A practice in the City of Derby area

3. Miss A complains about the care her mother, Mrs A, received from the GP practice between July and 10 September 2023 when she had a tumour and biopsy wound in her groin area.

4. She specifically says the GP practice did not treat her mother’s wound, recognise the signs of deterioration and risk of bleeding. She also says it did not communicate any concerns to oncology and gynaecology teams at hospital.

5. Mrs A died suddenly from a catastrophic bleed on 10 September. This was traumatic and unexpected for Miss A. She said if she was aware her mother was at high risk of bleeding, she would not have gone on holiday at the time. Her mother was with a carer, friends and neighbours on the day of her death, and Miss A feels upset that her mother was terrified and in pain without her. She felt unprepared for her mother’s end of life, and this has led to her own distress. Miss A believes the NHS let her mother down because she was denied a peaceful death.

6. By making her complaint, Miss A seeks:

• an investigation • accountability • an apology with recognition of the impact • service improvements • financial remedy.

7. Mrs A had a history of vulval cancer which was treated with surgery and radiotherapy in 2022.

8. From May 2023, Mrs A had persistent groin pain and swelling to the area.

9. Mrs A’s GP practice arranged a biopsy, and an oncologist diagnosed a discharging necrotic tumour (where cells had deteriorated within the tumour). Her gynaecology oncologist recommended palliative chemotherapy and referred her to the community district nursing team (DNs) for wound management. The DNs are not part of the GP practice.

10. The area began to bleed extensively on 10 September. Mrs A’s carer called an ambulance, and she sadly died on the same day.

11. The coroner said Mrs A’s death was because of vulval cancer that spread to the groin, with damage to the adjacent blood vessels of the leg resulting in a catastrophic bleeding.

15. Before we decide if we should conduct a detailed investigation of 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.

16. To help us understand what the GP practice should have done, our GP adviser referred us to GMC Good Medical Practice. It says: ‘you [doctor] must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:

• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.’

17. GMC’s Treatment and care towards the end-of-life: good practice in decision making is also relevant. It says, ‘you [doctor] must also give early consideration to the patient’s palliative care needs, and take steps to manage any pain, breathlessness, agitation or other distressing physical or psychological symptoms that they may be experiencing, as well as keeping their nutrition and hydration status under review.’

18. An oncologist saw Mrs A on 25 July 2023 and said Mrs A’s wound was a necrotic tumour and the malodorous smell was from the tumour and not an untreated infection. They said there was no further treatment options for the tumour, and they made referrals to the local community Trust for regular community DNs to visit and manage the wound. The DNs were also seeking advice from a tissue viability nurse (not part of the GP practice).

19. On 29 July, a DN requested the GP practice review Mrs A at home. The GP practice uses a different organisation to provide home visits, the home visiting service.

20. The GP practice therefore requested a home visit via the home visiting service and a doctor from that service saw Mrs A on 1 August. They told the GP practice that odour was present at Mrs A’s wound site and they had prescribed antibiotics. On 8 August a GP from the GP practice spoke to Miss A to explain that the DNs would continue to monitor her mother.

21. The DNs continued to assess the wound throughout August and contacted the GP practice about its deterioration on 29 August. The GP practice wrote to Mrs A’s oncologist the same day to ask for further advice about the deteriorating wound. We consider this was in line with the section of GMC Good Medical Practice as the GP was referring ‘to another practitioner when it serves the patients needs’. It also advised the DNs to seek advice from oncology or gynaecology.

22. The GP practice also arranged for a GP from the home visiting service to see Mrs A on 1 September. The GP from the home visiting service reviewed the photographs taken by the DNs. They shared information with the GP practice who made a request to bring forward Mrs A’s oncology appointment on 15 September so the oncologist could look at the wound and provide specialist advice.

23. In its complaint response, the GP practice said it acted in a timely manner in organising care for Mrs Sailsbury when the DNs escalated concerns. It arranged for a doctor from the home visiting service to see Mrs A at home .

24. We know the oncologist made referrals to the DNs to manage Mrs A’s wound and provide comfort palliative care. Our GP adviser explained it was not necessary for the GP Practice to further examine her wound because the DNs were reporting its condition, and the home visiting service had reviewed photographs. We understand this must have been a worrying time for Miss A and her mother. It appears the GP practice acted in line with GMC guidance by arranging assessments for Mrs A via the home visiting service and acted upon the information the DNs gave. We would not expect it to have taken any further action because Mrs A’s oncologist had requested the DNs to provide day to day care. When the GP practice needed further specialist advice from the gynaecology oncology team, it contacted them for advice and an urgent review.

25. There is no indication the GP practice had an active role in Mrs A’s wound care. It appears the DNs and oncology team at the hospital were managing Mrs A’s overall care relating to her wound management and comfort. We have not seen indicated failings in terms of the role the GP practice had with Mrs A at this time.

26. We understand the upset and distress these concerns have caused Miss A and her family. We are mindful of how important her complaint is to her and the difficult experience she has had. We hope our decision on what happened, can bring some closure to these sad events and care provided by the GP practice.

1. We have carefully considered Miss A’s complaint about a GP practice in Derby (the GP practice). We are sorry to read about the events that led to Miss A’s concerns. We understand this has been and remains to be a very upsetting time. We offer our condolences to Miss A for the loss of her mother.

2. We have decided not to look at this complaint further at detailed investigation. We did not see any indication that anything went wrong in the care provided by the GP practice. It appears it acted in line with guidelines we would expect it to follow. We have explained the reasons for our decision within this statement.