A practice in the Test Valley area

8. Mr O complains between November 2022, and January 2023 the Practice failed to identify Mrs O’s symptoms were indicative of lung cancer and refer her promptly for further tests.

9. Mr O says this delayed Mrs O’s diagnosis of lung cancer by three months, and she lost the opportunity for a better clinical outcome and more time with her family due to this delay. He adds this was very distressing for his family and caused him to struggle with his mental health.

10. Mr O would like the Practice to acknowledge and apologise for what happened. He would like service improvements and financial compensation.

11. Mrs O had COVID-19 at the start of October 2022. By 1 November she had lost a stone in weight as she had not been eating properly. Between 22 November and 17 January 2023, the Practice arranged three blood tests which all came back as abnormal. On 25 January the Practice referred Mrs O on a suspected cancer pathway. Mrs O was diagnosed with lung cancer on 17 February and sadly died on 23 June 2023.

15. Mr O complains the Practice failed to recognise Mrs O’s symptoms were indicative of lung cancer and refer her for further tests.

16. We reviewed this issue with the help of our GP adviser using Mrs O’s medical records.

17. NICE suspected cancer guidance says, the clinician should offer an urgent chest X-ray (to be done within two weeks) to assess for lung cancer in people aged 40 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

18. On 1 November 2022 Mrs O had a telephone consultation with the Practice. She reported having COVID-19 in October and suffering with a cough and shortness of breath. She reported no fever or chest pain but said she had a poor appetite and had lost a stone in weight.

19. Our GP adviser said the Practice asked relevant questions regarding Mrs O’s symptoms and noted this would have been somewhat challenging at the time, as her recent COVID-19 diagnosis would account for many of her symptoms.

20. We note there is no documentation during this telephone consultation of Mrs O’s smoking status although it may have been visible to the GP. Our GP adviser said it is beneficial to demonstrate the clinician has considered the patient’s smoking status as this is relevant when considering potential diagnoses.

21. On receiving our provisional views, the Practice confirmed it did not check Mrs O’s current smoking status on 1 November. Instead, it relied on information documented in 2011 when Mrs O had reported having stopped smoking. The records show the Practice asked about Mrs O’s smoking status on 25 January 2023. On this day, Mrs O advised she had been a smoker for 50 years and smoked between 10 and 19 cigarettes per day.

22. Our GP adviser said specifically in a patient with a prolonged cough, their current smoking status should be confirmed. This is taking a basic medical history in accordance with Good Medical Practice which says, ‘in providing good clinical care you must adequately assess a patient’s condition taking into account their history.’ We consider this is a failing.

23. The Practice prescribed antibiotics for a suspected chest infection with safety netting advice to call back if her symptoms did not settle.

24. As Mrs O had reported recently having had COVID-19, this would have explained her symptoms therefore an urgent chest X-ray was not indicated. It was appropriate to prescribe antibiotics with safety netting advice to return if symptoms persisted at this appointment.

25. The Practice saw Mrs O during a face to face appointment on 24 November as her symptoms had not improved. The Practice took a history and carried out a physical examination including all vital observations and weight. Mrs O reported an ongoing cough and no energy or appetite.

26. In view of Mrs O’s ongoing symptoms and mild fever the Practice prescribed alternative antibiotics. Our GP adviser confirmed there was no indication from this assessment, Mrs O required hospital admission or specialist referral, and it was appropriate to try a different antibiotic.

27. In view of Mrs O’s lack of energy (fatigue) and appetite, recent weight loss and smoker status (to the Practice’s knowledge Mrs O had been a smoker), blood testing and an urgent chest X-ray was required at this point. We have seen evidence the Practice did request blood testing and a chest X-ray at this appointment but there is nothing to suggest it requested an urgent chest X-ray.

28. There was a significant delay between the Practice requesting a chest X-ray on 24 November and the results being available on 22 December. The cause of this delay is unclear and may have been outside the Practice’s control.

29. Mrs O’s blood results came back on 1 December and showed she had raised platelets at 562 (normal range 150 – 450). The clinical term for raised platelets is thrombocytosis.

30. Significantly, the blood results also showed Mrs O’s calcium was raised at 2.77 (normal range 2.15 – 2.6). The clinical term for raised calcium is hypercalcaemia.

31. The blood results also showed raised white cells, mild anaemia and very low albumin (a marker of liver function and overall health). These results are in keeping with significant infection or inflammation.

32. The Practice contacted Mrs O on 2 December to discuss her abnormal blood results. Mrs O reported feeling slightly better. She also reported passing small amounts of dark urine. The Practice prescribed antibiotics for a urinary tract infection (UTI) noting this could explain the blood results.

33. The Practice planned to repeat the blood tests the following week. These further blood results were available on 6 December and were again abnormal showing mild anaemia, raised platelets, and calcium.

34. NICE hypercalcaemia guidance states, ‘refer all people with hypercalcaemia to an appropriate specialist, with the urgency and route of referral depending on the calcium level severity and clinical picture, unless hypercalcaemia is mild, asymptomatic, and a reversible cause has been identified and, when removed, calcium has returned to normal.

• if the person has mild hypercalcaemia (calcium greater than 2.6 but less than 3 mmol/L) and is asymptomatic, then make a full clinical assessment and arrange initial investigations so as to establish the probable cause and refer to the appropriate specialty, unless a correctable cause is found • if malignancy is suspected, refer via a local suspected cancer pathway highlighting the presence of a raised calcium level.’

35. NICE thrombocytosis guidance states:

• ‘a normal platelet counts lies within the range 150 – 450 × 109/L • thrombocytosis is a platelet count greater than 450 × 109/L • thrombocytosis can be a marker for potential cancer, including lung, endometrial, gastric, oesophageal or colorectal cancer • management of thrombocytosis should include arranging referral for people with persistent and unexplained counts over 450 × 109/L • repeat blood counts in four to six weeks for other people where no underlying cause is identified, and the person remains asymptomatic.’

36. A persistent raised platelet count can be due to numerous reasons including infection but can also be a finding that indicates underlying cancer. The NICE guidance advises consideration of a referral where the results are unexplained.

37. Whilst it could be argued Mrs O’s raised platelets may have been due to a chest infection rather than unexplained, the fact she was a smoker (to the Practice’s knowledge been a smoker) with a persistent cough should have highlighted the real risk of underlying lung cancer.

38. Our GP adviser said, at this stage the Practice had access to two sets of abnormal blood results in a patient over the age of 60 who smoked (to the Practice’s knowledge had smoked). Mrs O had multiple assessments and contacts with the Practice since 1 November. Despite multiple antibiotics, her blood results were significantly abnormal and not improving.

39. The chest X-ray results were still not available by 6 December, and we have seen no evidence to show the Practice tried to chase these results.

40. The Practice requested further blood testing on 12 December, and the results again were abnormal.

41. Mrs O had a telephone consultation on 15 December to discuss the results. She reported feeling better. The Practice planned to repeat the blood tests in one week and noted a chest X-ray was planned for the following week.

42. The Practice now had three sets of abnormal blood results with no apparent plan other than another follow up.

43. Mrs O had an appointment at the Practice on 23 December. It is unclear if this was in person or by telephone. Although Mrs O reported feeling well, her bloods were very concerning, and this was another potential opportunity to admit or urgently refer her on a suspected cancer pathway.

44. On 28 December, Mrs O had a telephone consultation to discuss her chest X-ray result. It appears the GP incorrectly assumed Mrs O was on cephalexin antibiotic. However, Mrs O was not, and this led to a further telephone consultation the following day in which a plan was made to treat a chest infection with antibiotics and repeat the chest X-ray.

45. Our GP adviser told us this is standard protocol after an abnormal chest X-ray result. However, the Practice had access to abnormal blood results in conjunction with a suspicious chest X-ray in a smoker and this was a further opportunity to refer Mrs O on a suspected cancer pathway.

46. The Practice contacted Mrs O on 13 January 2023 to discuss her persistently abnormal blood results. These results showed a further rise in calcium (2.78) and platelets (729). A face to face review was arranged for the following week.

47. On 17 January the Practice reviewed Mrs O again. The assessment recorded a significant weight loss of 10kg over a two month period. This, in conjunction with Mrs O’s very abnormal blood results was another clear opportunity to refer her on a suspected cancer pathway. The Practice requested further bloods and noted a chest X-ray was planned.

48. The Practice assessed Mrs O again on 25 January. The Practice explained it was very concerned about her blood results and the potential she could have lung cancer. The Practice referred Mrs O on a suspected lung cancer pathway.

49. We have seen evidence the Practice should have referred Mrs O on a suspected cancer pathway as early as 6 December in accordance with NICE guidance, when repeat blood tests were persistently abnormal. We find this was a failing.

Impact of failings identified

50. We sought advice from our oncologist adviser to consider the impact of the failings we have identified in the care provided by the Practice.

51. We consider the Practice should have referred Mrs O on a suspected cancer pathway as early as 6 December when it had access to two sets of abnormal blood results. The Practice eventually referred Mrs O on 25 January 2023. This represents a delay of seven weeks.

52. Mrs O admitted herself to hospital on 30 January. She was an inpatient until 10 February during which time clinicians were carrying out tests to determine her diagnosis.

53. On 10 February before being discharged from hospital, Mrs O was reviewed by the palliative care team for a referral to the community palliative care team. At this stage it was felt likely she had metastatic lung cancer, but it had not been formally diagnosed.

54. Mrs O reported no pain, breathlessness, nausea or anxiety and declined any further procedure or treatment from the palliative care team. The team noted her wish not to be contacted by the community palliative care team but gave her the number to call if she needed to contact them.

55. On 15 February, the oncology team diagnosed Mrs O with metastatic squamous cell lung carcinoma (an advanced form of lung cancer) with tumour in left main bronchus (a vital airway). There was evidence of metastases (cancer that has spread) in the adrenal gland and neck region of the spine. There was also oedema (build-up of fluid) in the right kidney which clinicians thought may be related to the cancer.

56. Our oncologist adviser told us if Mrs O had been referred in December it is likely she already had incurable metastatic cancer at this time. This is because her blood results showed persistently raised calcium levels which is an indicator of advanced cancer.

57. Information from Cancer Research UK says, ‘high blood calcium levels sometimes happen if cancer is advanced. It is less likely to happen if your cancer is at an early stage.’

58. The oncology team were concerned the tumour may cause her lung to collapse and offered surgery to reduce the size of the tumour. Mrs O declined saying she was not keen for any surgical intervention.

59. The oncology team recommended palliative radiotherapy to help shrink the tumour and relieve pain Mrs O was experiencing in her shoulder. Mrs O accepted this therapy on 15 February.

60. On 20 February Mrs O had an appointment with the oncologist team and discussed having palliative radiotherapy in five doses delivered over one week to reduce the risk of further collapse in her left lung. They also planned to deliver a single dose of radiotherapy to her spine to help with pain Mrs O was feeling in her neck and shoulder due to metastatic cancer in that area.

61. On 17 March the palliative care team reviewed Mrs O. She complained of severe pain in her right arm that she said had been present for months. She reported she was unable to sleep due to the pain. Mrs O agreed to be followed up by the community palliative care team at this point.

62. The palliative care team discussed pain medication with Mrs O. She advised she did not want to take morphine as she had tried it as an inpatient in hospital and it made her hallucinate. The team started Mrs O on pregabalin and clonazepam for the pain and suggested adding oxycodone the following week if she responded well to these.

63. Also on 17 March, the oncology team reviewed Mrs O and consented her for Pembrolizumab immunotherapy (a drug that helps the immune system fight certain types of cancer). The oncology team noted Mrs O did not want to discuss her prognosis, but she was aware treatment was palliative and that without a response to treatment her life expectancy was likely to be short.

64. On 29 March Mrs O had the palliative radiotherapy on her spine for the pain in her neck and shoulder. On 30 March, the oncology team reviewed her. She reported there was a slight improvement in the pain she had been experiencing and was optimistic the palliative radiotherapy would continue to gradually improve this.

65. We note there is no record of Mrs O receiving the palliative radiotherapy which was recommended to shrink the tumour in her airway. It is not clear why this did not go ahead, although the records do say this was discussed rather than actually planned.

66. The first cycle of Pembrolizumab immunotherapy started on 31 March with a plan to repeat every three weeks. Mrs O received three rounds of Pembrolizumab immunotherapy at three weekly intervals.

67. On 31 May an oncologist reviewed Mrs O. The oncologist noted she was now very frail with clear progression of disease. The oncologist noted new masses in the chest wall and groin. The oncologist explained the treatment was not working and they agreed to stop it. Mrs O was not fit enough for more chemotherapy and there was no other drug based treatment the oncologist could offer her.

68. The oncologist and Mrs O discussed her wishes for end of life care. The oncologist noted her life expectancy was likely to be short. Mrs O wished to die at home with support from the community palliative care team. Mrs O sadly died on 23 June.

69. We asked our oncologist adviser might Mrs O have had more time if she had started immunotherapy sooner. Our oncologist adviser told us had Mrs O been referred and diagnosed seven weeks sooner she may have remained well enough to have sufficient immunotherapy to help shrink the cancer.

70. However, a study by the New England Journal of Medicine shows Pembrolizumab immunotherapy only has a 44% response rate, meaning more than half of patients will not respond to this treatment. We have seen evidence Mrs O did not respond as her cancer was progressing despite receiving three rounds of immunotherapy.

71. Due to this and also how advanced the cancer likely was in December, we cannot say with any certainty Pembrolizumab immunotherapy would have prolonged Ms O’s life or for how long.

72. On the balance of probabilities, we have not seen evidence to suggest Mrs O’s death could have been avoided had the delay in referral not occurred or that she would have lived longer.

73. We think Mrs O received input from the palliative care team for her pain relief at the time she needed it. She had initially declined any intervention stating she had no pain, breathlessness or nausea. We saw she did accept input from the team when her symptoms became such that she needed it, so an earlier referral would not have made a difference.

74. We do however consider the delay in referring Mrs O for suspected cancer meant she missed opportunities for an earlier diagnosis and palliative radiotherapy, which may have improved her comfort sooner.

75. We consider this caused uncertainty for Mr O. This is because he will understandably wonder what Mrs O’s care and support might have been, if she was referred for suspected cancer or been under the oncology team sooner.

76. We have not seen these failings and the impact have been recognised by the Practice.

1. Mr O brings a complaint to us about the care provided to his wife, Mrs O. Mr O says the Practice missed opportunities to recognise Mrs O’s symptoms indicated lung cancer and refer her for further investigations.

2. We have seen failings in the care provided by the Practice. We consider it missed opportunities to refer Mrs O sooner under a suspected cancer pathway. We consider Mrs O would more than likely have received an earlier diagnosis had these failings not occurred.

3. We have not seen evidence to suggest Mrs O’s death could have been avoided or that she would have had more time had the delay in referral not occurred. We do however consider the delays in referring her meant she missed opportunities for an earlier diagnosis and consideration of palliative radiotherapy which may have improved her comfort sooner.

4. We think this has caused uncertainty for Mr O around what Mrs O’s care and support might have been had she been referred sooner.

5. We have not seen these failings and the impact of these have been recognised by the Practice. We therefore make recommendations to address this at the end of our report.

6. We partly uphold Mr O’s complaint.

7. We thank Mr O for discussing his concerns with us. We understand how important his complaint is and recognise the distress he and his family have felt.