14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the standard of care has fallen below what we would expect to see, in accordance with the relevant guidelines. We do this by comparing what should have happened with what did happen.
15. If we do identify a failing, then we look to see if an injustice and impact ‘flows’ from the failing that we can link and next what the organisation has done to correct matters or ‘remedy’. If we consider the remedy to be insufficient, we may recommend more to be done. When we consider remedy, we account for the individual circumstances of a complaint and apply a fair, reasonable and proportionate approach.
16. Mrs L complains that during her appointment on 24 April 2024, the Advanced Nurse Practitioner dismissed her symptoms as viral without providing an adequate examination of her or seriously considering the possibility of cancer, delaying her diagnosis.
17. The relevant guidance here is NICE guideline NG12, which states that healthcare professionals should consider an urgent referral for suspected cancer if an adult presents with unexplained lymphadenopathy (swollen lymph nodes with no clear cause), particularly when associated with additional symptoms such as fever, night sweats, shortness of breath, pruritus (itchy skin), or weight loss.
18. Additionally, the GMC guide to Good Medical Practice requires clinicians to provide good standards of practice and care, including appropriate patient assessments and referrals when necessary.
19. We can see from the records that Mrs L first contacted the Practice on 22 April 2024. During her telephone appointment, she reported lumps in her neck and flu-like symptoms. Given these symptoms, the Practice arranged to see her via a face-to-face appointment for further assessment, this is in line with the GMC guidance of adequately assessing patient condition by asking the Mrs L to attend the Practice to assess her further.
20. The records state Mrs L said she was unavailable on the afternoon of 22 April 2024, so the face-to-face appointment was arranged for 24 April 2024.
21. During the face-to-face appointment with the ANP on 24 April 2024, Mrs L reported symptoms of swelling in her neck lasting two days, accompanied by fatigue and a cough. The clinical records documented at the time confirm that a physical examination took place where the ANP checked Mrs L’s blood pressure, temperature (36.5°C), heart rate (88 beats per minute), and oxygen saturation (99%).
22. The ANP assessed Mrs L’s neck and noted cervical lymph node swelling, although detailed characteristics such as the size and consistency were not recorded. We asked the independent clinical GP adviser regarding this examination and from that information note a detailed written documentation of lymph node characteristics would have been beneficial, this does not indicate inappropriate clinical judgment or compromise Mrs L’s care.
23. We note the ANP sought to escalate this and then ask advice from a GP, who then recommended taking a watch-and-wait approach and instructed Mrs L to return if her symptoms continued and persisted beyond a three-week time frame. We asked our clinical adviser if the advice provided to Mrs L during this appointment was clinically appropriate and in accordance with relevant guidelines. Our adviser told us that swollen lymph nodes are commonly associated with viral infections and commonly resolve within a three-week time frame. This is consistent with NICE guidance NG12, which advises that unexplained lymph node swelling may not necessarily require urgent referral unless it persists beyond a three-week period or is accompanied by other concerning symptoms such as fever, night sweats, or weight loss.
24. Mrs L returned to the Practice on 4 June 2024 (approximately six weeks later) with significantly worsened symptoms including night sweats, significant bilateral cervical lymph node swelling (enlarged lymph nodes on both sides of the neck), and swollen supraclavicular lymph nodes (swelling above the collarbone).
25. During this appointment, photographs of the lymph node swelling were taken and the GP ordered urgent blood tests which taken at the Practice that morning. The GP also completed the urgent referral documentation.
26. The following morning on 5 June 2024, following receipt of the results from Mrs L’s blood tests, the Practice appropriately referred Mrs L urgently under the two-week wait pathway for suspected cancer, consistent with NICE guidance NG12.
27. Following her referral on 5 June 2024, Mrs L was seen promptly by the head and neck service and underwent biopsies on 16 June 2024. She subsequently received her diagnosis on 24 June 2024 and were pleased to hear that Mrs L has now completed her course of treatment.
28. We understand the considerable distress caused to Mrs L following her diagnosis and subsequent treatment and acknowledge the difficult experience she has been through.
29. After reviewing the information and speaking with our clinical adviser, we consider the approach adopted by the Practice at Mrs Ls appointment on 24 April 2024 was appropriate and consistent with relevant clinical guidelines and standards, that the presenting swelling could have been other matter to and to take a conservative watch and wait approach for three weeks was the correct clinical judgement.
30. NICE guidance NG12 explains that unexplained lymph node swelling usually resolves within three weeks and may not need an urgent referral unless it continues beyond three weeks or is accompanied by other concerning symptoms.
31. In Mrs L’s appointment on 24 April 2024, the ANP sought advice from a GP and advised Mrs L to return if her symptoms worsened or had not resolved within three weeks. This advice is consistent with NICE guidance NG12.
32. After reviewing the records, we have not identified any indications that anything has gone seriously wrong with care and treatment provided to Mrs L and therefore will not be continuing our investigation of this complaint.