The Practice’s investigation into Mr P’s deterioration
20. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we cannot link the events complained about with the negative impact Mrs P has claimed.
21. Mrs P complains the Practice failed to listen to her concerns and respond to Mr P’s deterioration in health.
22. The Practice said in its response that Mr P’s presenting complaint was a late manifestation of metastatic disease which the GP did consider and arrange blood tests for. The Practice did acknowledge its poor record keeping of the home visit on 13 March 2024.
23. We have considered how the Practice responded to Mr P’s deterioration and whether it should have done anything differently. We have also considered if we can link this to Mr P’s death.
24. Mr P had a fall in January 2024 and was being seen in the Practice for this. On 15 January 2024, the Practice prescribed naproxen due to Mr P’s ongoing shoulder pain after his fall.
25. On 12 February 2024, the Practice had a telephone consultation with Mr P and his wife. He complained of the pain keeping him up at night, weight loss, loss of appetite and night sweats. The Practice advised him to continue with pain relief and it ordered urgent blood tests.
26. Mr P’s blood tests came back on 14 February 2024 and were reported as borderline. The records state he had a raised ESR (erythrocyte sedimentation rate, used to detect inflammation in the body), with inflammation or abnormal renal function being the likely cause.
27. On 28 February 2024, he had a face-to-face appointment at the Practice. The Practice planned to check his bloods again in four weeks’ time. The Practice also prescribed further naproxen.
28. On 13 March 2024, the Practice arranged a visit at home. The GP did not document the visit. In the complaint response, it said the GP recalled Mr P having increased pain and difficulty swallowing. They said his observations were normal and his chest was clear. The GP felt he needed bloods and imaging or endoscopy.
29. On 15 March 2024, he had difficulty swallowing, confusion and was unwell. He was passing black liquid. Ms P spoke to the Practice who advised her to take Mr P to A&E.
30. Our adviser said ESR levels are tested to detect any inflammation in the body. They said there is no national guidance for what to do with a raised ESR level alone, but it should be considered in line with his symptoms.
31. Section 7 of the GMC guidance says in providing clinical care doctors must carry out a physical examination where necessary.
32. Section 1.13.2 and 1.13.3 of the NICE cancer guidelines says for people with unexplained weight loss and appetite loss, carry out an assessment for additional symptoms, signs, or findings that help to clarify which cancer is most likely and offer urgent investigation or a suspected cancer pathway referral.
33. Our adviser said Mr P had concerning symptoms on 12 February 2024, including weight loss and loss of appetite. In line with the GMC guidelines, and the NICE cancer guidelines, Mr P should have been invited in for a physical examination. Our adviser said there is a lack of information in the records about his weight and weight loss at this consultation, and there were inadequate investigations into his symptoms at this consultation.
34. On 28 February 2024, he had a face-to-face appointment. There was no examination recorded, and his weight was not taken. Our adviser said there was a lack of information gained at this appointment. We consider the Practice did not act in line with the GMC guidelines by carrying out a physical examination.
35. Mr P reported weight loss at both appointments. In line with the NICE cancer guidelines, the Practice should have examined him and offered further investigation into his symptoms. Our adviser said considering his symptoms, in line with the NICE cancer guidelines, he should have been sent for urgent investigations or put on the two-week referral pathway for suspected cancer.
36. Section 70 of the GMC guidance outlines how a clinician should record information. It says they should take a proportionate approach to the level of detail, but patients’ records should usually include:
a.)relevant clinical findings b.)drugs, investigations or treatments proposed, provided or prescribed c.)the information shared with patients d.)concerns or preferences expressed by the patient that might be relevant to their ongoing care, and whether these were addressed e.)information about any reasonable adjustments and communication support preferences f.)decisions made, actions agreed (including decisions to take no action) and when/whether decisions should be reviewed g.)who is creating the record and when.
37. On 13 March 2024, Mr P had a home visit from a GP at the Practice. The GP did not make any notes of the appointment. This is not in line with the GMC guidelines. The GP should have made note of the investigations they did into Mr P’ symptoms. Mrs P said the GP was unable to get an oxygen reading at this appointment.
38. Our adviser has been unable to say whether anything further should have been done at this appointment as there is no record of his presentation, or the GP’s findings and plan. Our adviser did say it is likely he would have had concerning symptoms considering his admission to hospital two days later.
39. We have seen an indication of failings by the Practice, it missed two opportunities on 12 February and 28 February to appropriately examine Mr P and offer further investigation into his symptoms. In line with the NICE cancer guidelines, he should have been sent for urgent investigations or put on the two-week referral pathway for suspected cancer. We have also seen a failure by the Practice to record the at home visit on 13 March 2024.
40. We have to consider if the injustice claimed by Mrs P occurred in consequence of the failings we have seen. In doing so, we have been unable to establish Mr P’s deterioration was due to the Practice’s failure to investigate his symptoms appropriately.
41. Our adviser said if he was referred to hospital in February 2024, by the time he was referred, had investigations, and received the results of these, he would likely have already been admitted to hospital as he was on 15 March 2024 or a few days previously. Our adviser said this is a very short window of time, and we are not able to say this would have made any difference to his outcome as he was admitted to hospital soon after these appointments.
42. Our adviser said based on Mr P’s presentation in February 2024, he did not have significant symptoms that would require a hospital admission. The missed window of opportunity was a matter of days, and therefore it is very unlikely that Mr P would have received any different treatment.
43. We are unable to say what should have happened on 13 March 2024, but we do not think this is likely to have made a difference to Mr P overall outcome. We do not think Mr P would have likely been advised to go to hospital had notes been taken, as based on Mrs P’s recollection of events, he did not have the symptoms of black stool and hallucinations which are the symptoms he reported on 15 March 2024 which resulted in the Practice’s advice to go to hospital. We also think it is unlikely that Mr P missed an opportunity for a better outcome considering he was admitted to hospital two days later and his condition was very progressed.
44. We are very sorry Mr P died suddenly, and we recognise how upsetting this is for Mrs P. We also recognise Mrs P’s concerns about the Practice, and we do think that it did not respond to his deterioration appropriately, and further investigations should have been done.
45. We are very sorry this did not happen. We have not been able to link this to Mrs P’s claimed impact, that Mr P missed an opportunity for treatment or more time. We have not seen evidence that Mr P would have had a different outcome had he been referred to hospital earlier. We think it is unlikely that anything would have changed in this short window of time. Therefore, we are not going to investigate this complaint any further.
Prescribing naproxen
46. Mrs P complains the Practice prescribed further naproxen on 28 February 2024 without performing further blood tests.
47. The Practice said in its response it was unable to predict Mr P would suffer gastric bleeding.
48. On 15 January 2024, the Practice prescribed naproxen due to Mr P’s ongoing shoulder pain after his fall.
49. The Practice requested Mr P have urgent bloods during a telephone consultation on 12 February 2024. These came back on 14 February 2024.
50. On 28 February 2024, the Practice prescribed further naproxen and requested blood tests for four weeks’ time.
51. The NICE CKS on naproxen says for people with an estimated glomerular filtration rate (eGFR) less than 30ml, naproxen should be avoided. Mr P’s eGFR was 84mL on 14 February 2024.
52. The NICE CKS on naproxen says a risk factor for a gastrointestinal adverse event includes being over the age of 65. This meant Mr P was at moderate risk of a gastrointestinal adverse event. It says to manage people who are at moderate or high risk, or people who are elderly, co-prescribe a proton pump inhibitor (PPI) with the naproxen.
53. Our adviser said naproxen is prescribed for pain management. Mr P was reporting muscular pain on 28 February 2024 and prescribing this was appropriate. Our adviser said the Practice appropriately prescribed it alongside a PPI which reduces the risk of gastrointestinal complications which is in line with the NICE CKS.
54. The NICE CKS says for people at high risk of gastrointestinal adverse events, to monitor haemoglobin levels one to four weeks after the treatment has started. Although Mr P was moderate risk, the Practice did blood tests on 12 February which is within four weeks of him starting naproxen on 15 January 2024. The haemoglobin levels came back normal. There is no requirement in the NICE CKS for the Practice to have arranged further blood tests.
55. We understand Mrs P’s concerns about the Practice prescribing further naproxen, as Mr P sadly went on to experience gastrointestinal bleeding. We are sorry Mrs P feels this could have been avoided. We have seen evidence the Practice acted in line with the CKS guidelines by prescribing the naproxen alongside a PPI and had recently reviewed blood tests. We do not think the Practice missed an opportunity to prevent what happened to Mr P. Therefore, we are not going to investigate this complaint any further.