A practice in the Windsor and Maidenhead area

3. Mr I complains the Practice delayed six months from April 2023 before diagnosing him with irritable bowel syndrome (IBS) in November 2023.

4. He complains it:

• delayed five days from 6 April before giving him blood test results • should have prescribed IBS medication after he asked if he had IBS • delayed requesting his endoscopy results from the hospital until July and told him he should request the result directly from the hospital • wrongly told him on 25 July his Barratt’s oesophagus (a condition where some cells in the oesophagus grow abnormally) was causing his lack of energy • delayed from April until August before ordering a colonoscopy.

5. Mr I says he has been impacted physically by the Practice’s delay. He says for the first two weeks he had complete exhaustion and struggled to move. He said for the rest of the six months delay he was still very tired, had severe lower abdominal pain and had to use the toilet very frequently. He says this could have been avoided as the medication he is now on has made these symptoms a lot better. He says he had a painful bowel endoscopy and other investigations which could have been avoided if the Practice diagnosed him sooner.

6. Mr I said this led him to have a low mood. He felt frustrated the Practice was not helping and just referred him for lots of different invasive tests. He felt abandoned while he was in pain and now does not trust the Practice with his medical care.

7. Mr I is seeking financial remedy of £10,000.

8. Mr I was 62 years old. He first felt unwell in April 2023 and approached the Practice for care and treatment. He had many appointments and tests and the Practice referred him to the local hospital’s upper and lower gastrointestinal pathways to check for any signs of cancer or serious illness. The Practice diagnosed him with IBS on 3 November 2023.

12. Before we decide if we should conduct a detailed investigation of 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.

Blood test results

13. Mr I complains the Practice delayed five days before giving him his blood test results. Mr I said he tried to call the GP for his results but the GP was closed so he had to wait until it reopened to get his results.

14. GMC guidance says doctors should ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’.

15. The Practice had a consultation with Mr I on 3 April and requested a blood test then. The results returned to the Practice on 6 April at 5.41pm. It messaged him at 7.16pm asking him to make a routine telephone call appointment with his GP to discuss the results. It was the easter bank holiday on 7 and 10 April so the Practice was closed for an extended time. It reopened on 11 April and gave Mr I his blood test results on 13 April, 2 working days after it had received the blood test results.

16. None of Mr I’s results were urgent and our adviser has confirmed they were suitable to be delivered in a routine consultation rather than immediately. The results arrived close to the end of the day and the Practice arranged a consultation for Mr I two days after it reopened. While it was unfortunate for Mr I this fell on a bank holiday weekend, we can see no indication the Practice did not act in line with GMC guidance on this occasion.

Endoscopy results

17. Mr I complains the Practice delayed requesting his endoscopy results from the hospital and told him he should request his results directly. It said he had to chase the Practice who eventually looked up his results on the system in July and shared them with him.

18. The BMA advises doctors that responsibility for test results likes with the consultant responsible for the patient’s care or the individual who has ordered the test. In cases where multiple services or doctors can see results in an online portal, it must be clear who is taking action on those results.

19. The Practice referred Mr I to the local hospital’s upper gastrointestinal cancer twoweek referral pathway on 19 May. The local hospital decided he needed an endoscopy to explore his symptoms. The Practice said it received a letter on 31 May informing it that a short segment of Barrett’s oesophagus was seen. It said this letter did not direct the Practice to do anything. We have not seen the letter itself. The Practice said it had issues scanning this letter in and the local hospital has no record of this letter on file. We therefore will not be able to determine what this letter said. However, other evidence shows Mr I was still under the local hospital’s care at this time and had not been discharged.

20. The local hospital sent us the clinic letters attached to Mr I’s care. The hospital discharged Mr I after a further colonoscopy and scan on 12 October 2023. Therefore, at the time of his endoscopy results Mr I was still under the care of the hospital. In line with BMA guidance, this means it was the hospital’s responsibility to inform Mr I of the results. We cannot see any indication the hospital delegated this to the Practice.

21. We see no indication the Practice did not act in line with guidance here and we consider it acted in line with guidance by directing Mr I to contact the hospital who had ordered the endoscopy. We appreciate it must have been worrying for Mr I as he was waiting for his endoscopy results.

Tiredness

22. Mr I says during his appointment on 25 July he asked if his Barrett’s Oesophagus would cause a lack of energy. He said the doctor told him it could, then later said this was unlikely to be the cause.

23. The Practice told us that the doctor told Mr I it could be possible this was causing his lack of energy.

24. Our adviser highlighted information about Barrett’s oesophagus. This explains that the common symptoms of reflux, heartburn, nausea, and pain in the upper abdomen can wake people at nighttime. Our adviser explained that while this condition does not directly cause fatigue, it could affect the quality of sleep due to these symptoms.

25. Therefore, we cannot see any indication from the information available the Practice should not have told Mr I this. We appreciate Mr I was frustrated at what he felt was conflicting information.

Colonoscopy

26. Mr I complains the Practice delayed from April, when he came to it with his symptoms, until August to request a bowel colonoscopy. He says if the Practice had done this earlier he would have been diagnosed with IBS sooner and experienced a shorter period of symptoms.

27. NICE guidance for colorectal cancer explains the most common symptoms are diarrhoea, constipation, rectal bleeding, loss of weight, and abdominal pain.

28. GMC guidance says doctors must promptly provide or arrange suitable advice, investigations or treatment where necessary.

29. The Practice referred Mr I to the lower gastrointestinal two-week referral pathway on 29 August. The local hospital decided he needed a colonoscopy and scan to exclude some causes.

30. Mr I presented on 3 April with abdominal pain, hot flushes, lethargy, loss of appetite, reduced urine output and increased thirst. The Practice then did various urine and blood tests. After these results did not indicate a clear cause, it sent him for a faecal immunochemical test (FIT) and abdominal ultrasound on 12 April. The ultrasound showed a fatty liver which would not explain his symptoms. The FIT test results also came back on 2 May and was negative.

31. On 11 May it requested further blood tests when it saw Mr I for a consultation, which again did not indicate a particular cause when they came back on 18 May. The Practice then referred Mr I to the upper gastrointestinal cancer pathway on 18 May.

32. Our adviser said the negative FIT test made colorectal cancer more unlikely. We can see at the time Mr I was showing red flag symptoms in line with NICE guidance. He reported losing one stone in a month and had abdominal pain from 12 April through until this referral was made on 18 May. Due to the persistence of symptoms that are commonly found with colorectal cancer as in NICE guidance it was in line with GMC guidance to refer Mr I at this point.

33. Mr I then had an endoscopy on the upper gastrointestinal cancer pathway on 25 May. The Practice looked up these results on 25 July which said he had Barrett’s oesophagus but his symptoms persisted with more weight loss, fatigue and lower abdominal pain into August. The Practice then referred him to the urgent lower gastrointestinal pathway on 25 August where he then had the colonoscopy.

34. We cannot see any indication of delay on the Practice’s part here. It did the appropriate investigations, in line with GMC guidance, when these did not indicate any clear cause and Mr I was showing red flag symptoms of cancer as listed in NICE guidance. It first referred him to the upper gastrointestinal urgent cancer pathway, and when that was ruled out but his symptoms persisted, referred him to the lower gastrointestinal urgent cancer pathway to rule out cancer or other serious illness. It took Mr I’s red flag symptoms seriously and referred him appropriately to the urgent cancer pathways to rule this out. We appreciate Mr I had to go through several tests which were not pleasant for him in order for these serious conditions to be ruled out.

Medication

35. Mr I complains the Practice should have provided him with IBS medication sooner than it did. He says he asked the Practice if he had IBS at an earlier appointment, but could not remember when this was.

36. The Practice is in the Frimley Health and Care Integrated Care Area so uses its Primary Care IBS pathway. This says that before patients can be diagnosed with IBS the Practice needs to rule out serious causes of red flag symptoms and have at least three months of symptoms. After this the patient can be diagnosed under certain criteria and then given appropriate medication, one of which is mebeverine.

37. It lists the following red flag symptoms:

• unintentional weight loss • rectal bleeding • family history of bowel/ovarian cancer • anaemia • abdominal/rectal mass • nocturnal symptoms • raised inflammatory markers • bloody diarrhoea • systemically unwell.

38. NICE IBS guidance says that in the absence of any alarm symptoms or signs to suspect IBS in patients who have had abdominal pain or discomfort, bloating, or change in bowel habit for at least six months. It explains all people with suspected IBS should be assessed for symptoms and signs of serious conditions that may present with similar clinical features to IBS such as bowel cancer, ovarian cancer, or inflammatory bowel disease. Alarm symptoms include unintentional and unexplained weight loss.

39. In order for the Practice to prescribe Mr I with IBS medication he needed to be diagnosed with IBS. In line with the local pathway and NICE guidance, as Mr I was showing red flag signs of unintentional and unexplained weight loss and abdominal pain, which are indicators of colorectal cancer, this needed to be ruled out first.

40. The Practice followed this guidance by doing blood tests, scans and referring him to the lower and upper gastrointestinal cancer pathways to rule out more serious conditions. Once these had been ruled out in mid-October, it could then suspect IBS.

41. It did this on 3 November during a consultation and diagnosed him with IBS. It then started him on mebeverine in line with the local IBS pathway.

42. We can see no indication of failings from the Practice here. It ruled out Mr I’s red flag symptoms before suspecting IBS and providing him with medication in line with NICE guidance and the local pathway. We appreciate Mr I suffered with his symptoms while this was being ruled out and are sorry that he could not have had the medication that he found helpful sooner.

1. We have carefully considered Mr I’s complaint about the Practice. We are sorry to hear about how much pain he experienced while waiting for medication and we are glad to hear the medication he now has been helpful for him.

2. We have seen no indication that anything went wrong in the Practice’s care and treatment of Mr I. We will now go on to explain our decision in detail.