A practice in the Lincolnshire area

4. Mr N complains about the care the Practice provided to Mrs N in July 2023. He says Mrs N presented to the Practice on multiple occasions with severe headaches, but the doctors did not take this seriously. He says they did not refer her to hospital for testing. Mr N says his wife was subsequently admitted to hospital where doctors diagnosed her with a brain tumour.

5. Mr N also complains that when his wife arrived home from hospital, a doctor arrived with a Do Not Attempt Resuscitation (DNAR) form despite not knowing what or where the tumour was. Mr N says this was insensitive and caused further upset.

6. Mr N says if the Practice had taken his wife’s condition seriously, she may have been diagnosed sooner. He says this could have meant treatment started before the tumour enlarged. Mr N says due to the delayed diagnosis his wife died nine weeks later leaving him a widower with two young children to bring up.

7. As an outcome to the complaint, Mr N would like service improvements to ensure this does not happen again to anyone else.

8. Mrs N attended a face-to-face appointment at the Practice on 13 July 2023 due to headaches. The GP took her history and examined her. They noted there was some mild sinus tenderness and Mrs N described a pressure feeling in her nose. The GP diagnosed a viral infection leading to a headache. The GP prescribed medication to help with the headache and advised Mrs N to return if she did not improve.

9. Mrs N attended a further appointment on 18 July as her headache was continuing. An advanced nurse practitioner (ANP) saw her, taking her history and examining her. The ANP prescribed Mrs N a course of antibiotics as they suspected a sinus infection and advised she should keep a headache diary. They also advised her to seek urgent review if her symptoms changed or she became unwell.

10. Following this, Mrs N had two telephone appointments with NHS 111, a service which is not the subject of this complaint.

11. Mrs N then had a telephone consultation with another ANP on 24 July. The ANP recorded she had previously been diagnosed with a migraine (although this was incorrect as the previous GP and ANP had not mentioned migraine). The ANP prescribed migraine medication and advised Mrs N to keep a headache diary for four weeks to then review. The ANP again gave advice to return earlier or seek urgent advice if she developed new or worsening symptoms.

12. Mrs N presented to a hospital Accident and Emergency (A&E) department on 25 July, which led to her being diagnosed with a brain tumour. She sadly died on 18 September.

Appointments between 13 July and 24 July 2023

15. We understand that Mr N is very concerned that Mrs N presented to the Practice on several occasions with headaches only to then later be diagnosed with a brain tumour.

16. When we consider 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 something went wrong in the care the Practice provided to Mrs N.

17. The NICE guidance for headaches provides advice to doctors on assessing a person presenting with a headache. This advises that the assessment of a headache should include the exclusion of red flag symptoms which suggest a serious underlying cause requiring a specialist admission or referral.

18. The guidance outlines questions for the clinician to ask, advises to examine the patient, and advises to consider arranging investigations dependent on the likely underlying cause and clinical judgement.

19. It says if there are any red flags or a serious underlying cause of secondary headache, then to arrange specialist admission or referral. A secondary headache is when a clinician suspects the headache is caused by something serious or an underlying condition.

20. The doctors did not document Mrs N had any clear red flags listed in the NICE guidance for headaches at any of her appointments with the Practice.

21. At her first appointment on 13 July 2023, Mrs N presented with a headache. The GP took her history and performed an examination. They also took her observations. They diagnosed her with a suspected viral headache and prescribed pain relief. There were no red flags noted from this assessment and the GP acted in line with the NICE guidance for headaches.

22. Mrs N then had her second appointment on 18 July with an ANP where she reported she had had a migraine for a week and a half. The ANP examined her and checked for red flags, in line with the NICE guidance for headaches. Mrs N reported that she had pressure in her face when bending forward. The ANP decided to try Mrs N on antibiotics in case she had sinusitis. Again, Mrs N had no clear red flag symptoms at this appointment which would warrant a referral or investigations at this point.

23. Mrs N had her third appointment with another ANP on 24 July. The ANP noted she had an ongoing persistent headache varying in severity. The ANP also noted she had previously been diagnosed with a migraine, which was incorrect as she had previously been diagnosed with a viral headache and sinusitis.

24. We recognise the ICB said in its complaint response that a thorough assessment had not been carried out on 24 July and that this may have led to a further investigation or referral. However, in stating this, the ICB has not referred to any relevant national guidelines or standards. We understand from our own review of the evidence available, including input from our GP adviser, there were no clear red flag features which suggested a secondary headache, or which would warrant a referral at this time in line with the NICE guidance for headaches.

25. Taking into account this advice, we have seen no indications anything went wrong at this appointment. We are also reassured that Mrs N attended A&E the following day, meaning she was diagnosed very quickly after that time.

26. The NICE guidance for suspected cancer also says when doctors should suspect a brain tumour. This says doctors should consider an urgent MRI scan of the brain to assess for brain or central nervous system cancer in adults with progressive, subacute loss of central neurological function.

27. Our GP adviser said this would have included symptoms such as loss of sensation or loss of strength in the limbs. We understand from the evidence available and from our adviser that Mrs N did not have any symptoms of progressive, sub-acute loss of central neurological function at any of her appointments with the Practice which would warrant a referral.

28. Taking all the above advice into account, we can see no indications that anything went wrong in the care provided to Mrs N at her appointments with the Practice. We have not seen indications she should have been referred for an MRI scan sooner than she was.

29. We were sorry to hear that Mrs N was subsequently diagnosed with a brain tumour and for the pain this has caused Mr N. In reaching this decision, we are in no way underestimating how difficult this has been for Mr N and his family.

Home visit 30 July

30. Mr N also complains that when his wife arrived home from hospital, a doctor arrived with a DNAR form despite not knowing what or where the tumour was. Mr N says this was insensitive and caused further upset. We were sorry to hear of how upsetting Mr N found this at what was an already incredibly difficult time for him.

31. The GMC guidance says doctors must plan ahead as much as possible to ensure timely access to safe, effective care and continuity in its delivery to meet the patient’s needs. It explains the emotional distress and other pressures inherent in situations in which patients are approaching the end of their life sometimes lead to misunderstandings and conflict between medical professionals and patients and those close to them. It says this can usually be avoided through early, sensitive discussion and planning.

32. In line with this guidance, we would expect doctors to have initiated discussion with Mrs N and her family at the earliest opportunity regarding her preferences for end-of-life care. They also should have done this as sensitively as possible.

33. On 29 August, the medical records show that Mrs N’s sister-in-law rang the Practice and spoke to a doctor, making them aware that Mrs N had deteriorated significantly over the last four days. She advised that Mr N was not coping, and a nurse had advised that Mrs N needed community assessment for fast-track care and a GP review.

34. The GP attended Mrs N’s home on 30 July as requested by Mrs N’s sister-in-law. The GP noted they had briefly discussed the RESPECT form. A RESPECT form creates personalised recommendations for a person’s clinical care and treatment in a future emergency. The GP noted Mrs N was too tired to make any decisions that day, so they left the form at the house for the patient and sister-in-law to talk through.

35. As the GMC guidance notes, it is common for this discussion to lead to conflict and misunderstandings if this matter is not discussed sensitively. As we were not present at the time, we cannot comment on the sensitivity or communication skills of the doctor in this discussion. What we can say is that it was in line with the GMC guidance to discuss this at the time. We have therefore seen no indications of failings in this aspect of the complaint, based on the evidence available to us.

36. We are sorry we are unable to take Mr N’s complaint further and for any upset this causes. We hope our consideration of his complaint provides him with some closure to his concerns.

1. We were sorry to hear of the death of Mr N’s wife, Mrs N. We offer our sincere condolences to Mr N and his family. We were also sorry to hear of the concerns Mr N had about his wife’s care from the Practice leading up to her brain tumour diagnosis. We can see these concerns have been difficult for Mr N to deal with and that they continue to have a profound impact on him.

2. We have carefully considered Mr N’s complaint about the Practice. We have seen no indication that anything went wrong in Mrs N’s care.

3. We hope Mr N is able to take some reassurance from our findings that we have not seen anything to indicate Mrs N could have been diagnosed any sooner. We also recognise he may be disappointed with our findings as we know how strongly he feels about these matters.