A medical practice in the Barnsley area

5. Mrs L says a medical practice in the Barnsley area (the Practice) failed to refer Mr L for suspected cancer sooner than 12 October 2020. Mrs L says the symptoms he had and presented to the Practice in 2019 and 2020 warranted a referral for further investigation earlier than 12 October.

6. Mrs L says had the Practice done a suspected cancer referral sooner, Mr L would have been diagnosed with lung cancer earlier, and the Practice could have managed his pain sooner and more effectively.

7. Mrs L wants the Practice to apologise, and she wants to ensure the same thing does not happen to someone else.

8. Mr L’s chest X-ray findings were returned as ‘normal’ on 21 March 2019. The report stated that his ‘lungs and pleural spaces are clear.’ Therefore, there was no further action required.

9. Mr L returned to the Practice in June 2020 presenting with headaches, and between July and September he attended several appointments due to pain in his back, leg, and hip.

10. The Practice referred Mr L for musculoskeletal physiotherapy in August and an X-ray, confirmed mild osteoarthritis (a common form of arthritis which affects joints in the hands, spine, knees and hips) of both hip joints.

11. Mr L attended appointments on 3 and 8 September due to pain and discussed the pain medication he was currently taking. During an appointment on 18 September, Mr L informed the Practice about his weight loss.

12. On 22 September Mr L again informed the Practice of his weight loss and said that he had lost a stone in weight since June. Mr L attended several other appointments in September and October regarding his back and leg pain, loss of appetite, fatigue, and weight loss.

13. On 5 October, Mr L’s blood test results and c-reactive protein results were returned as abnormal.

14. On 6 October, Mr L’s spinal X-ray was returned as ‘abnormal,’ with the reporting saying, ‘Degenerative-spondylotic changes with intervertebral space narrowing and anterior osteophytes.’

15. On 12 October, Mr L attended the Practice to discuss his blood test results, cough, loss of appetite and weight, and pain. The Practice referred Mr L for a chest X-ray under the two-week cancer care pathway.

16. An abnormal result was returned on 14 October. The report stated, ‘Indeterminate appearances adjacent to right hilum. Impression of subtle opacities towards the lateral side of RUL.’

17. The Practice made Mr L aware that he likely had cancer.

18. In late October, Mr L was diagnosed with lung cancer.

19. On 18 November, Mr L complained of his pain being constant and therefore a MacMillan nurse requested for the Practice to prescribe Zomorph and Oramorph. Shortly after this request, the Practice prescribed the above to Mr L.

20. In December, Mr L sadly died from lung cancer.

Issue 1 – Delay in referring Mr L for suspected lung cancer

24. Mrs L feels that the Practice should have referred Mr L for suspected cancer much earlier than 12 October 2020, as he attended the Practice on several occasions in 2019 and 2020 presenting with symptoms.

25. The NICE guidance 1 says: ‘Offer an urgent chest X-ray (to be performed within 2 weeks) to assess for lung cancer in people aged 4 years and over if they have two or more of the following unexplained symptoms, or if they have ever smoked and have one or more of the following unexplained symptoms: · Cough · Fatigue · Shortness of breath · Chest pain · Weight loss · Appetite loss.’

26. The NICE guidance 1 goes on to define ‘unexplained’ as ‘symptoms or signs that have not led to a diagnosis being made by the healthcare professional in primary care after initial assessment (including history, examination, and any primary care investigations).’

27. We understand from Mr L’s medical records that the Practice first referred him for a chest X-ray in March 2019 as he was a smoker and presented with a cough. This was in line with the NICE guidance 1, which says that a patient should be referred for suspected lung or pleural cancer if they have a cough and are a smoker. The results showed a normal result and therefore cancer was not suspected.

28. We understand that Mrs L believes there may have been more than one appointment in 2019 when the Practice should have referred Mr L for a potential cancer diagnosis. However, after reviewing Mr L’s medical records we understand that following his appointment in March 2019, the next appointment was on 3 June 2020. We are unable to evidence any other appointment in 2019 that warranted a referral for potential cancer.

29. Mr L presented to the Practice in June 2020 with headaches and then in July and August with back pain. In line with the NICE guidance 1 this does not warrant a referral for suspected lung cancer. Instead, we understand that the Practice made a referral for musculoskeletal physiotherapy following his appointment on 10 August. The Practice also considered that the pain Mr L was suffering from was neuropathic (disease of the nerves). Therefore, it advised Mr L of typical neuropathic pain symptoms, such as worsening pain or pins and needles, and advised him to get back in touch should he present with any of these symptoms. The Practice advised him to continue with co-codamol and naproxen at this point.

30. However, on 18 September, Mr L had a telephone consultation where he discussed his weight loss with the Practice. We understand that Mr L said that he believed that this was because he had recently given up alcohol. However, our GP adviser said that because Mr L was over 40 years old, was a smoker and presented with weight loss, the Practice should have referred him for an urgent X-ray in line with the NICE guidance 1.

31. We also understand from Mr L’s medical records that he also attended appointments on 22 September, 29 September, and 5 October, in which the Practice discussed his weight loss and lack of energy. On 5 October, the Practice believed the pain was neuropathic and therefore prescribed gabapentin. In all these appointments, in addition to the leg, back and hip pain he was experiencing weight loss and lack of energy. These were discussed but no referral was made. These were also missed opportunities to refer him under the suspected cancer pathway, as per NICE guidance.

32. It is noted that Mr L’s blood test results were returned on 7 October and came back as abnormal. His C reactive protein results also came back as abnormal on this day. We can see that the Practice attempted to contact Mr L to discuss these results. It was not until his appointment on 12 October that these results were discussed and the Practice referred Mr L under the suspected cancer pathway. During this appointment Mr L presented with a cough, loss of weight and appetite, pain, and anaemia. A diagnosis of lung cancer was made on 28 October.

33. We have seen no evidence Mr L presented with any symptoms that would have warranted a cancer referral before 18 September. The symptoms he would need to have presented with would have been a cough, fatigue, shortness of breath, chest pain, weight loss or appetite loss, as per the NICE guidance. We have found the Practice should have referred Mr L on 18 September. We also found further missed opportunities for them to refer him on 22 and 29 September and 5 October.

34. Our GP adviser said that had the Practice referred him in September his lung cancer diagnosis would have been made around 4 October, which is three and a half weeks before his actual diagnosis was made. This is based on the time it took from the Practice referring Mr L on 12 October to him being diagnosed on 28 October.

35. We therefore consider the Practice failed to keep to the NICE guidance 1 in not referring Mr L based on his presenting symptoms during his appointment on 18 September. We have considered the impact that this had on Mr L’s pain medication below.

Impact

36. Mrs L feels that if the Practice had referred Mr L for suspected lung cancer earlier, they could have managed his pain more effectively.

37. At this stage, following on from our findings above, we consider that Mr L’s diagnosis could have been made three and a half weeks earlier.

38. We understand from Mr L’s medical records that the Practice was actively managing his leg, back and hip pain prior to his cancer diagnosis and prescribed him co-codamol and naproxen. During Mr L’s appointment on 22 and 29 September, his pain is discussed, and it is understood that he raised concerns the naproxen was not working. During the appointment on 29 September, the Practice advised that it would wait for his blood test results before making any changes to his medication. On 5 October Mr L was prescribed gabapentin and zapain, as Mr L reported a shooting pain down his leg. We understand that shooting pain can be a red flag for neuropathic pain. We therefore need to consider that if Mr L had been referred on 18 September, and diagnosed around 4 October, would his pain management have been any different.

39. The NICE guidance 2 says: ‘Consider a stepwise approach, using the World Health Organization analgesic ladder. Start at the appropriate point of the analgesic ladder, moving up the ladder when the maximum dose at each step is reached until the person is comfortable. The steps are: · Step 1: non-opioid analgesic such as paracetamol and/or nonsteroidal anti-inflammatory drug (mild pain) · Step 2: weak opioid such as codeine, dihydrocodeine, or tramadol (controlled drug), with or without a non-opioid analgesic (mild to moderate pain) · Step 3: strong opioid such as morphine with or without a non-opioid analgesic (severe pain).’

40. On 5 October we can see from Mr L’s medical records that the Practice prescribed gabapentin and Zapain, which is also step 2 on the ladder. This is because at this point the Practice considered his pain to be neuropathic as he complained of pain shooting down his leg. The Practice therefore prescribed gabapentin which is a neuropathic painkiller. We understand that Mr L informed the Practice that the gabapentin was not working on 12 October, therefore the Practice increased his dose on 14 October, 19 October, and 23 October. On 5 October, Mr L began on 100mg of gabapentin, three times a day and by 23 October, the Practice had prescribed 300mg, three times a day. Therefore, we consider that the Practice were trying to control Mr L’s pain. This is also in keeping with the NICE guidance 2 that says you ‘should move up the ladder when the maximum dose at each step is reached until the person is comfortable.’

41. We also understand that when the Practice prescribed morphine on 20 November, Mr L reported an ease in pain shortly after this.

42. It was clear Mr L was struggling with the pain during his 5 October appointment. It was at this point that Mr L was prescribed gabapentin and Zapain, which is a step 2, weak opioid. However, our GP adviser said that if Mr L’s cancer diagnosis had been made on 4 October, it would have been possible for the Practice to prescribe a strong opioid, step 3 of the pain ladder.

43. However, our GP adviser adds that it would be impossible to say that this is the action the Practice would have taken. They said the Practice believed that the pain Mr L was suffering from was neuropathic and therefore were correct to prescribe gabapentin, as this is a neuropathic painkiller. They added that a strong opioid (step 3) would not be prescribed for neuropathic pain as it would not help, and that gabapentin can be prescribed in the same way for patients both with and without cancer.

44. Also, had Mr L been diagnosed on or around 4 October, we cannot say for certain the Practice would have prescribed stronger pain relief, such as that in step 3 of the ladder, as the guidance indicates you should only prescribe the amount of pain relief needed to relieve the pain. As the guidance advises a step wise approach is taken to increasing pain relief, although a strong opioid could have been prescribed by this point, it does not necessarily mean it would have been appropriate.

45. Our GP adviser also added that it is likely Mr L’s pain would increase as the cancer developed. This may have been why the Practice did not prescribe a strong opioid until 18 November, around three weeks after Mr L’s cancer diagnosis, as the pain at this point required a strong opioid. We understand that a MacMillan nurse asked for the Practice to prescribe morphine following an urgent referral to them by Mr L about the pain he was suffering from. The Practice completed this request on 20 November. Before prescribing a strong opioid, a Practice needs to consider the side effects, which is why even in cancer patients’ a Practice would work its way up the pain ladder until the pain was managed effectively. This is in keeping with the GMC’s prescribing guidance (paragraph 39-40) which says, ‘you should identify the likely cause of the patient’s condition and which treatments are likely to meet their needs the likely benefits, risks, and impact…’.

46. There is no way of knowing whether an earlier cancer diagnosis would have changed the way the Practice treated Mr L’s pain. We consider that when Mr L explained that his pain was not easing after his appointment on 29 September, the Practice appropriately prescribed gabapentin and Zapain on 5 October. The Practice appropriately increased his dose of gabapentin on 14 October, 19 October, and 23 October. We consider that as the Practice believed that the pain was only neuropathic until the diagnosis on 28 October and it continued to increase the dose until it was appropriate. As stated above, the gabapentin and Zapain prescribed for neuropathic pain can also be prescribed in the same way for patients both with and without cancer.

47. The Practice followed NICE guidance when it gradually increased the pain relief when Mr L reported that his pain was not resolving. As neuropathic pain can still be present in cancer patients the pain treatment was appropriate. We also understand that the pain relief prescribed by the Practice on 23 October appears to have relieved Mr L’s pain up until 18 November when he reported to the Macmillan nurse that he required stronger pain relief.

48. Therefore, we cannot say the pain relief prescribed during this period was insufficient.

49. We understand from looking at Mr L’s medical records and listening to Mrs L’s complaint that this must have been a very difficult time for them both. It is clear that Mr L was suffering from pain. While we cannot say that Mr L’s pain relief was not sufficient, we hope that our findings reassure Mrs L that the Practice were trying to control his pain.

1. We would like to thank Mrs L for bringing this complaint to us and we would like to offer our condolences for her loss. We understand how hard it must have been for Mrs L to revisit what would have been a very difficult time in both her and her husband’s, Mr L’s, life.

2. Based on the evidence, we partly uphold this complaint. This is because we have identified failings in the Practice not referring Mr L for further assessment following his appointment on 18 September 2020. Therefore, we consider that Mr L’s diagnosis could have been made earlier however, we cannot say at this point that the delayed diagnosis would have had any impact in how the Practice managed Mr L’s pain.

3. While we understand that knowing Mr L’s cancer diagnosis could have been made earlier will cause upset to Mrs L, we hope that this report reassures her that Mr L’s pain was adequately managed.

4. We are recommending that the Practice writes to Mrs L and apologises for not referring Mr L in September. We also recommend that the Practice puts in place an action plan to ensure that all staff are clear on the National Institute for Clinical (NICE) guidance and when to refer a patient.