A medical practice in the Essex area

3. Mr R complains the Practice delayed the diagnosis of his brother, Mr A’s, cancer between January 2020 and August 2020.

4. Specifically, Mr R complains the Practice: • failed to record an appointment in early January 2020 where his brother reported blood in his stools and mentioned cancer • should have made an earlier cancer referral for investigations.

5. Mr R says if the Practice had taken action earlier, the tumour may have been small enough to be removed. This may have allowed his brother to live longer.

6. Mr R wants clarification that his brother did attend an appointment in January 2020 and to be given an apology. Mr R also mentions he seeks financial compensation.

7. Mr A was over 40 years old at the time of these events.

8. Mr R says Mr A had an initial appointment with his GP early in January 2020 as he had identified blood in his stools, and had mentioned a concern of cancer. Mr A said the doctor laughed at him and said it was nothing to worry about. This appointment is not recorded anywhere in the medical notes. We have considered the evidence relating to this below.

9. Mr A had an appointment at the Practice on 29 January 2020. He reported constipation and a GP prescribed a laxative. Following this, the GP confirmed the medication had improved Mr A’s condition.

10. Mr A had a number of appointments with a GP at the Practice from February to May 2020. These appointments included discussions about Mr A’s constipation symptoms and diabetes care.

11. Mr A reported having an abscess on his rectum via a telephone consultation on 27 May 2020. Following this, his GP saw him almost daily to assess, clean, and re-dress the abscess.

12. On 29 June 2020, a GP noted in the records at one of Mr A’s GP appointments that there was a small lump near the abscess. The GP advised Mr A that if the lump increased in size or became more painful, he should contact them.

13. On 15 July 2020, a GP found a lump to the side of the abscess again. The GP also noted that Mr A had said it felt as though he was sitting on a hard lump but there were no complaints of pain.

14. The GP referred Mr A to hospital when his abscess was not healing, and he was admitted on 15 July 2020.

15. Mr A had a Magnetic Resonance Imaging (MRI) scan at the hospital on 22 July 2020 to detect the depth of the wound. It was from these results that Mr A was diagnosed with bowel cancer on 3 August 2020.

16. Sadly Mr A died about a year after receiving his cancer diagnosis.

20. Before we decide if we should carry out a detailed investigation into 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. We have done this and have not found any indications that something has gone wrong.

Documenting an initial GP appointment and blood in Mr A’s stools

21. Mr R says that his brother initially saw his GP in early January 2020, regarding blood in his stools. Mr R does not have confirmation of the date of this appointment.

22. We spoke to Mr R and he said his brother had told him about the appointment. When we spoke to Mr R more recently, he said he took his brother to the appointment and waited in the car for him. We have carefully considered the evidence for what happened, taking the account Mr R gave us as part of this.

23. In its response to the complaint, the Practice said there was no record of an appointment in early January.

24. After reviewing Mr A’s medical records, the first appointment documented is from 29 January 2020 regarding him suffering with constipation.

25. There is nothing in the medical records of an appointment in early January, with Mr A reporting blood in his stools. There is also no mention of rectal bleeding (or blood in stools) at any follow up appointments. A GP also completed a rectal examination and there were no indications of this.

26. Our Principles of Good Administration contain guidance for organisations, including on record keeping. The section on being open and accountable says: ‘Public bodies should create and maintain reliable and usable records as evidence of their activities. They should manage records in line with recognised standards to ensure that they can be retrieved and that they are kept for as long as there is a statutory duty or business need.’

27. We can see that what the Practice says happened and what Mr R says happened are different. We have considered whether there is other evidence available to support either account. The other evidence available is the medical records, and there is not further independent evidence we can review. We recognise that Mr R does not agree with what the records say, and we do not discount his recollection.

28. When someone complains to us about events which are disputed by the other party, our role is to gather evidence and reach a view about what is more likely to have happened.

29. We have taken into account Mr R’s recollection of taking his brother to an appointment and waiting for him outside, and his account of speaking to his brother about the appointment. Having balanced that alongside the other evidence, we think overall there is not sufficient evidence of the appointment taking place.

30. The evidence indicates the Practice met the standard for record keeping in our principles as we consider it made a reliable record of its activities.

31. For the reasons outlined above, we have seen, on the balance of probabilities, there is no indication of a failing in the Practice’s record keeping.

Referral for investigations prior to diagnosis

32. Mr R complains the Practice should have referred his brother for investigations so he could have been diagnosed with cancer sooner. We are sorry Mr R has been left with this concern and appreciate it has been difficult for him.

33. We discussed this case with an independent GP adviser with over 20 years’ experience (our adviser). They review patients who might have symptoms related to colorectal cancer as part of their regular practice. Our adviser has the appropriate knowledge and experience to advise on this case.

34. Our adviser explained to us NICE guidance NG12 is relevant for GPs seeing patients in the same circumstances as Mr A.

35. Given below are the NICE guideline red flags for colorectal cancer. They set out when a GP should refer, or consider referring, a patient onto a cancer pathway:

‘1.3.1 Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer if: • they are aged 40 and over with unexplained weight loss and abdominal pain or • they are aged 50 and over with unexplained rectal bleeding or • tests show occult blood in their faeces. [2015]

1.3.2 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer in adults with a rectal or abdominal mass. [2015]

1.3.3 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer in adults aged under 50 with rectal bleeding and any of the following unexplained symptoms or findings: • abdominal pain • change in bowel habit • weight loss • iron deficiency anaemia. [2015]’

36. Mr R says his brother attended a GP appointment in early January 2020 where he reported having blood in his stools, and mentioned a concern of cancer. As we have explained above, there is not sufficient evidence of this initial appointment for us to say it took place.

37. Mr A was seen by his GP on 29 January 2020 for constipation, and was prescribed medication to treat this. He also had a rectal examination and blood tests completed around this time.

38. Mr A’s medical records contain several entries for appointments from February to May 2020. There are no records of Mr A reporting rectal bleeding, weight loss, or abdominal pain. There are also no records of iron deficiency anaemia in the blood tests the Practice took during that period.

39. Mr A had a telephone consultation with his GP on 27 May 2020 where he reported that an abscess had developed on his rectum. A GP prescribed antibiotics to treat the abscess. From 9 June 2020, Mr A was being seen regularly to have the area cleaned and dressed appropriately.

40. Our adviser stated there were no indications of the need for an emergency cancer referral as there were no red flags prior to the diagnosis, and no symptoms that would have alerted the doctors or nurses.

41. Our adviser said the lump identified within the area of the abscess is likely to have been over granulation. Over granulation generally refers to over healing or too much scar tissue formation on the outside of the wound. This is referenced on 2 and 9 July 2020 within the medical records. They said the lump did not appear to be anything other than directly related to the abscess. In reference to the above guidance, the lump is not likely to have been a rectal or abdominal mass.

42. The abscess did take a long time to heal. Our adviser said that this can happen, however, when it was taking too long, the GP did refer Mr A to the hospital.

43. Having reviewed all the evidence we have seen, in the time the Practice saw Mr A, there was no mention of rectal bleeding. This also was not discovered when he had a rectal examination.

44. We reviewed the blood test results during that time and saw no findings of iron deficiency anaemia from blood loss, which could have been the case if Mr R was experiencing regular rectal bleeding. Our adviser helped reassure us we had interpreted these results correctly.

45. The evidence indicates the Practice acted in line with the relevant NICE guidance. This is because there is no evidence Mr A had the symptoms the guidance says should prompt a GP to refer. Based on this, there were no indications that a cancer referral was required prior to diagnosis. The evidence therefore does not indicate any failing in the Practice’s actions.

46. To fully consider this part of Mr R’s complaint we also considered how the GP assessed Mr A. We also discussed the Practice’s assessments with our adviser. They told us GMC Good Medical Practice was relevant to this case. The GMC guidelines say:

‘15. You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a. 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 b. promptly provide or arrange suitable advice, investigations or treatment where necessary c. refer a patient to another practitioner when this serves the patient’s needs.’

47. We have seen in the medical records (as we mention above) the Practice carried out blood tests for Mr A on occasions throughout this period of events. The GP also carried out a rectal examination, and assessed Mr A by phone when there were signs of infection within the abscess.

48. The evidence indicates the Practice carried out assessments and examinations for Mr A in line with the GMC guidelines. As we have commented above, the GP also referred Mr A to another practitioner. We consider this was at the point that served Mr A’s needs, as set out in the GMC guidance.

49. Having considered all the evidence, including the input from our adviser, we have not seen indications of failings in the assessments the Practice carried out.

50. We are sorry if our decision not to consider Mr R’s complaint further is difficult for him to receive. We are grateful to him for bringing his concerns to our attention.

1. We have carefully considered Mr R’s complaint about a medical practice in the Essex area (the Practice). We were very sorry to hear about the loss of Mr R’s brother, Mr A. We were sorry to hear about the impact this has had on Mr R and that he feels more could have been done for his brother.

2. We have seen no indication that anything went seriously wrong with the Practice’s care and treatment. The evidence indicates the Practice followed relevant guidelines in how it both assessed Mr A and acted on the symptoms he had. We have decided not to consider Mr R’s complaint further.