Tests 13. Miss T told us the Practice did not ensure her father, Mr H had a blood test to rule out myeloma. She has told us he attended the Practice in February 2020 following a fall at the gym and the Practice referred him for an X-ray which he had on 19 February. She says he was not told he had been referred for a blood test, so this was missed and not followed up by the Practice until he attended with further symptoms on 16 November. She said the blood test delay resulted in a delay in a referral to haematology and in her father’s myeloma diagnosis. We were sorry to hear that Mr H sadly died in March 2021.
14. NICE guidance on suspected multiple myeloma says if urgent admission is not indicated and for people aged 60 years or older with persistent bone pain, particularly back pain, or unexplained fracture offer investigations including a full blood count.
15. We have seen evidence Mr H attended the Practice on 18 February. At this appointment the GP referred him for an X-ray with the results of a mild fracture and general wear and tear changes discussed on 20 February with his daughter, Miss T. During this discussion, Miss T reported her father was feeling better with painkillers, so the plan was to check myeloma screen and full blood count and to review if pain persisted.
16. Our clinical adviser explained there were no red flag symptoms at this stage and in line with NICE guidance a myeloma screen was not necessary as Mr H’s fracture and back pain was not unexplained. In addition, the symptoms appeared to have been improving.
17. We therefore consider the GP considered additional action to the guidelines in advising they would request a myeloma screen at this point. The blood test did not go ahead as there appears to have been confusion regarding the plan of care between the Practice and Miss T and the tests were never arranged.
18. Mr H did not return then to the Practice until 16 November as he had started to lose weight and his appetite. At this appointment, due to these new red flag symptoms, the GP arranged urgent bloods and a referral to haematology on a two-week pathway (this referral is to investigate symptoms and find out what is wrong and if it could be cancer). We have seen evidence Mr H had an appointment in January 2021 with the haematology service where he was given a working diagnosis of LgG Mgus, an abnormal protein in the blood which has a low risk of blood cancer.
19. We therefore consider that although the blood test arranged in February did not go ahead, there was no symptoms to indicate that this was needed at the time in line with the NICE guidelines. We were pleased to see the blood test did go ahead in November when Mr H presented with further symptoms to indicate this was needed and this led to a referral to haematology.
20. We hope our explanations have reassured Miss T that the delay in blood tests did not result in a delay in her father receiving a cancer diagnosis and we will therefore not take further action on this part of the complaint.
Referral 21. Miss T complains the Practice did not make a timely cancer referral for her father in 2020 and mismanaged it when it was made. Miss T has told us the Practice should have completed a 2-week pathway referral for her father following his fall in February but that this was delayed until his symptoms worsened in November. She also says once the referral was completed it was not actioned correctly as it took over the two weeks for her father to be seen by a haematologist as he was not seen until January 2021.
22. NICE guidance on suspected cancer recognition and referral, says often referred to as ‘red flags’, there are several signs or symptoms for each specific cancer which should lead to a GP referral on a two-week pathway.
23. We have seen evidence in the medical records, when Mr H attended the Practice on 18 February 2020, this was due to a fall and when the Practice discussed the results of the recommended X-ray on 20 February with Miss T. The results were mild fracture and general wear and tear changes. During this discussion, Miss T reported her father was feeling better with painkillers, so the plan was to check myeloma screen and full blood count and to review if pain persisted.
24. Our clinical adviser explained there were no red flag symptoms at this stage and as explained above a myeloma screen was not necessary as Mr H’s fracture and back pain was not unexplained.
25. In line with NICE guidance, it appears there were no red flags at this appointment that would require the Practice to refer Mr H on a two-week pathway to haematology to investigate for myeloma.
26. We have seen evidence in the medical records, Mr H did not return to the Practice until 16 November as he had begun experiencing additional symptoms to his back pain including loss of appetite and weight loss.
27. At this appointment, the Practice referred Mr H for urgent blood tests and completed a two week wait referral to haematology due to his presenting red flag symptoms. We have seen in the medical records, Mr H did not receive a haematology appointment until January 2021 which was outside of the two-week wait time for this type of referral. However, the actions relating to this were outside of the Practice’s control as the appointment and the timing of this was managed by the haematology team at another NHS organisation.
28. Therefore, we consider the Practices’ actions in relation to a two-week wait referral for Mr H was managed in line with NICE guidance in both February and November 2020 and we will not take further action on this part of the complaint.
Diagnosis 29. Miss T complains the Practice diagnosed her father with obstructive sleep apnoea (OSA) without appropriate investigations.
30. She says the first she knew of this diagnosis was following a subject access request after her father’s death when she reviewed his medical records in 2023. She says this diagnosis is incorrect as no investigations took place to confirm this.
31. GMC guidance says a practitioner must make sure any other records you are responsible for, including financial, management or human resources records, or records relating to complaints, are kept securely and are clear, accurate and up to date.
32. We have seen evidence in the records that this diagnosis was put on Mr H’s medical notes in 2009 following a consultation on 13 July.
33. In its final response, the Practice has explained this diagnosis was noted without further tests or referral as Mr H was not keen on exploring this further or in the only treatment available for OSA which is a continuous positive airway pressure (CPAP) machine you wear at night. It went on to say the Doctor involved had since left the Practice and the Practice itself has had a system change.
34. Our clinical adviser has explained that in 2009, prior to system changes in the UK, there was no option to input free text to a coded diagnosis to advise if it was suspected or it had been made without further tests.
35. Therefore, we consider the Practice acted in line with GMC guidance when noting Mr H’s symptoms and risk factors as they were suggestive of OSA, but it was not able to confirm it due to Mr H declining further tests or treatment. We will not take further action on this part of the complaint.
Communication Miss T says the Practice did not manage her subject access requests for her father’s medical records correctly when she requested them in September 2021. She says specifically it told her the records had been transferred to Primary Care Support England (PCSE) as her father had died and that requests should be completed through them. Miss T says when she contacted the PCSE she was informed that this was not the case and shortly after received her father’s medical records from the Practice.
36. The Practice told us that as Mr H was deceased at the time Miss T requested his medical records, the request was managed under its access to deceased patient’s medical records policy.
37. The policy says where the patient has died, the patient’s personal representative or any person who may have a claim arising out of the patient’s death may take an application. It also says after a person has died; their GP health records will be passed to PCSE so they can be stored. To access the GP records, patients should apply to the records manager in the relevant local area.
38. We have seen evidence when Miss T requested her father’s medical records, the Practice advised her to contact PCSE in line with its policy. We understand that she was directed back to the Practice, as her request was for electronic copies which the Practice were able to manage.
39. There appears to be some confusion as to what medical records the Practice was able to provide at the time of the request which we recognise would have added to the impact Miss T has told us about. She has told us the issues she had accessing her father’s medical records added to the distress she was already feeling and impacted the separate legal claim she had.
40. We were pleased to see that when Miss T returned to the Practice it actioned her request in a timely manner with her receiving the medical records on 19 October.
41. The Practice has apologised to Miss T for the confusion in its communication and has reflected on how this could be improved on in the future.
42. Our Principles say that to put things right organisations should provide an apology, explanation, and an acknowledgement of responsibility, as well as remedial action.
43. We are satisfied that the actions of the Practice in providing an apology to Miss T and in reflecting on its communication skills to ensure future good practice, are in line with the above Ombudsman’s Principles for putting things right. We will therefore not take further action on this part of the complaint.
Complaint Handling 44. Miss T says the Practice did not manage her complaint correctly as there were significant delays. Rate
45. Our Principles of good complaint handling say wherever possible, staff should:
• explain why things went wrong and identify suitable ways to put things right for people when mistakes have occurred • ensure the apologies and explanations they give are meaningful, sincere, and openly reflect what impact the mistake has had • take human factors into account, and ensure any learning is acted upon • use any learning to support staff complained about.
46. We have seen evidence Miss T raised her concerns about her father’s care with the care quality commission (CQC) in October 2021 after she had received her father’s medical records. The CQC then contacted the Practice in November for a response to the issues raised. We have seen the Practice responded to the CQC on 14 December as per its request, but a copy of the response was not sent to Miss T until June 2022.
47. We have seen there was then communication between Miss T and the Practice in the months following due to her having further questions and concerns which it appears to have answered fully and promptly.
48. We therefore consider the only delay in the complaints process to be that of the six months between the final response being sent to the CQC and Miss T receiving a copy which appears to be a delay with the CQC process rather than the Practice itself.
49. We consider the Practice acted in line with our Principles in that it has responded to the CQC and then Miss T’s additional concerns in a timely manner with responses which reflected on the complaint and gave a meaningful response.
50. It is understandable from what Miss T has told us that she felt let down by the Practice in relation to her father’s care and treatment. This has clearly been a very difficult for Miss T and her family who continue to grieve for her father.
51. We hope that our explanations and our adviser’s expertise have given her reassurance that the Practice did not do anything seriously wrong in relation to her father’s care. We are also satisfied the Practice acknowledging and apologising for her experience as well as reflecting on its practice are enough to put right any additional distress this caused for the family.