A practice in the Castle Point area

3. Mr L complains that GPs at the Practice took too long to refer his father, Mr K, for urgent investigations after he presented with a range of worsening symptoms between April and July 2024. Specifically, these symptoms were, persistent back and hip pain, shoulder pain, lethargy, night-time urination, chest pains, shortness of breath, and persistent earache.

4. Mr L says his father lost the opportunity to have his kidney cancer diagnosed at an earlier date. This meant he lost the opportunity for a better outcome and he may not have died or may have lived for longer in better health. He adds that this was very difficult for the family, who did not have much time to prepare for their bereavement.

5. Mr L is seeking a financial remedy and service improvements.

6. Mr K exercised regularly and was in good health before 2024. He began to experience a range of symptoms and attended the Practice for advice and treatment on several occasions between April and July that year.

7. In July 2024 Mr K went to his local emergency department with pain in his back, ribs, shoulders, hips and muscles. The doctors suspected he might have a pulmonary embolism (a serious condition in which a blood clot blocks an artery in the lungs). They carried out a CT scan (that takes detailed pictures of the inside of the body) to investigate their suspicions. While this found Mr K did not have a pulmonary embolism, it did show he had kidney cancer which had spread to his liver and bones.

8. The cancer had already advanced too far for curative treatment and Mr K sadly died in September 2024.

12. Mr L said his father attended the Practice on many occasions between April and May 2024 with worsening symptoms, which Mr L now thinks his advanced kidney cancer caused. He complains that, despite this, the GPs did not order any investigations or referrals that resulted in a diagnosis of kidney cancer. He says this means his father could have lost an opportunity for a better outcome, even if he may still have died. He also explains his family could have had longer to come to terms with his distressing diagnosis. We recognise that events progressed quickly, and this added to the impact of the family’s bereavement.

13. The Practice said that its clinicians acted quickly in organising appropriate diagnostic tests and urgent referrals for Mr K in the short time between him reporting back pain and his diagnosis with cancer. It explained GPs cannot order some types of imaging, such as the CT scan which found Mr K’s cancer.

14. When GPs think a patient has ‘red flag’ symptoms for cancer they can make a referral in line with NICE guideline NG12: ‘Suspected cancer: recognition and referral’. Section 1.6.6 deals with suspected renal (kidney) cancer. This says:

‘Refer people using a suspected cancer pathway referral for renal cancer if they are aged 45 and over and have:

• unexplained visible haematuria [blood in the urine] without urinary tract infection [UTI] or • visible haematuria that persists or recurs after successful treatment of urinary tract infection’.

15. Mr K did not have a UTI during this time so this means if he had reported visible blood in his urine (a red flag for kidney cancer), his GP should have referred him for tests to confirm or rule out kidney cancer. Our adviser reviewed Mr K’s records and confirmed that Mr K did not report blood in his urine, which they explained was a typical symptom of kidney cancer. Mr L explained his father had many symptoms, but these did not include blood in his urine.

16. We considered whether the Practice’s clinicians carried out appropriate referrals and investigations during his attendances, even if they did not have a reason to refer him on the suspected cancer pathway. Our adviser reviewed Mr K’s GP record to inform our consideration.

17. Mr K’s first attendance at the Practice (although he had been registered since 2020) was in April 2024, when he complained of jaw pain and difficulty opening his mouth. The GP suggested he visit his dentist. Our adviser confirmed these symptoms were not a red flag and it was better suited for a dentist to investigate. Good Medical Practice, section 15c says ‘you must provide a good standard of care and practice. If you assess diagnose or treat patients, you must refer a patient to another practitioner when this serves the patient’s needs’. The GP referred Mr K to his dentist which was in line with this guidance. Mr K did not report difficulty opening his mouth again.

18. Mr K returned to the Practice a few days later with shoulder pain. Mr L told us that his father’s cancer spread to the bones in this shoulder and, with hindsight, this could have been a symptom of his cancer.

19. The Practice physiotherapist reviewed Mr K. He had previously had a frozen shoulder (pain and stiffness in the shoulder joint) so the physiotherapist diagnosed a recurrence of this condition and advised him to follow the same rehabilitation exercise plan he had used before. They also referred him to a local musculoskeletal (MSK) service, which treat conditions which effect the joints, bones and muscles. Clinicians in this service can order an MRI scan if they think one is needed.

20. In May, a paramedic at the Practice reviewed Mr K, with a GP providing advice on the plan. He said he’d been experiencing hip pain for 12 weeks and back pain for around five. The pain was only present when moving. He also had an ear infection. The pain was now in both hips and he was feeling more tired than usual. He said he did not have any shortness of breath or heart palpitations (a fast, fluttering or pounding heartbeat). The paramedic examined Mr K and his observations (oxygen levels, heart rate, blood pressure) were normal. His chest was clear.

21. The paramedic prescribed antibiotics and eardrops for the ear infection. They also ordered blood tests and X-rays of Mr K’s hips and back to look for a cause of the symptoms. Our adviser explained that Mr K’s age and joint pain could have suggested arthritis. NICE guideline NG226: ‘Osteoarthritis in over 16s: diagnosis and management’ says that diagnosis of arthritis in over 45s does not require imaging such as X-rays. In this case the clinicians ordered investigations above what might have been indicated by Mr K’s symptoms.

22. The blood tests showed that Mr K’s iron levels were slightly low and his kidneys were not working as well as they should do. The GP reviewed him again that May and noted he now had an irregular pulse, as well as tiredness, lethargy, and aches and pains. They ordered an ECG to check his heart rhythm, which our adviser explained could account for some of his symptoms. The GP also ordered further blood tests to check his kidney function again and ultrasound scans of his abdomen and kidneys. Kidney function can vary with time, so it was appropriate to check this again. At that time, Mr K’s symptoms did not meet the criteria for a suspected cancer referral or a same day referral, so the investigations were reasonable.

23. Shortly after this appointment, the hospital sent the X-ray and ultrasound results to the GP. The X-ray reported changes suggesting arthritis. Our adviser explained this was a potential cause of Mr K’s joint pain. The ultrasound showed Mr K had hydronephrosis (a blocked kidney). It showed no sign of a kidney cancer, although this may not mean there is no cancer. We understand this was a worrying time for Mr K.

24. The (NICE) clinical knowledge summary for chronic kidney disease says that clinicians should ‘arrange referral to a urology specialist, the urgency depending on clinical judgement, if there is suspected urinary tract obstruction (for example the bladder is palpable or hydronephrosis is seen on renal tract ultrasound)’. The GP informed Mr K of this result and made urgent referrals to urology and nephrology, which specialise in diseases of the urinary tract and the kidney. This was the most urgent action the GP could take in view of Mr K’s symptoms and results and is in line with NICE guidelines.

25. In June, Mr K went back to the Practice for a review of his ear problem. Our adviser explained that a build up of ear wax is not a red flag symptom. A GP also reviewed him, as he was now reporting chest pains and palpitations, as well as his existing symptoms. Our adviser explained that the new symptoms are not usually linked with cancer and Mr K and the GP were waiting for the outcome of his referrals. At this stage the GP was unable to pinpoint the cause of his symptoms, and appropriate investigations had already been actioned, including an urgent referral to hospital. There was no reason to order new investigations or make any more referrals, so it was reasonable to wait for the outcome of the existing referrals.

26. In July, a GP reviewed Mr K’s pain medication and ordered more X-rays as his knees and hips were very painful. These X-rays showed arthritic changes and there was no reason for the GP to take further action. Shortly after this, Mr K learned he had cancer after he went to the hospital with chest pain. We recognise this was a difficult time for Mr K and his family.

27. In summary, Mr K’s ear problems were not a reason to suspect kidney cancer and may not have been connected to his diagnosis. Mr K had a collection of other symptoms which seem to have been caused by his cancer. It appears he did not experience blood in his urine, a typical symptom which should lead to a referral on the suspected kidney cancer pathway. It was also unfortunate that his cancer was not visible to the ultrasound. We saw no indication the GP should have ordered other tests, delayed ordering the tests and investigations they did request, or made a more urgent referral for a same day admission. This means we have decided not to take further action about his concerns.

28. We are sorry to learn Mr K died two months after his diagnosis, which meant his family did not have long to prepare for their bereavement. We hope that by bringing this complaint to us, Mr L and his family are now able to find a measure of closure.

1. We have carefully considered Mr L’s complaint about the Practice. We have seen no indication the Practice should have referred Mr K on a suspected cancer pathway or referred him sooner for other investigations. This means we will not take further action about Mr L’s concerns.

2. We are sorry to learn Mr L’s father, Mr K, did not learn he had kidney cancer until he was unable to have curative treatment and shortly before he died. This understandably made the family’s bereavement more difficult and caused them to wonder about whether he should have learned sooner. We hope they find our decision helpful and reassuring.