there was no improvement.

14. On 20 September, Mrs H contacted the Surgery via email to explain she had been hospitalised abroad and that she would need her coil removed when she returned.

15. She spoke to a GP on 22 September, who noted she was still in pain, and that this was not responding to pain relief. They noted that it would be a good idea for her coil to be taken out.

16. Mrs H attended the Trusts emergency department (ED) on 25 September 2022 with pain. A urine test did not show any concerns, and Mrs H says staff told her the pain was likely to be her IBS. The hospital referred her to the emergency Gynaecology clinic at the Trust the following day.

17. When she attended the Gynaecology clinic, her coil was removed. She had an ultrasound scan which showed the cyst on her ovary had burst.

18. She next attended the Surgery on 3 October. Mrs H reported ‘ongoing lower…abdomen pains’ which were ‘sharp and twisting’. A GP examined her and planned to do additional blood tests. The results came back on 11 October and were normal.

19. On 13 October, Mrs H called the Surgery to complain of further strong stomach pain which was getting worse. She attended in person the same day and a GP examined her. They planned to do another faecal immunochemical test (FIT) test and advised her to attend the ED if her pain got worse. The results of the test showed she potentially had cryptosporidium, a parasite that can cause bowel infection.

20. On 18 October, Mrs H told the Surgery she was ‘really struggling with lower abdominal pain’ and that she ‘can’t cope’. A staff member examined her and felt this was linked to her IBS. They prescribed her morphine and again advised her to attend the ED if the pain did not settle. They also requested an ultrasound scan.

21. On 21 October, Mrs H contacted the Surgery to explain that Environmental Health had told her she had a parasite. The Surgery advised her to stay hydrated and to attend the ED if she had symptoms of a kidney injury.

22. Mrs H attended the Surgery on 25 October and had a long discussion with a GP. They discussed her ongoing symptoms and weight loss. The GP recorded that Mrs H met the criteria for an urgent (two week) referral to hospital, but that she needed an X-ray and blood tests before she referral. The blood tests took place on 27 October.

23. On 28 October, Mrs H attended the Trust’s ED. She was given pain relief but not referred for further investigation. This was because her GP was in the process of referring her on the two-week cancer pathway.

24. On 31 October, Mrs H had a chest X-ray. The Surgery made the two-week referral on 3 November.

25. Mrs H attended the ED at another hospital on 18 November, with the same symptoms. She was admitted.

The Trust

Investigation of symptoms

29. Mrs H complains the Trust did not carry out full investigation into her symptoms when she presented at hospital across August and November 2022.

30. She says she expected clinicians would have asked for CT scans (computed tomography scan, a medical imaging scan to see internal images of the body) to establish the cause of her pain, but that instead, the Trust referred her back to her GP.

31. In its response to her complaint, the Trust apologised for Mrs H feeling there had been a lack of care in the ED and that she was not listened to. It explained the ED does not offer CT scans routinely because of the potential of unnecessary exposure to radiation. It also said she had a CT scan in May 2022 which did not show a bowel condition, so a repeat scan was not an emergency.

32. When we investigate a complaint, we consider what should have happened and compare this against what did happen. We can see what should have happened by looking at what the relevant guidance says.

33. GMC’s Good medical practice, 15.a, says doctors must ‘adequately assess the patient’s conditions, taking into account of their history (including symptoms…) their views and values, where necessary, examine the patient’.

34. The NICE guidance irritable bowel syndrome in adults: diagnosis and management clause 1.1.1 says IBS should be considered where a person has any of three symptoms for a period of at least six months ‘abdominal pain or discomfort, bloating, change in bowel habit’.

35. NHS England’s ‘About urgent and emergency care’, explains what emergency care is and the role of the ED. It says this is needed where the patient experiences ‘life threatening illnesses or accidents which require immediate, intensive treatment. Services that should be accessed in an emergency include ambulance (via 999) and emergency departments.’.

36. It goes on to explain the ED is not intended as an investigative function and ED clinicians will send a patient home, sometimes with medication, referring them to the appropriate specialism if needed.

37. Urine Dipstick Analysis; Performing Urine Dipstick Analysis | Patient explains the meaning of urine test results. In respect of protein, it says where protein is greater than 250mg, this can indicate clinical proteinuria which can indicate renal disease.

38. Mrs H attended the Trust’s ED on 25 September 2022, after returning from her holiday, with abdominal pain. The medical records say blood tests came back clear, and a urine test showed +1 for protein. According to the relevant guidance, this was not a concern as Urine Dipstick Analysis; Performing Urine Dipstick Analysis | Patient explains ‘healthy adults normally excrete 80-150mg protein in urine daily’ and +1 indicates no more than 150mg of protein. This is less than the 250mg level which may indicate renal disease.

39. As the scan carried out abroad had shown an ovarian infection, the ED clinician made Mrs H an appointment with the Trust’s emergency Gynaecology clinic for the following day.

40. We asked our ED adviser about the visit and asked what should have happened. They reviewed the medical records and gave their view the Trust acted correctly. They felt it acted in line with GMC guidance, assessing Mrs H and considering previous history and symptoms. They said the medical records showed an examination and basic tests took place, and it made a referral to the correct specialism, Gynaecology.

41. Considering the medical records, we can see the actions taken by the Trust were in line with GMC guidance. Not only were Mrs H’s medical history and symptoms considered, but clinicians also made a referral to a more suitable specialism.

42. When Mrs H attended the emergency Gynaecology clinic on 26 September, the medical notes show the Trust performed an ultrasound. This found fluid around the ovaries, but the cyst shown on previous scans was no longer there, indicating it had burst. The Trust removed her contraceptive coil and provided pain relief.

43. Mrs H returned to the ED on 28 October 2022 with the same symptoms. The discharge letter sent to her GP noted the Trust had looked at her previous medical history as well as the symptoms leading to her returning to the ED.

44. The letter listed the tests caried out in the ED which included blood and urine tests and that the results did not show any abnormality. It says the pain settled after Mrs H took morphine and she was able to undergo a full physical examination.

45. The letter went on to say that, as Mrs H’s GP was referring her to hospital under the two-week-wait pathway, surgeons did not think her symptoms made surgery necessary, and there was nothing further the ED could do.

46. We asked our ED adviser about the tests and treatment provided by the ED on 28 October, and asked what should have happened. They explained that, as the two-week-wait pathway was underway, it was justifiable for the ED clinician to discharge Mrs H home without referral to another specialism, particularly as her blood tests and observations were normal after taking pain relief. They said this was normal practice and we consider this is in line with GMC guidelines as referral to a more appropriate specialism was underway.

47. We also asked our adviser whether it would have been appropriate to carry out a CT scan when Mrs H attended the ED. They said there was no evidence to support the need for emergency investigation such as CT scan, particularly as the blood tests and observations were normal once she had pain relief.

48. Our adviser went on to say that as Mrs H was already moving to the two-week-wait pathway, further investigation and admission were unnecessary and referral back to a GP is common practice.

49. From reviewing the available evidence and advice received, we consider the Trust, specifically the ED, acted appropriately based on Mrs H symptoms and medical history. The medical records and letters sent to her GP show it followed the relevant guidance to make decisions about treatment and referrals.

50. In line with the NHS’s definition of the difference between the ED and other services, the ED does not provide investigative treatment with its role being to address the symptoms presented. The ED does not to act where a patient’s symptoms can be managed and do not require emergency treatment. Mrs H had already been referred to the correct specialism, and so we agree there was nothing further the ED could do.

51. There is evidence to support ED staff considering Mrs H medical history, carrying out blood and urine tests to help inform decision making on both visits in line with GMC guidance.

52. When Mrs H attended the ED on 25 September, the ED clinician referred her to the emergency Gynaecology clinic who investigated further. This was because she had been admitted to hospital whilst on holiday having a scan which showed an ovarian infection, and her pain could be attributed to this.

53. When Mrs H attended the ED on 27 October, she explained her GP was referring her for investigation for cancer on the two-week-wait pathway. Thus, we can understand that once her pain was under control, the ED clinician discharged her and referred her to her GP as any necessary investigation would take place on this pathway.

54. On both occasions the ED met the requirements of GMC guidance. The ED acted within its remit as there was nothing to support immediate treatment other than administering pain relief and it made referrals based on medical history and observations.

55. We acknowledge Mrs H suffered a great deal of pain across this time and that this affected her everyday living. This will have been very distressing and worrying for her and her family.

The Surgery

Failure to refer

56. Mrs H complains about the Surgery’s delay in referral for further investigation across the period August to October 2022.

57. In its response to Mrs H’s complaint, the Surgery explained that, after consideration of the appointment notes and symptoms, the doctor did 'everything that could be expected from a GP’. It described her condition as presenting as ‘extremely complex and difficult to understand’ and that the usual tests and scans for bowel tumours showed as normal.

58. As above, GMC’s Good medical practice, 15.a, says doctors must ‘adequately assess the patient’s conditions, taking into account of their history (including symptoms…) their views and values, where necessary, examine the patient’.

59. The NICE guidance irritable bowel syndrome in adults: diagnosis and management clause 1.1.1 say IBS should be considered where a person has any of three symptoms for a period of at least six months ‘abdominal pain or discomfort, Bloating, change in bowel habit’.

60. The NICE guidance on Gastrointestinal tract (lower) cancers explains the criteria for referral on the two-week-wait pathway. These include weight loss and loss of appetite and other symptoms such as deep vein thrombosis, abdominal or rectal mass.

61. The Patient info Cryptosporidium | Causes, Symptoms and Treatment | Patient explains the symptoms of this infection. These include diarrhoea and abdominal cramps, vomiting and loss of appetite.

62. The records show Mrs H attended the UTC on 11 September 2022 with the same symptoms of pain and abdominal cramps as she had prior to her diagnosis of IBS in May 2022.

63. The medical records show the UTC considered Mrs H’s earlier history, including the CT scan of May 2022. The records show the doctor examined her and took a urine test which was clear. The records say Mrs H said she was under some stress at the time. From this information and the examination, the UTC said the pain was likely due to IBS.

64. During the consultation, the medical records say the UTC discussed diet with Mrs H as well as ‘red flags’, making her aware of when and how to seek emergency help. They told Mrs H to book in to see her usual GP if she did not improve.

65. The medical records show Mrs H contacted the Surgery on 20 September whilst she was on holiday. She had been admitted to hospital abroad and asked the Surgery to refer her to Gynaecology to have her contraceptive coil removed on her return. She enclosed scans and test results from the hospital which showed an infection on her right ovary.

66. In the medical records, it says Mrs H contacted the Surgery on her return to ask for stronger medication. It recommended Mrs H remain on the medication prescribed abroad while waiting for a gynaecology appointment.

67. The next time Mrs H attended the Surgery was on 3 October. The medical records say she told the GP the pain in her lower left quadrant was sharp and twisting and that she had ‘bright red PR (rectal) bleeding’. The GP did not find any masses in the abdomen when examining her and arranged blood tests and a faecal immunochemical test (FIT), a test of faeces to check for bowel cancer.

68. The medical records show both the FIT and blood tests came back normal, ruling out bowel cancer. However, on 13 October, the GP asked Mrs H to keep a food diary and to provide another faeces sample, noting she had lost weight and had a family history of diverticular disease (where small sacs in the wall of the colon develop).

69. On 18 October, Mrs H attended the Surgery to go through the test results. The medical notes say these had all come back as normal. Examination found her to have the same tenderness in her abdomen and the GP referred her for an ultrasound (a scan of internal organs using high frequency sound waves) of her abdomen and pelvis as well as prescribing alternative treatment for her IBS.

70. We asked our adviser about the above tests and investigations and whether these were appropriate. They gave their view that these were in line with GMC guidance, based on Mrs H symptoms, as the GP had acted to ‘promptly provide or arrange suitable advice, investigations, or treatment necessary’.

71. The medical records show that after the faeces sample, Environmental Health contacted Mrs H. Her sample had shown a cryptosporidium infection (a parasite that can cause bowel infection). This can cause symptoms of abdominal cramps, vomiting, diarrhoea, and loss of appetite, lasting usually 12 to 14 days but sometimes as long as a month. These are similar symptoms to those Mrs H experienced at this time.

72. The Surgery spoke with Mrs H on 25 October to discuss the cryptosporidium infection and the GP went through her test results. Mrs H said she had lost weight, losing a stone in a short space of time. The GP referred her for further blood tests and a chest X-ray (required criteria) to be able to refer her to the two-week-wait pathway for lower gastrointestinal (the large intestine) cancer.

73. On 3 November 2023, the medical records show the Surgery referred Mrs H to the two-week-wait pathway (fast track for investigation for cancer), after receiving the blood test results and chest X-ray. In addition, the GP requested another FIT test. The results of this were abnormal but, as the Surgery had already referred Mrs H on the two-week-wait pathway, it did not take further action.

74. We asked our adviser about the referral. They felt the Surgery had met the requirements of the NICE guidance in respect of when to refer. They explained one of the main criteria for referral is where a FIT test shows the haemoglobin level to be too high. This was the case in the second test by which time Mrs H the referred to the hospital on the two-week pathway had been made.

75. From this, our view is that the Surgery acted appropriately based on Mrs H’s symptoms and medical history. The medical notes show it followed the relevant guidance to make decisions and, when Mrs H’s condition did not improve, acted to investigate further by instigating the two-week-wait pathway.

76. On each occasion Mrs H attended the Surgery, it carried out thorough examinations and requested blood, urine, and faeces samples to rule out cancer. As symptoms worsened and she had more symptoms, it arranged for the chest X-ray and blood tests to enable referral on the two-week-wait pathway for cancer.

77. We have not found any delay in referring Mrs H for the two-week-wait pathway. The Surgery considered earlier medical history and her symptoms in each appointment and acted within GMC and NICE guidance.

78. As Mrs H’s symptoms appeared typical of IBS, a condition diagnosed in May 2022, it treated her for this. Cancer tests, such as the FIT test, returned as normal in the first instance. This was not the case a month later as a second FIT test returned as abnormal. At this time, the Surgery had already referred Mrs H on the two-week-wait pathway as it had concerns about gastrointestinal cancer.

79. We recognise this has been a very stressful and upsetting time for Mrs H and that her diagnosis came as a shock. This will have had a big impact on her and her family.

1. We have investigated Mrs H’s complaint about County Durham and Darlington NHS Foundation Trust (the Trust) and a GP surgery in the County Durham area (the Surgery).

2. We are sorry to hear of the shock and distress Mrs H experienced when she was diagnosed with a bowel condition and bowel cancer. We recognise this has had a significant impact on her.

3. We have not found any failings in the treatment provided by either organisation. We think both organisations acted in line with guidance, making the appropriate referrals at the right time. As such, we have not upheld the complaint.