Calderdale and Huddersfield NHS Foundation Trust

4. Mrs B complains between February and May 2024, the Practice failed to consider Mr A had cancer or refer him to a cancer specialist despite his repeated appointments and serious symptoms of breathlessness, pain in his right lung, and significant weight loss.

5. Mrs B said as a result, Mr A’s condition deteriorated, and he sadly died. She said this has caused her significant distress, ongoing grief, and a sense that his life could have been prolonged with timely and appropriate care.

6. To resolve her complaint, Mrs B seeks service improvements and an apology.

7. Mrs B complains the Trust inappropriately discharged Mr A from A&E on 28 May 2024, despite him not being medically fit to leave. She also complains it failed to provide treatment for Mr A’s pneumonia on the same day.

8. Mrs B said as a result, Mr A’s condition deteriorated, and he sadly died. Mrs B specifically says because the Trust did not treat Mr A’s pneumonia promptly it meant he did not get the cancer treatment he needed. She said this has caused her significant distress, ongoing grief, and a sense that his life could have been prolonged with timely and appropriate care.

9. To resolve her complaint, Mrs B seeks service improvements and an apology.

10. Mr A was in his mid-sixties at the time of the events Mrs B complains about. He had a background of chronic obstructive pulmonary disease (COPD), a condition where the airways in the lungs have become narrowed, inflamed, and damaged. It typically causes shortness of breath and coughing.

11. On 16 February 2024, Mr A had an appointment with a GP at the Practice. He complained of a cough that was getting worse and said he was feeling shivery. The GP diagnosed him with exacerbation of COPD (the sudden worsening of COPD symptoms brought on by infection) and prescribed antibiotics and steroids.

12. On 21 March, Mr A saw a different GP at the Practice. He complained he was still coughing and said he had an aching pain in the right side of his chest. The GP referred Mr A for a chest X-ray and prescribed a second course of antibiotics and steroids. The chest X-ray was booked for 29 April.

13. Mr A visited the Practice again on 10 April. He told the GP he was still coughing, had very little energy, and had lost weight. The GP arranged blood tests and referred Mr A for an urgent X-ray which took place on 15 April. Mr A’s X-ray and blood test results were reported as ‘normal’ on 24 April.

14. Mr A next had an appointment with a GP at the Practice on 2 May. He still had a cough and reported constant right sided pain and discomfort in his chest. He was also still losing weight. The GP referred Mr A for an urgent CT scan and the results of this showed a mass in his right lung.

15. On 23 May, a GP at the Practice had a telephone consultation with Mr A. They informed him that sadly, the results of the CT scan showed suspected cancer. The GP referred Mr A on a ‘two week-wait’ (2WW) cancer pathway, a fast-track referral that ensures a patient with suspected cancer is seen within 14 days.

16. Mr A discussed the results of his CT scan with a GP in person on 28 May. At this appointment, Mr A reported he was suffering from shortness of breath and the GP advised he attend the Trust’s Emergency Department (ED). In the ED, Mr A was diagnosed with community-acquired pneumonia. A doctor assessed him and discharged him with antibiotics, steroids, and other medication.

17. Mr A was formally diagnosed with lung cancer on 31 May. He had a biopsy on 5 June and was due to begin chemotherapy on 11 July. However, he was admitted to hospital on 7 July with worsening symptoms, including pneumonia, a blood clot, and fluid on the lung. He remained in hospital until his sad death on 20 July.

Cancer diagnosis and referral

21. As we have seen in the background section of this report, Mr A visited the Practice four times before he was diagnosed with suspected lung cancer. The records show at the first of these appointments, on 16 February, the GP asked Mr A about any ‘red flag’ symptoms. We understand from our GP adviser these are symptoms that could indicate a serious underlying cause. The GP documented that Mr A had no ‘worrying’ symptoms such as weight loss, chest pain, coughing up blood, or night sweats.

22. The records show the GP examined Mr A and heard crackles and wheezes on both sides of his lungs. Our GP adviser said it was reasonable, based on their assessment, for the GP to reach the conclusion that Mr A had an exacerbation of COPD at this time. They said there was nothing to suggest the GP should have done more to investigate the cause of Mr A’s cough on this occasion as exacerbation of COPD was the most likely diagnosis.

23. There is evidence, from the note of Mr A’s appointment on 21 March, that the GP considered risk factors for lung cancer. The GP noted he had symptoms on only one side of his chest, and that he was, at the time, a smoker. The GP referred Mr A for a chest X-ray.

24. The NICE guidance on the management of cough tells clinicians what to consider when assessing a person with a persistent cough. It says clinicians should consider arranging a chest X-ray if a person has a chronic cough and there is uncertainty about its cause. Our GP adviser said it was appropriate for the GP to refer Mr A at this point because with these new symptoms, it no longer looked like COPD was the most likely cause.

25. On 10 April, the GP noted Mr A now had additional ‘red flag’ symptoms, including a loss of appetite, weight loss, and fatigue. At this stage, the GP planned to refer Mr A to the respiratory clinic on a 2WW pathway. However, the Trust’s referral criteria says ‘all patients should have an up-to-date chest X-ray’ before they can be referred on a 2WW lung cancer pathway. The evidence shows the GP immediately arranged for Mr A’s chest X-ray to take place urgently.

26. We cannot explain why there was a gap of nearly five weeks between Mr A’s referral for an X-ray and the date the procedure was initially arranged for. Our GP adviser said this is longer than we would expect to see within the NHS. However, this is not an indication the Practice should have done something differently. Once it had made the referral, the responsibility for arranging the appointment would have been between Mr A and the Trust.

27. As we know, the GP referred Mr A for an urgent CT scan on 2 May. The GP noted they were doing so on the basis they needed to ‘rule out’ cancer.

28. Based on everything we have looked at, we think there is evidence the GPs at the Practice considered the possibility that Mr A had cancer at each appointment between February and March 2024. We can understand that from Mrs B’s perspective nothing seemed to be happening, but the records show at each appointment a GP took action to investigate or rule out the possibility of cancer.

29. Furthermore, we are satisfied the Practice acted in line with NICE guidance when it referred Mr A for an X-ray on 21 March, and for an urgent X-ray on 10 April. We hope this reassures Mrs B.

Discharge on 28 May 2024

30. The NICE guidance on the management of COPD tells clinicians how they should assess a person with a suspected acute exacerbation, and what they should consider when deciding whether that person needs to be admitted to hospital. The guidance says to assess the severity of a person’s symptoms, clinicians should check their ‘vital signs’ (including temperature, pulse, blood pressure, and heart rate), ‘assess for confusion or impaired consciousness’ and ‘examine the chest’.

31. The records show the Trust observed Mr A’s vital signs on at least three occasions while he was in the ED. The records show these did not change significantly during this time – Mr A’s temperature, oxygen level, blood pressure, and heart rate did not get worse or better. Our ED adviser said this is evidence that Mr A’s condition was clinically stable.

32. The Trust also took blood tests and a chest X-ray while Mr A was in the ED. From the evidence we have seen, there is nothing to suggest the results of these showed signs Mr A needed emergency treatment. In addition to this, we have seen nothing to suggest the Trust assessed Mr A as having ‘confusion’ or ‘impaired consciousness’.

33. Based on Mr A’s vital signs, chest X-ray and observations, the Trust reached the conclusion that he did not require admission to hospital. Our ED adviser said there was no indication the Trust should not have reached this conclusion.

34. The NICE guidance also sets out how clinicians should treat a person with acute exacerbation of COPD, but who does not require admission to hospital. It says doctors should consider prescribing steroids and antibiotics. It also says they should arrange a follow-up to assess any changes in their symptoms. The guidance suggests clinicians should consider referring the person to a respiratory specialist should they have a serious underlying lung condition.

35. The records show the Trust prescribed Mr A steroids and the antibiotic doxycycline. Unfortunately, Mr A did not tolerate doxycycline, and it made him vomit in the ED. The Trust then changed the antibiotic to co-amoxiclav. Both antibiotics are mentioned as an appropriate choice for the treatment of an exacerbation of COPD. The records also show the Trust referred Mr A to the respiratory department for follow-up within two days.

36. Based on everything we have looked at, we are satisfied the Trust acted in line with the NICE guidance. We recognise Mrs B’s concern that the Trust discharged Mr A despite him having pneumonia, COPD, asthma, and a very recent diagnosis of suspected lung cancer. We do not doubt her account of how unwell Mr A was. We hope we have been able to reassure Mrs B the Trust assessed Mr A as it should have and discharged him with the right care in place.

Treatment for pneumonia

37. The BTS guideline for the management of community acquired pneumonia sets out the care clinicians should initially provide a person who has been admitted to hospital with this diagnosis. It says ‘all patients admitted to hospital with suspected community acquired pneumonia should have a chest [X-ray]’ to allow an accurate diagnosis. It also says clinicians should measure the person’s oxygen saturations and take blood tests.

38. The guideline says people with a confirmed diagnosis of community acquired pneumonia should be treated with antibiotics, with the first dose given while the person is still in hospital. It lists both doxycycline and co-amoxiclav as appropriate antibiotic choices.

39. As we have already seen, the Trust performed a chest X-ray and prescribed antibiotics to Mr A. It gave him the first dose in the ED. Our ED adviser said the Trust treated Mr A’s community acquired pneumonia in line with the BTS guidance.

40. We understand how worrying this time was for Mrs B and Mr A, particularly given his very recent diagnosis of suspected lung cancer. We recognise Mrs B would have wanted the Trust to do all that was necessary to treat Mr A’s pneumonia, and we hope we have been able to assure her that it provided the treatment it should have.

41. We fully empathise with how Mrs B’s life has been affected by Mr A’s rapid deterioration and sad death. We can see how much work she has put into understanding what happened and raising her complaint. We hope our statement clearly explains the reason why we cannot consider the complaint further.

1. We thank Mrs B for her complaint about the care the Practice and the Trust provided her father, Mr A. We recognise how important the complaint is to her and the effort she has made to share her experience with us. We offer our sincere condolences to Mrs B for her sad loss.

2. We have carefully considered everything Mrs B told us and through our work, we have seen no indication that things went wrong with the care the Practice provided Mr A. The evidence we have looked at shows the GPs at the Practice considered Mr A might have cancer at each appointment between February and May 2024. Additionally, we have seen no evidence the Practice failed to refer Mr A to a cancer specialist.

3. Mrs B accompanied Mr A to the Trust’s Emergency Department (ED) within only a few days of learning he had suspected lung cancer. We can understand how worrying this time was. Based on everything we have looked at, we think the Trust treated Mr A’s pneumonia and discharged him in line with relevant guidelines.