Tower Hamlets GP Care Group CIC

6. Mrs K complains about regarding the care provided to her daughter Miss K from the Group on 3 October 2023.

7. Mrs K says that Miss K was turned away from A&E at Royal London Hospital Urgent Treatment Centre (UTC) wrongly when she attended with symptoms of extreme pain and abdominal distention. She says staff mis-recorded Miss K’s pain levels and abdominal swelling due to her appearance as a trans-woman. She says staff made misogynistic and transphobic comments, and when Miss K expressed her unhappiness at not being admitted to hospital, she was wrongly directed back to join the A&E queue instead of being referred to a specialist or for more tests as she was a kidney transplant patient.

8. Mrs K says the mismanagement of Miss K’s attendance forced her to seek treatment elsewhere and she ended up travelling another part of the country where she was admitted to hospital immediately, placed on morphine and diagnosed with Burkitt’s Lymphoma. She says this resulted in a 36-hour delay in treatment, which caused her avoidable suffering and resulted in her death 4 weeks later due to the delay in diagnosis and treatment, and Miss K not being seen at a hospital familiar with her with access to her records, and with less resources

9. Mrs K seeks acceptance of failings, service improvements and a financial remedy.

10. Miss K was a trans woman who was transitioning from male to female gender. She had been under specialists at Royal London Hospital since 2017 as a transplant patient. Mrs K informs us Miss K became ill with kidney dysfunction in October 2021 and had recently been seeing her GP for the past 2 weeks for abdominal pains and bloating. This had been treated by the GP with laxatives as suspected faecal impaction. Mrs K says Miss K’s GP had made a referral to her kidney consultant a week prior and had said they would chase up if no response was received within 10 days.

11. On 30 September 2023, prior to the day in question, Miss K had attended the ED at Royal London Hospital seeking help for abdominal pain but had left before being reviewed due to long waiting times. A follow up phone call established she had taken Movicol laxatives and she been advised to wait to see if this helped and seek medical attention if this did not resolve the problem.

12. On 3 October 2023, Miss K attended A&E again seeking admission to hospital. She was initially triaged and referred to the UTC to see a GP. Following an assessment and examination the GP advised they were unable to admit her to hospital due to not finding any clinical reason to justify admission. Miss K was unhappy, and the GP advised they were unable to help further but she was entitled to seek a second opinion by waiting to see another GP in the UTC or return to the ED to be seen there.

13. Miss K left the hospital, and the next day sought help from Mrs K to travel to the area where her family is from. She attended New Cross Hospital ED approximately 36 hours later, where she was diagnosed with severe ascites (fluid in the abdomen caused by her cancer), and admitted to hospital.

14. She was diagnosed with Burkitt’s Lymphoma (a rare and aggressive form of cancer that can affect immune suppressed individuals, such as transplant patients). Miss K later died from this on 31 October 2023.

19. The Group has accepted some failings, which it has apologised for and made service improvements to address. Mrs K agrees with these failings, if not the overall impact of them. As a starting point, it is useful to set these out initially.

20. The Group accepts that Miss K met local exclusion criteria guidance for referral to the UTC, and that her medical history should have been better considered by the ED. As a transplant patient, Miss K should not have been referred to a GP in the UTC to be assessed. The ED should have recognised her medical history as a transplant patient, that this made her a complex case and unsuitable for the UTC, and she should have been assessed in the main ED at Royal London Hospital. It does not agree that Miss K was improperly assessed or that the seriousness of her condition was disregarded.

21. The Group also accepts that Miss K should have been better informed about the UTC service at the time, and that some of the language used by clinicians and in its initial response had been insensitive to transgender persons. The Group apologised for the offense and upset these caused. It set out reassurances that this was unintentional on the part of the individuals involved. It outlined the measures that had been put in place to educate and retrain staff on gender identity issues and use of appropriate language.

22. While the Group has acknowledged the emotional impact of this, it did not accept that Miss K received a poorer standard of care because of transphobia or misogyny, or that the accepted failings resulted in Miss K suffering the injustices claimed. We therefore considered if there are indications the established failings linked to those claims.

23. Specifically, Mrs K says Miss K was forced to seek medical attention elsewhere and travel to another part of the country in pain and distress to access care. She also says this resulted in a lesser standard of care as Miss K’s her transplant specialists were at Royal London Hospital, where she was known, and which was better resourced to manage patients with her health needs than the hospital she went to later.

24. Having considered the complaint, we cannot link the events complained about with the negative impact Mrs K has claimed. It would be difficult to conclude the Group has not already done enough to put right the impact of these events if there is no evidence linking the failings to the serious impacts claimed. To help us come to this view we asked our adviser to comment on the care provided.

25. Our adviser said there is no obvious national guidance they could find related to Emergency Department management of a transplant patient. Usual practice would be to manage the symptoms a transplant patient has presented, with bearing in mind that they are potentially immune suppressed (transplant patients are on regular medication to prevent organ rejection). They said it would be normal practice to also liaise with the transplant surgery team if there are any concerns.

26. This would be in line with GMC guidance on Good Medical Practice (Domain 1 - 16d) which says, ‘in providing clinical care you must…consult colleagues where appropriate’.

27. Our adviser noted the Group already acknowledged that Miss K should not have been streamed to the UTC GP service in line with its local procedure. They said that, if there was an abnormality detected on investigations, this would have led to earlier initiation of treatment.

28. In the absence of any applicable national guidance apart from the GMC ethical guidance, this means we need to establish if the assessing clinician had (or should have had) any concerns due to finding abnormalities which should have prompted further action.

29. The GP’s physical examination documented a soft abdomen with no tenderness, guarding or distension. These are findings that suggest a normal appearing abdominal examination. Miss K was recorded as reporting a pain level of 3 out of 10 and her physiological observations were all within normal range and showing no physical sign to indicate a high level of pain was affecting these. A urine dipstick test also did not detect any abnormality in Miss K’s urine sample.

30. Mrs K says the GP mis-recorded pain levels and abdominal swelling. She says Miss K was in extreme pain and her abdomen greatly distended. This is not what the GP’s account, or what is recorded in the medical records, supports. Unfortunately, Mrs K’s only supporting evidence is her account of what Miss K told her later and medical information about Miss K’s condition upon admission to hospital later. While the latter establishes how ill she was later, it does not rule out the possibility that this was not apparent when she attended the ED on 3 October 2023.

31. We understand why Mrs K may feel the GP’s assessment was affected by subconscious transphobia or misogyny. The indications are the GP’s decisions were guided by the objective clinical information collected at the time, consisting of physical examinations and measurable physiological observations.

32. On balance of probability, we think the consultation would have resulted in the same outcome regardless of the patient’s identity in the absence of any abnormal clinical signs (which was the case). We therefore cannot say the GP did not act in line with GMC guidance because there were no abnormal clinical findings to raise suspicion.

33. Based on the clinical information available to the GP, we are unable to find any indication there was an abnormality prompting the need for greater concern and liaison with colleagues. On balance of probability, we cannot say the advice provided by the GP was inappropriate. In the event of normal physical signs, it is not unreasonable for a clinician to say they could not admit a patient to hospital.

34. Providing advice on diet was also consistent with Miss K’s local GP recent approach of treating her for suspected faecal impaction and the lack of any medical history indicating any prior concern about Miss K suffering from cancer.

35. Miss K was unhappy with this advice and the GP’s unwillingness to admit her on the information they had available. She (correctly) was concerned there was some more serious underlying condition affecting her and challenged the GP’s decision and advice. This does not necessarily mean the GP failed to assess correctly as they had to make decisions with very limited information.

36. We also took into account that Miss K attended the ED several days earlier with the same presentation. While she left before being seen in person, she was contacted and reviewed by a Senior from the ED. The ED advice provided on that day was not significantly different from the GP advice on 3 October 2023.

37. The Patient’s Association advice on Getting a Second Opinion says, ‘The NHS encourages patients to seek second opinions if they have any doubts or concerns about their diagnosis or treatment.’ This would be in line with GMC guidance on Good Medical Practice (Domain 1 - 16) which says, ‘in providing clinical care you must… respect the patient’s right to seek a second opinion’.

38. Disagreements with doctors do occur and patients are entitled to question clinical decisions and seek a second opinion. The correct thing to do in this situation would be to respect Miss K’s right to seek a second opinion and offer her that second opinion. We see this is what the GP did by offering to arrange for Miss K to be examined by another GP in the UTC, or for her to return to the ED and wait to be seen there.

39. While we accept that Miss K was upset and decided to leave, directing her for an initial assessment in the UTC resulted in a delay rather than a refusal to investigate her illness further. Potentially the UTC was able to offer an initial assessment sooner than the main ED could. EDs usually place high priority on acute emergencies over patients who are not at risk of imminent death.

40. We are unable to see how Miss K feeling she had been discriminated against by an individual would prevent her seeking an alternative view from someone else. We cannot say she was denied the opportunity to access the care she needed, or that she had to travel elsewhere to receive the correct care.

41. Miss K had the option of returning to the ED or to be seen by a different GP in the UTC on that day. She could also have contacted her community GP again (as it was just past midday on a Tuesday) or return to the ED later. Her local GP had also already made a referral to the transplant team at Royal London Hospital, which was pending.

42. We recognise Burkitt’s Lymphoma is an aggressive form of cancer, and Mrs K is correct in saying swift intervention can greatly increase rates of survival. Miss K died weeks later so a delay of just over a day does not appear likely to have significant influence on the overall outcome. Also, due to the number of options available, we cannot say the 36-hour delay claimed was unavoidably due to the Group’s failings. There is no indication Miss K had no other choice but to take the course of action she did by travelling to another part of the country.

43. We also took into account the fact that Mrs K also has made us aware of complaints about Miss K’s wider care. She says between October 2021 to 3 October 2023 she suspects her daughter first developed her cancer and opportunities were missed to detect it earlier. She also says her daughter’s care after 3 October 2023 was of a poor standard and this plus delays in treatment resulted in Miss K not surviving her cancer and dying on 31 October.

44. On balance of probability these concerns would have much more influence on the outcome for Miss K than the relatively brief interaction in the UTC on 3 October 2022 considered under this complaint.

45. This leaves us to consider if the Group has done enough to put matters right. As we do not see indications of failings that led to a worse outcome for Miss K, the Group appears to have correctly recognised the severity of the injustice caused. This was the emotional impact of the upset caused by her experience on 3 October 2023, and to Mrs K in the course of the handling of her complaint.

46. The NHS Complaints Standards say organisations should openly identify instances when things have gone wrong, or where services have had an unfair impact, and take responsibility for these. They make sure staff can offer a range of ways to put things right for the individual. Staff should also look at what action will be taken to learn from the experience to continuously improve services and help support staff.

47. We consider that by acknowledging the failings in sending Miss K to the UTC and in the use of language causing offense, apologising for this and providing detailed of the service improvements and training put in place to prevent future occurrences, the Group acted in line with the Complaint Standards and has taken proportionate action to put right the impact caused by its error in communication.

48. We are glad to see that it recognised this poor service in its complaint investigation and took appropriate steps to put right the frustration and distress caused. With this in mind, we will take no further action.

49. We understand this complaint is very important to Mrs K and we thank her for sharing her concerns with us.

1. We have carefully considered Mrs K’s complaint about Tower Hamlets GP Care Group CIC (the Group). We have decided we cannot link the events complained about to the impact claimed.

2. Mrs K’s central concern is that her daughter, Miss K’s death was avoidable if not for failings in the consultation she had after attending the Emergency Department (ED) in October 2023. While we agree there were failings (in relation to triaging Miss K to be assessed by a GP first instead of in the main ED, and insensitive use of language), the indications are these had minimal impact on Miss K’s overall outcome.

3. The Group looks to have accepted the failings fully and taken proportionate action to put right the emotional impact caused. The key disagreement is on whether the full impact has been addressed.

4. We have decided enough has already done enough to put right the impact of these events on Mrs K. While it is not ideal to have caused further upset with poor communication with the patient and in its responses to the complaint, we have seen no indication this has a wider material impact relating to Miss K’s later death.

5. We were saddened to learn of Miss K, and her mother, Mrs K’s experiences and have carefully considered Mrs K’s concerns as we appreciate how traumatic the events surrounding her daughter’s final months were for her.