A practice in the York area

6. Mr S complains the Practice failed to properly treat his wife, Mrs S’s, cyst between April and August 2021. He complains the Practice:

• did not see his wife face-to-face when needed • over-prescribed pain medication • missed red flag symptoms of cancer.

7. He says as a result of these circumstances, he has struggled to come to terms with his wife’s death and feels ‘angry’. He says her not being seen face-to-face caused a delay in her being diagnosed with cancer. He says the GP prescribed over 100 tablets instead of checking the cause of her pain.

8. Mr S says had the Practice been more proactive, he could have had time to say goodbye in a ‘dignified and humane manner’. He says while an earlier visit from a doctor would not have changed the outcome, an earlier diagnosis and treatment may have given them the opportunity to say their goodbyes.

9. Mr S wants an apology and service improvements.

10. Mrs S had a history of hypothyroidism (a condition where the body does not make enough thyroid hormone).

11. The Practice saw Mrs S during May and August 2021 about an infected cyst (a round lump filled with fluid or pus). The doctor found she was not taking her thyroxine (a medication to treat hypothyroidism) and explained to Mrs S the benefits of taking it.

12. Mrs S contacted the Practice on 20 August 2021 as she had deteriorated suddenly and was in a lot of pain with her back and into her legs. The advanced nurse practitioner (ANP) saw her at home and they arranged an admission at the Trust the same day.

13. The Trust did a chest, abdomen and pelvis computerised tomography (CT) scan (a scan that takes images of the organs in the chest, stomach and pelvic areas) on 23 August 2021. This scan showed Mrs S had cancer. She sadly died soon after. The Trust did a malignancy (cancer) of unknown origin meeting to see if it could find the cause of Mrs S’s cancer. It found it was unable to find where the cancer had started.

Appointments and cyst

18. Mr S says the Practice did not treat his wife’s cyst properly, as they did not see her face-to-face because of COVID-19. He says this stopped it treating his wife properly. We are sorry to hear about the issues Mr S told us about. We appreciate this must have been an incredibly distressing time for him and his wife.

19. GMC guidance says doctors ‘must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: adequately assess the patient’s conditions, taking account of their history […], their views and values; where necessary, examine the patient [and] promptly provide or arrange suitable advice, investigations or treatment’.

20. The records show Mrs S and the Practice had a telephone appointment on 20 May. She said she had had issues with her knees since 2018 but her pain was getting worse. The doctor arranged to see Mrs S at a face-to-face appointment the following day. This was in line with GMC guidance. She was complaining about worsening pain, and because it was not getting better it reviewed her face-to-face to assess her condition.

21. The GP reviewed her, and Mrs S said she had a fall two years ago but her pain was getting worse. The doctor arranged a referral for physiotherapy and diagnosed her with osteoarthritis. NICE osteoarthritis guidance says a GP can ‘consider supervised therapeutic exercise sessions for people with osteoarthritis’. The GP referring Mrs S for physiotherapy was in line with this guidance.

22. Mrs S next contacted the Practice on 30 July where the doctor saw her face-to-face about her cyst which she had since 2017. The doctor lanced the cyst to check for infected fluid and prescribed antibiotics because they suspected it was infected.

23. Mrs S had a telephone appointment with the Practice on 10 August, where she said her cyst had now stopped leaking pus. She said she was queasy and tired and was taking ibuprofen (a type of anti-inflammatory pain relief) for her pain. The doctor assessed Mrs S and found she had not been taking her thyroxine, which they thought was causing her tiredness. NHS guidance on underactive thyroid says common symptoms are ‘tiredness, slow movements, muscle aches and weakness’.

24. NICE thyroid disease guidance says, ‘offer levothyroxine as first-line treatment for adults with primary hypothyroidism’. The Practice prescribed levothyroxine in line with NICE guidance. It investigated her symptoms and prescribed treatment for her underactive thyroid. Our adviser explained the GP fully explored Mrs S’s symptoms. There was no sign Mrs S’s condition was getting worse or that she needed a face-to-face examination.

25. Mrs S contacted the Practice on 20 August to say she was in lots of pain across her back and into her knees. She said she had not been out of the house for a month. The GP arranged for an ANP to see her face-to-face because her condition was getting worse. This was in line with GMC guidance as it arranged for a face-to-face assessment. The ANP reviewed her and arranged an admission to hospital.

26. The only time the GP did not see Mrs S face-to-face after a telephone appointment was on 10 August. During this appointment her condition was not getting worse, and the GP found she was not taking her levothyroxine. The Practice saw Mrs S face to face after its telephone consultations on 20 May and 20 August, and on 30 July.

27. We appreciate this situation must have been distressing for Mr and Mrs S. We have not seen any signs anything went wrong in how the Practice managed his wife’s cyst, or that it did not see his wife face-to-face when needed. Most of his wife’s appointments were face-to-face. We will not consider this part of his complaint further.

Pain medication

28. Mr S says the Practice prescribed over 100 paracetamol tablets for his wife to take over a week, without investigating the cause of her pain. We are sorry to hear about the concerns Mr S had about his wife’s pain relief medication.

29. NICE analgesia guidance says people in mild to moderate pain can be prescribed 500mg to 1g of paracetamol every four to six hours.

30. During the appointment on 10 August, Mrs S complained about pain and said she was taking ibuprofen. The GP recommended she stop this and gave her some paracetamol to try. They prescribed 1g three times a day and gave her a one-month supply.

31. The GP’s management of Mrs S’s pain was in line with NICE analgesia guidance and GMC guidance. It assessed her, reviewed her pain management when she complained of pain, and prescribed her paracetamol at a dose that was in line with NICE guidance.

32. Mr S says the GP told his wife to take over 100 paracetamol tablets over the course of a week. But from what we have seen, it told her to take 1g three times a day which is not the highest dose the NICE analgesia guidance recommends.

33. We have not seen any signs anything went wrong in how the Practice managed his wife’s pain, or that it told Mrs S to take 100 paracetamol tablets in one week. We will not consider this part of his complaint any further.

Cancer

34. Mr S says the GP prescribed a ‘bag of drugs’ and missed his wife’s cancer.

35. NHS guidance on signs of cancer says, ‘It’s important to speak to a GP if you think something is not right, or you keep feeling tired and unwell and you’re not sure why’.

36. The records show Mrs S presented with knee pain, but this had been there since a fall she had in 2019. The GP arranged a referral to a physiotherapist. When this did not help, they gave her pain medication.

37. NICE cancer recognition guidance sets out symptoms that should prompt a referral for further investigation. The section on non-site-specific cancers advises doctors to look for weight or appetite loss. Mrs S presented with neither.

38. Some parts of that NICE guidance also mention unexplained fatigue. Mrs S did complain of tiredness on 10 August but the GP found she was not taking her levothyroxine for her underactive thyroid. A common symptom of an underactive thyroid is tiredness.

39. Our adviser explained Mrs S was not showing any ‘red flags’ (warning signs) for cancer. The records show Mrs S was not losing weight or appetite. Although she had tiredness, it was not unexplained because this was thought to be caused by her underactive thyroid.

40. We have not seen any signs the Practice missed signs that Mrs S had cancer. We will not consider this part of his complaint any further.

41. We realise how difficult and upsetting this matter has been for Mr S and thank him for bringing his complaint to us. We hope he takes some reassurance from knowing the Practice could not have done any more to find his wife’s cancer sooner.

1. We have carefully considered Mr S’s complaint about a Practice in the York area (the Practice). It is clear from what Mr S told us that events at the Practice have caused him great distress and upset.

2. Regarding his wife’s appointments and treatment of her cyst there are no signs that anything went wrong. The Practice managed his wife’s conditions in line with relevant guidelines and saw her at a face-to-face appointment when needed. We will not be taking further action on this part of his complaint.

3. We saw no signs anything went wrong with Mrs S’s pain medication. The Practice prescribed his wife paracetamol with two to be taken three times a day - enough to last her a month. The actions the Practice took to help his wife’s pain were in line with relevant guidelines. We will not be taking further action on this part of his complaint.

4. We then looked at if the Practice missed any red flag symptoms of cancer. We did not see any signs anything went wrong. Mrs S had pain and tiredness which are potential signs of cancer, but these were not unexplained. Her pain had been present since a fall in 2019. She had also not been taking her underactive thyroid medication and a common symptom of this is tiredness. Her tiredness was not unexplained. We will not be taking further action on this part of his complaint.

5. We want to thank Mr S for the time he has taken to bring his complaint to us. We hope our explanations below explain why we will not be taking his complaint further.