A practice in the West Suffolk area

4. Mr B complains about the care and treatment provided to his late wife, Mrs B, by the Practice between March 2022 and June 2022. Specifically, he says the Practice:

• failed to refer Mrs B for an X-ray in March 2022 • misdiagnosed Mrs B a number of times between May 2022 and June 2022 with a cyst, gastroesophageal reflux disease, neuralgia, and bowel cancer • failed to accurately record information regarding the above diagnoses • provided an inaccurate response to his complaint in November 2022.

5. Mr B says the failure to refer Mrs B for an X-ray meant she missed an opportunity for an earlier diagnosis and subsequently missed an opportunity to start treatment sooner than she did.

6. As an outcome to his complaint, Mr B would like an acknowledgement of failings.

7. In March 2022, Mrs B had a telephone consultation with the Practice followed by a face-to-face appointment. During this appointment, she reported appetite loss, weight loss, chest pain and breathing difficulties. The Practice conducted a faecal immunochemical test (FIT) (a test used for bowel cancer screening by looking for blood in a sample of a patient’s stool) to look for blood in Mrs B’s stool sample and assess for bowel cancer. The results showed some abnormality which was likely due to straining. The Practice conducted a second test which came back normal.

8. Mrs B attended the Practice again in May 2022. Mrs B suggested her pain may have been a return of polymyalgia rheumatica, an inflammation causing pain and stiffness in the shoulders, hips and other large muscle groups. She also presented with a lump on her neck which was diagnosed as a cyst. Mrs B was prescribed steroids. Mr B said this did not resolve the pain and as such the medication was stopped six days later.

9. Mrs B returned to the Practice nine days later as her symptoms were not resolved. At this point she was diagnosed with gastro-oesophageal reflux disease (GORD). GORD is a condition where acid from the stomach leaks up into the oesophagus (gullet). The Practice prescribed Amitriptyline, a medicine to treat nerve pain.

10. The next day, Mrs B was diagnosed with terminal neuralgia. Terminal neuralgia is sudden, severe facial pain often described as a sharp shooting pain or like having an electric shock in the jaw, teeth or gums.

11. In June 2022, Mrs B’s lump was examined again, and she was referred for an X-ray. This took place the same month. A computerised tomography (CT) scan was arranged and completed in July 2022. A CT scan is a type of imaging that uses X-ray techniques to create detailed images of the body.

12. Sadly, this scan confirmed Mrs B had widespread cancer. Mrs B died one week later.

13. Mr B complained to the Practice in October 2022. The Practice responded six weeks later. The response directed Mr B to us if he remained unhappy.

16. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is good reason the complainant could not complain earlier.

17. We consider Mr B became aware there were problems with Mrs B’s diagnosis and the potential for an earlier X-ray referral in July 2022. This is because while Mr and Mrs B had questioned the diagnoses at earlier appointments, the cancer diagnosis was only confirmed following Mrs B’s CT scan in July 2022. At this point, they would have become aware the Practice’s earlier investigations and diagnoses did not find Mrs B’s cancer.

18. We consider Mr B became aware of inaccuracies in his wife’s medical records and in the Practice’s response to his complaint in November 2022. This is because Mr B could only be aware of this when the Practice provided the details within its response and he reviewed it.

19. Mr B complained to us in July 2025. Based on the latest date we saw he was aware of the issues he has raised with us, Mr B complained to us one year and seven months outside of our time limit.

20. In considering whether we should set aside our time limit, we considered what happened in the period from November 2022 until he complained to us. We saw, in its response in November 2022, the Practice told Mr B to approach us if he was dissatisfied with the outcome of its investigation.

21. We asked Mr B why he did not raise his complaint with us until July 2025. Mr B explained:

• he approached a solicitor in January 2023, who advised they could not take on his case • he then asked the Practice for his wife’s care records in February 2023, but the Practice did not send them to him until June 2023 • he then spent time reviewing his wife’s records, including meeting with an oncologist (a cancer specialist) about her care and did not complete his review until November 2024 • he sent the Practice his review in November 2024, and it did not reply to him until January 2025 • he complained again to the Practice in February 2025, and it did not reply again until June 2025.

22. We asked Mr B why he needed to review his wife’s records before approaching us. Mr B explained he needed to carry out a full appraisal of the records to identify what he thinks the Practice did wrong.

23. We can see in November 2022, Mr B was unhappy with the Practice’s response and actively took steps on his complaint. We can also the Practice directed Mr B to us at this time. Mr B did not contact us to complain until April 2025, one year and five months outside of our time limit.

24. While we understand why Mr B would want to analyse his wife’s medical records, we would not expect complainants to carry out this level of analysis before raising a complaint with us. As Mr B was taking steps to progress his complaint, we cannot see a reason preventing him from complaining to us when he received the Practice’s original response in 2022. Instead Mr B chose to do his own investigations and pursue other resolution routes, and not to contact us until 2025.

25. This means we would have expected Mr B to complain to us sooner, and we cannot see good reasons to set aside our time limit and consider Mr B’s complaint further.

26. We recognise this outcome is likely to be disappointing for Mr B given the ongoing concerns he has. We hope we have cleared explain the reason for our decision.

1. We have carefully considered Mr B’s complaint about the Practice. We were sorry to hear how Mr B and his partner, Mrs B, were affected by the concerns he has raised. It is clear they experienced a difficult time.

2. After considering the information provided by Mr B, we have decided his complaint falls outside of our time limit and we have not identified any exceptional circumstances that would allow us to put this to one side.

3. We will explain the reasons for our decision in this statement. Complaints give us valuable insight into the organisations we investigate, so we would like to thank Mr B for sharing his experience with us. It is important to acknowledge that although we are unable to look at the concerns he has raised, this does not detract from the experience he and his wife had.