A medical practice in the Sunderland area

3. Mr T complains about the following aspect of the care and treatment he received from the Practice. Specifically, he complains that the Practice did not appropriately review his urinary symptoms in April 2019.

4. As a result, in September 2019, Mr T attended A&E as his urinary symptoms had worsened. Mr T underwent further investigations by his hospital and was diagnosed with bladder cancer. Mr T believes that the Practice should have referred him for further investigations in April 2019 and he has missed an opportunity to receive the treatment he needed earlier. This has caused Mr T a lot of stress and upset over the last two years and he has been in a depressed state.

5. As an outcome to his complaint, Mr T would like service improvements.

6. Mr T is over 60 years old. He attended the Practice on 22 March 2019 as an emergency appointment for a number of urinary symptoms. The GP conducted several tests and advised Mr T to come back for a further appointment.

7. On 5 April, Mr T returned to the Practice and discussed the results of the tests which were all normal.

8. Mr T attended A&E on 14 August as his urinary symptoms had worsened. He underwent several tests at hospital and was diagnosed with bladder cancer on 21 August.

The Practice did not appropriately review Mr T’s urinary symptoms in April 2019

13. To help frame our analysis of the complaint, it is important to outline what happened in the appointment Mr T had on 22 March 2019.

14. In NHSE’s response, it says that Mr T attended the Practice on 22 March 2019 as an emergency appointment because he was passing urine frequently and uncomfortably. Mr T also said that he thought he had seen blood in his urine the day before, although his urine on the day of the appointment was clear. A urine test for blood and infection was arranged, as well as blood tests to check his prostate. The GP asked Mr T to come back to the Practice for a digital examination of his prostate.

15. Mr T attended the Practice again on 5 April 2019, although there is some confusion between Mr T and the GP as to what procedure both parties’ thought were being carried out.

16. The GP discussed the test results and advised Mr T that they were all normal. He also explained that Mr T’s urine contained five blood cells. This is less than the threshold number of ten, which may be considered significant. The response says Mr T reported that his symptoms had resolved, and he had experienced no further symptoms since his previous appointment.

17. Our adviser refers to NICE guidance on suspected cancer. Section 1.6.4 provides information on bladder cancer. It says to:

18. ‘Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for bladder cancer if they are:

· Aged 45 and over and have: o Unexplained visible haematuria without urinary tract infection or o Visible haematuria that persists or recurs after successful treatment of urinary tract infection, or · Aged 60 and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test’.

19. Based on Mr T’s clinical presentation, our adviser says the GP’s actions were appropriate and in line with NICE guidance. The GP wanted to determine whether there was an infection, as this can cause blood in the urine, and Mr T had other possible symptoms of a urinary tract infection such as passing urine more frequently.

20. Considering the above, there are no indications of failings in the appointment on 22 March 2019.

21. Similarly, we asked our adviser about the appointment on 5 April.

22. The result of the tests showed that Mr T did not have a urinary tract infection. As such, in line with the NICE guidance, our adviser says Mr T should have been referred on a two-week suspected cancer pathway referral because of the ‘unexplained visible haematuria without urinary tract infection’. In terms of the presence of blood in the urine, our adviser says Mr T had two tests to check for this – a urine dipstick test (dipping a special strip of paper in a sample of urine) done in the Practice, and a laboratory urine analysis.

23. The urine dipstick test showed the presence of significant blood (rated as +++ in the medical records), however the laboratory urine analysis did not show significant blood. Our adviser says it is not possible to reconcile the difference, however this does not matter as Mr T reported visible blood in his urine previously.

24. Considering the Practice did not follow the NICE guidelines at the appointment on 5 April 2019, there are indications of failings here.

25. There is a missed opportunity here as there is a gap of approximately four months between the appointment in April 2019 and when Mr T was diagnosed with bladder cancer on 21 August.

26. Our adviser says that there was a potential delay in treatment, however they say we would not have known at the time whether a referral would have led to further investigations and diagnosis. Similarly, in NHSE’s response of 16 January 2020, it received advice from a consultant urologist. They also explained that we cannot know whether Mr T’s treatment and prognosis would be different if he had been referred four months earlier.

27. Considering the advice that we have from our own adviser; this supports the position shown in NHSE’s response. As such, we do not know whether an earlier referral would have led to further investigations and/or diagnosis.

28. However, knowing that he should have been referred by the Practice four months earlier, it is understandable that this has caused Mr T a lot of stress and upset.

29. In NHSE’s response of 16 January 2020, the Practice apologised to Mr T, however this was mainly regarding the fact that Mr T was eventually diagnosed with bladder cancer. It reassured Mr T that his complaint was taken very seriously. The Practice discussed the complaint amongst the clinicians in the surgery and was awaiting a review of protocols relating to investigation and referral thresholds.

30. NHSE also advised Mr T of the recommendations it has given to the Practice as a result of this complaint:

· ‘The GP should reflect on this case and provide a reflective account · The GP should undertake personal study/learning in relation to the guidelines for referral for suspected cancer and document their learning in the CPD log for appraisal · The GP should discuss the complaint at their appraisal · The GP should discuss this case at his GP practice and share this learning with his team members · The GP should review his medical record keeping’.

31. Our Principles say that ‘where maladministration or poor service has led to injustice or hardship, the public body responsible should take steps to provide an appropriate and proportionate remedy’.

32. The only outcome Mr T is looking for is service improvements. We have considered what the Practice has done in its attempt to put things right, and also what NHSE has asked it to do. These are in line with our Principles, and we could not ask the Practice to do more than what it has done, or what it is going to do.

33. We appreciate how important this complaint is to Mr T, and we are sorry that this may not be the outcome he was hoping for.

34. In summary, we have decided we will not take further action on this complaint. We hope we have explained the thorough consideration we have given this complaint and clearly outlined the reasons for it.

1. We have carefully considered Mr T’s complaint about a medical practice in the Sunderland area (the Practice). We have decided to take no further action on Mr T’s complaint as we have seen the Practice, and the actions recommended by NHS England (NHSE), are enough to put things right.

2. We have reviewed all the relevant evidence and there are indications of failings in the appointment Mr T attended on 5 April 2019. However, we are satisfied that what the Practice has done, what it is planning to do, and the actions NHS England has asked it to do sufficiently recognise the impact the events have had on Mr T. We were sorry to hear of the events complained about, and we have no doubt how much of an impact these events have had on Mr T.