A practice in the Charnwood area

4. Mrs E complains about the care and treatment provided to her husband, Mr E by a GP Practice between July 2024 and January 2025. She complains the Practice:

• failed to investigate his progressive symptoms and ‘red flags’ that warranted urgent cancer investigation • delayed referring him onto the cancer pathway, despite the fact he met NICE guidance criteria for this • did not carry out basic diagnostic blood tests until very late in the progression of the cancer • did not thoroughly evaluate blood test results from 11 October 2024 for cancer markers • did not properly review the private MRI scan results from October 2024 and missed crucial indicators of potential malignancy.

5. Mrs E says as a result of the delayed diagnosis and lack of timely care and treatment, her husband died two months after being diagnosed with Stage 4 Pancreatic cancer. By the time he was diagnosed, the cancer had progressed to an inoperable stage, impacting his quality of life for the time he had left. She says his death has had a profoundly devastating impact on his family including his young daughter.

6. As well as this, Mr E was the main earner in the family, and his death has resulted in financial difficulties as well as mental health related issues for Mrs E and her young daughter.

7. As a result of bringing this complaint to us, Mrs E is seeking recognition of the failings in the form of an apology, service improvements and financial remedy.

8. Mr E first went to the Practice in July 2024 complaining of severe back pain.

9. Mrs E says between September and December 2024 Mr E went back multiple times to the Practice to report ongoing and new symptoms including severe abdominal pain, nausea and rapid weight loss.

10. In October 2024 Mr E went for a private MRI scan via his personal health insurance and the results were sent directly to the Practice to review. The results were sent to the Practice via letter on 7 November 2024.

11. Mr E attended 3 more GP appointments throughout December complaining of pain. On 8 January, Mr E reported the pain had worsened and the GP referred him as an emergency to hospital.

12. Mr E was admitted to hospital as an emergency on 8 January 2025 resulting in a stage 4 pancreatic cancer diagnosis on 13 January 2025. Mr E sadly died in March 2025.

13. Mrs E complained to the Practice on 16 January 2025. The Practice sent its final response on 10 March 2025, and Mrs E brought the complaint to us on 15 April 2025.

The Practice failed to investigate his progressive symptoms and ‘red flags’ that warranted urgent cancer investigation.

The Practice delayed referring him onto the cancer pathway, despite the fact he met NICE guidance criteria for this The Practice did not carry out basic diagnostic blood tests until very late in the progression of the cancer The Practice did not thoroughly evaluate blood test results from 11 October 2024 for cancer markers.

17. Mrs E says the Practice failed to investigate her husband’s progressive symptoms. She says despite multiple visits to the Practice, no comprehensive investigation was undertaken. She says symptoms that warranted urgent cancer investigation were repeatedly attributed to stress or medication side effects.

18. Mrs E says the Practice missed the reg flags Mr E reported to them such as progressive abdominal pain, unexplained weight loss, development of new symptoms over several months and Mr E’s deteriorating condition despite his prescribed treatments.

19. She complains no urgent cancer pathway referral was made despite Mr E meeting the NICE guideline criteria and basic diagnostic tests were not done until very late in the cancer’s progression. Mrs E says despite Mr E reporting concerning symptoms, no CA19-9 or specific pancreatic blood markers were included in the blood tests. Mrs E says the blood tests the Practice performed on 11 October 2024 were not thoroughly evaluated for cancer markers.

20. Mrs E says the delayed diagnosis prevented timely care and treatment and her husband died two months after being diagnosed with Stage 4 Pancreatic cancer. She says by the time he was diagnosed, the cancer had progressed to an inoperable stage, impacting his quality of life for the time he had left. She says his death has had a profoundly devastating impact on his family including his young daughter.

21. The records show Mr E went to the GP in July 2024 complaining of ‘acute onset back pain, which started after a triathlon’. The GP examined Mr E and found his back to be tender over a couple of vertebrae and had reduced flexion (the ability to bend). As a result, he was referred to the physiotherapist.

22. In September 2024 he went back to the GP reporting work related stress. It was also documented he had abdominal pain which was not explored any further. He was signed off work for 2 weeks and the note was extended on 7 October for a further 2 weeks.

23. On 8 October, Mr E went to the GP with ongoing back pain, by this point he had had it for 3-4 months, but it had got worse over the last 3 weeks. He complained of pain with sitting back or lying on his back and exacerbated by eating. There was no weight loss, fever or neurological symptoms reported. On examination he was found to have spinal tenderness and a normal abdomen. The GP organised blood tests and it was arranged that Mr E would book an appointment with an orthopaedic surgeon for an MRI scan using his private health insurance.

24. The bloods taken by the Practice were kidney function, liver function, a full blood count, calcium, C reactive protein (a test for inflammation in the body) and Hb electrophoresis (a test to analyse the haemoglobin in the red blood cells). The results of these blood tests were all returned as normal.

25. Mr E had a further appointment with the GP on 11 October and reported there was no improvement in his back. Mild pain and tenderness in his abdomen was noted on examination. The GP took no further action at this point as Mr E was still due to see the orthopaedic surgeon and have his MRI scan.

26. On 7 November the Practice received a letter from the orthopaedic surgeon. The letter stated that the MRI was normal apart from some mild inflammation at the left T9 costovertebral junction which could be the cause of the pain. It was stated that there was ‘nothing of any concern’.

27. On 2 December, Mr went back to the GP, reporting ongoing back pain. He was prescribed amitriptyline and etorocoxib which is an anti-inflammatory pain killer. The Practice arranged a follow up appointment for 20 December.

28. During his follow up appointment on 20 December, Mr E reported to the GP that his back pain was worse. He also had abdominal pain, which was worse with eating. It was noted that he had no problem with swallowing, no blood in his stool and his stool was not black. The GP stopped his Arcoxia and suggested a review in 2 weeks.

29. On 24 December, Mr had a consultation with the GP, they discussed the use of co-codamol was causing constipation. Management with laxatives was recommended.

30. On 3 January 2025, Mr E had an appointment with the GP reporting ongoing back pain. It was also noted the co-codamol caused him to be constipated, he was only opening his bowels twice a week but if he took any more than 2 sachets of laxative he was sick. His abdomen was examined and was normal. The co-codamol was stopped and he went back on to the Arcoxia with proton pump inhibitor cover (to reduce stomach acid production).

31. On 6 January he went again to the GP with abdominal pain. It was noted that he was struggling to cope. He was examined and found to have abdominal tenderness and lower thoracic spine tenderness which is where he had been complaining of pain. A plan was made to stop the Arcoxia, continue the proton pump inhibitor and to review in a few days if not helping or abdominal pain was not easing.

32. On 8 January, Mr E reported the pain had worsened again and the GP referred him as an emergency to hospital. On 13 January Mr was diagnosed with stage 4 pancreatic cancer.

33. The NICE CKS ‘Recognition and referral for suspected gastrointestinal tract (upper) cancer’ states:

• Refer people using a suspected cancer pathway referral for pancreatic cancer if they are aged 40 years and over and have jaundice.

• Consider an urgent direct access CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 years and over with weight loss and any of the following: • Diarrhoea • Back pain • Abdominal pain • Nausea • Vomiting • Constipation • New-onset diabetes

34. The cancer referral 2 week wait forms that GP’s complete are based on the above CKS guidance. Therefore, if Mr E did not fit the above criteria the form could not be accurately completed.

35. Our advisor explained it is difficult to diagnose pancreatic cancer. It presents late, with vague/non-specific symptoms that can come and go. It is rare in younger patients and nearly half of people diagnosed are over 75.

36. A patient would only meet the criteria for a two week wait pathway if they are symptomatic and over 60 or over 40 and have jaundice. Risk factors to take into account would be smoking, being overweight, diabetes and a family history. We can see from the records Mr E was 42 at the time of presentation, not presenting with jaundice at any point, and no risk factors were highlighted.

37. Our advisor explains there is a blood test called CA 19-9 which is a tumour marker. Not all pancreatic cancers produce CA 19-9 and even with a high CA 19-9 it can be suggestive of other illnesses and not pancreatic cancer.

38. The CA 19-9 blood test measures the level of a protein called cancer antigen 19-9 and is primarily used to monitor pancreatic cancer and other gastrointestinal cancers. Our adviser said CA 19-9 is most appropriately used in monitoring disease progression or effectiveness of treatment once diagnosis of the tumour has been made and serum concentrations have been shown to be raised prior to treatment.

39. Other blood tests would be useful to look for alternative causes of the back/abdominal pain. For example, the full blood count could diagnose anaemia which could suggest bleeding from the GI tract, or Hb electrophoresis could diagnose myeloma which can cause bony pain.

40. Our advisor says it is not a requirement for GP’s to perform a CA 19-9 blood test and there is no guideline that stipulates it should be done to assist in diagnosing a patient.

41. We have seen that between July and November 2024 the Practice assessed Mr E appropriately based on the symptoms he reported. He did not meet the NICE criteria set out above for a cancer referral during this time.

42. Our advisor says the blood tests Mr had in October were appropriate baseline tests for someone presenting as Mr E was. Both the blood tests and the private MRI scan results did not highlight any concerns about cancer. Had the results of these been abnormal then this would have triggered further investigations. As such, we have not seen any indications of failings in the care provided during this time.

43. From 2 December onwards, although he still did not meet the NICE criteria for a cancer referral, Mr E began reporting worsening pain and expressed his continuing concerns.

44. The NICE suspected cancer guidance says to consider a review for people with any symptom that is associated with an increased risk of cancer, but who do not meet the criteria for referral or other investigative action. The review may be patient‑initiated if new symptoms develop, the person continues to be concerned, or their symptoms recur, persist or worsen.

45. Our adviser said, by December, as Mr E had been suffering with pain for over five months with no specific identifiable cause, and as his symptoms were worsening, based on this, he met the ‘patient initiated’ criteria mentioned above. In line with this, our adviser said the GP should have referred him for further investigation. The GP could also have carried out a CA 19-9 blood test by way of investigating further.

46. Mrs E says she feels as her husband was not listened to and referred in a timely manner, he missed the opportunity for earlier diagnosis and treatment. We recognise why she would have this view.

47. As Mr E still did not meet the 2-week referral criteria in December, our adviser said the GP should have made an urgent referral for a CT scan. Our advisor says it is likely Mr E would have had to wait a few weeks for this scan and then have to wait for the report, which may have been delayed further by the Christmas period. We can see ultimately that he was referred as an emergency and seen in hospital on 8 January 2024.

48. Had a CA 19-9 blood test been organised by the Practice in December and showed a raised CA-199 or abnormal liver function, our advisor says Mr E may then have been referred on a 2 week wait cancer referral. However, by the time he had had the bloods done and the results through it would have been at least a week later so the time frame would have been very similar to an urgent referral.

49. Had Mr E been referred as early as 2 December, by the time he had had a scan, and received the results from the scan, it is unlikely he would have been diagnosed much earlier than he was on 13 January.

50. We have seen indications of failings in the care the GP provided to Mr E from 2 December in that it should have referred him for further investigations from this point. However, due to the timeframe involved, we cannot say a referral at this point would have led to an earlier diagnosis.

51. Taking all of the evidence into account, we consider even if he had been referred as early as 2 December, it is likely he would still have been diagnosed around the same time he was in January. As such, we cannot link the indicated failing to the impact Mrs E describes. We recognise the upset caused by Mr E’s late cancer diagnosis and do not wish to detract from that.

The practice did not properly review the private MRI scan results from October 2024 and missed crucial indicators of potential malignancy.

52. Mrs E says the private scan results from October 2024 were reviewed superficially by the Practice and it missed crucial indicators of potential malignancy.

53. The records show that on 7 November the Practice received a letter from the orthopaedic surgeon with the results of the private MRI scan. The letter said that the MRI scan taken in October was normal apart from some mild inflammation at the left T9 costovertebral junction which could be the cause of the pain. It was stated that there was ‘nothing of any concern’.

54. In relation to the GP’s role, the GMC’s Good Medical Practice guidance says ‘in providing clinical care you must consult colleagues or seek advice from your supervising clinician, where appropriate’. It also says ‘refer a patient to another suitably qualified practitioner when this serves their needs’.

55. Our adviser said it is not the GP’s role to review scan images and report on these. This is the role of the specialists responsible for performing the scan. Our advisor says the scan would have firstly been reported by a radiologist and then reviewed by the orthopaedic surgeon before being sent on to the Practice. There was an abnormality mentioned on the MRI scan that was inflammation of the T9 costovertebral junction, which could account for the pain Mr E described.

56. In line with the GMC guidance, it was reasonable for the Practice to accept the specialist opinion from the orthopaedic surgeon as a suitably qualified practitioner. We do not consider anything was missed by the GP at this point that would have led to earlier detection of Mr E’s cancer.

57. Sadly, pancreatic cancer is very difficult to detect. We understand the quick deterioration of Mr E’s condition meant his death was a big shock to his family. This would unquestionably have had a significant impact on their ability to come to terms with his death, and we do not underestimate that.

1. We have carefully considered Mrs E’s complaint about the Practice. We were very sorry to hear about the circumstances of her complaint and the loss of her husband, Mr E.

2. We have not seen any indications that anything went wrong in the way the Practice treated Mr E between July and November 2024. We have seen an indication of a failing in that the Practice should have referred Mr E for further investigations on 2 December 2024. Having considered this, we do not think this would have led to an earlier cancer diagnosis. Therefore, we cannot conclude this indication of a failing led to any impact.

3. We do not wish to downplay the seriousness of the issues involved and thank Mrs E for bringing her concerns to our attention. We hope the following consideration reassures her we have considered this matter fully and carefully before reaching our decision to take no further action on this complaint. We hope reading this statement does not cause undue upset, as this is not our intention.