A practice in the Birmingham area

7. Ms C complains about aspects of the care and treatment her husband, Mr C, received from the Practice. Specifically, she said the Practice:

• failed to categorise a test result as abnormal in December 2024 • failed to refer Mr C for a cancer diagnosis in the same month • did not escalate matters appropriately when Mr C called to inform them of the issue with the test result on 27 December 2024.

8. Ms C said her husband had to endure several further weeks of painful and distressing symptoms, between 12 December and 3 January.

9. She also said he lost the opportunity of further treatment such as chemotherapy, and they had to pay for private healthcare.

10. She said her mental health has been severely affected, and she now suffers from depression. She also said the communication and failure to escalate on 27 December 2024 contributed to the stress Ms and Mr C were experiencing at the time.

11. Ms C would like an explanation from the Practice of what would have happened with her husband’s care if the test result had been interpreted correctly.

12. She would also like the Practice to make service improvements on interpretation and categorisation of test results.

13. She would also like financial compensation and reimbursement of the private care fees.

14. Mr C attended an appointment at the Practice on 12 December 2024. He had been experiencing gastrointestinal symptoms including constipation, diarrhoea, indigestion, reflux, and vomiting.

15. The physician associate arranged several tests, including up-to-date bloods, a faecal calprotectin test (a test used to detect inflammation in the intestines), and a Faecal Immunochemical Test (FIT) (a home-based test that checks for hidden blood in a stool sample to detect cancer).

16. Between 16 and 27 December the test results above came back to the Practice.

17. On 20 December, a doctor documented Mr C’s full blood count was abnormal. They spoke to Mr C and arranged a face-to-face review for 7 January, when the FIT and faecal calprotectin results should be back.

18. On 20 December, the faecal calprotectin test result came back as raised. It is documented a doctor reviewed the result on 21 December and assessed it as normal, requiring no further action.

19. On 21 and 27 December Mr C went to A&E due to worsening symptoms. On the second occasion A&E staff flagged the discrepancy in the faecal calprotectin test result. Mr C called the Practice to inform staff of the issue. They asked him to call again the following working Monday (30 December).

20. On 27 December the FIT test came back to the Practice as positive.

21. Unhappy with the treatment by the Practice, Mr C contacted a private provider on 28 December. He attended an initial appointment with the provider on 31 December.

22. On 2 January 2025 the Practice spoke to Mr C and explained he needed a two week wait (2WW) colorectal referral on account of his positive FIT test. This is the kind of urgent referral a GP may make to a specialist if they are concerned a patient may have cancer.

23. On 3 January, Mr C attended A&E again and was admitted as an inpatient. Following a colonoscopy, endoscopy, and gastroscopy on 8 January staff diagnosed him with primary oesophageal cancer and primary colorectal cancer with metastatic lesions in his liver. On 10 January, Mr C underwent emergency surgery.

24. Mr C’s condition continued to deteriorate, and he started palliative care around 27 January. He was then admitted into a hospice where he sadly died on 14 February.

How the Practice categorised Mr C’s test result

28. We saw both Ms C and the Practice agreed the Practice incorrectly marked Mr C’s faecal calprotectin test result as ‘normal’. For this reason, we have focussed on considering the alleged impact of this event.

29. Ms C said Mr C avoidably experienced painful and distressing symptoms from 12 December to 3 January he would not have had the Practice marked the test correctly. She also said he lost the opportunity of further treatment such as chemotherapy, and they had to pay for private healthcare.

30. She said her mental health has been severely affected, and she now suffers from depression because of this.

31. To consider if the claimed impacts were avoidable, we considered what likely would have happened if the Practice marked the faecal calprotectin test as ‘abnormal’ on 21 December.

32. Our clinical adviser said there are no specific guidelines on how a GP decides what action to take following a calprotectin test. The right course of action comes under the GMC Good Medical Practice guidelines, which states doctors must:

• adequately assess a patient’s condition(s), taking account of their history, including symptoms, relevant psychological, spiritual, social, economic, and cultural factors and the patient’s views, needs, and values • promptly provide (or arrange) suitable advice, investigation or treatment where necessary • refer a patient to another suitably qualified practitioner when this serves their needs.

33. A faecal calprotectin test is a stool test used to detect inflammation in the intestines. Intestinal inflammation is associated with, for example, some bacterial or viral infections and, in people with inflammatory bowel disease (IBD), it is associated with disease activity and severity.

34. Our clinical adviser said a faecal calprotectin test is not diagnostic but may be used to distinguish between IBD and non-inflammatory disorders and to monitor IBD disease activity.

35. Our clinical adviser said a doctor may request a faecal calprotectin test to help investigate the cause of a person's persistent watery or bloody diarrhoea. They added an abnormal calprotectin test would not activate a two-week cancer pathway referral as it is not cancer specific. It detects inflammation in the bowel, which could be an indication of many bowel diseases or conditions.

36. A calprotectin test is different to a FIT test. Our clinical adviser said a FIT test is a sensitive screening tool primarily used to detect early signs of bowel (colorectal) cancer, as well as other bowel conditions. An abnormal FIT test would activate the two-week wait pathway for cancer testing and treatment.

37. Mr C’s calprotectin test came back as abnormal on 20 December, and a clinician at the Practice noted it as ‘normal, no further action required’ on 21 December.

38. If the clinician had noted the test result as ‘abnormal’ as they should have done, our clinical adviser said they would expect, in line with GMC Good Medical Practice, for the clinician to have arranged a review of Mr C’s symptoms and a gastroenterology referral (not for cancer). The Practice did not do this.

39. However, Mr C had a review of his symptoms on 19 December (two days prior). Our clinical adviser said arranging a further review so soon after the previous one would not be necessary in this situation.

40. In addition, the Practice had arranged for Mr C to have a FIT test on 12 December. On 21 December, the Practice was still waiting for the results of this test. Our clinical adviser would expect the Practice to wait for the FIT test result to come back before deciding to make a referral to gastroenterology.

41. If it had made the referral to gastroenterology on 21 December, this would not have been done on the two-week pathway. It would have been a normal referral so Mr C would have been added to the waitlist which would have taken longer than two weeks.

42. The FIT test came back as positive on 27 December, and the Practice spoke to Mr C on 2 January and said he needed a 2WW colorectal referral on account of his positive FIT test.

43. NICE cancer guidance says clinicians should refer adults using a suspected cancer pathway referral for colorectal cancer if they have a FIT result of at least 10 micrograms of haemoglobin per gram of faeces. The Practice acted within this guidance based on the result of Mr C’s FIT test.

44. Therefore, although the Practice failed when it marked the calprotectin test as normal on 21 December, there was no impact of this failing on the pain management and cancer treatment available to Mr C. It did not cause a delay in referring him for a two-week cancer pathway. The FIT test result is what would be necessary to be referred for cancer care and treatment, not the calprotectin test.

45. The Practice acted within the relevant guidelines regarding the FIT test. This means we cannot see, even had the Practice marked the calprotectin test correctly, it would or should have referred Mr C for cancer care earlier. As this omission did not alter the course of events, we saw no indications this delayed his cancer care, and that the Practice needs to provide redress for the impacts Ms C’s describes.

46. The Practice apologised in its complaint response to Mr C and said it was treating this matter as a ‘Significant Event’. It said it would discuss this with its clinical and non-clinical teams to learn from this experience and improve their service. Specifically, it said it will focus on ensuring the clinical team takes the appropriate actions when reviewing possibly miscategorised results. It also said it will ensure the reception team is fully aware of the escalation procedures when addressing result-related concerns.

47. The Practice confirmed on 7 January 2026 it put processes in place to ensure tests are analysed in detail and actioned. It has also put in place regular audits on the filing of test results.

48. This is in line with the kind of improvements our Principles for Remedy recommend. They say public bodies can revise procedures to prevent the same thing happening again. Public bodies can also arrange staff training or supervision to achieve this.

49. Therefore, we have seen the Practice has done things to address its failing and make improvements to prevent similar incidents happening again in future. This means there is nothing more we would expect it to do and no reason to consider the matter further.

50. We recognise Ms C has concerns about the impact the Practice’s mistake had. We hope we have clearly explained what we saw, and this provides her some closure about what influence this event had on her husband’s care pathway.

Not referring Mr C for a cancer diagnosis in the same month

51. As outlined in paragraphs 42 to 45, the Practice acted in line with NICE cancer guidance. It referred Mr C for the two-week cancer pathway based on the result of his FIT test.

52. Therefore, we have seen no indications of failings or any delay in the Practice referring Mr C for cancer care and treatment.

Escalation of test result

53. Ms C said staff at the Practice did not respond well when her husband called with concerns about his test results on 27 December. She said the receptionist refused to pass on his message to a doctor and told him he had to ring back on the following Monday.

54. She said the Practice was aware of the seriousness of the test results but did not take appropriate action. She said she felt like the Practice put the responsibility on her husband to figure out what was happening and what actions needed to be taken. She said this added to the stress they were both already experiencing.

55. In its complaint response dated 28 January 2025, the Practice said when Mr C called, there was only a locum doctor on site, and none of its salaried GPs were available. This meant there was no doctor available to discuss his concerns. It said it had arranged a GP from another practice to cover emergencies, but regrettably, the reception team did not contact them on his behalf.

56. The Practice acknowledged its failings here and said it was treating this matter as a ‘Significant Event’. It said it would discuss this with its clinical and non-clinical teams to learn from this experience and improve its service.

57. Specifically, it said it will focus on ensuring the clinical team takes the appropriate actions when reviewing possibly miscategorised results. It also said it will ensure the reception team is fully aware of the escalation procedures when addressing result-related concerns from patients when they call about them.

58. On 7 January 2026, it confirmed the reception team have undergone training on the escalation process and pathways available.

59. Although the receptionist did not escalate Mr C’s concerns about his tests, as we have already explained, the Practice still acted on the result of his FIT test when it received it. This means we cannot see the receptionist’s oversight delayed Mr C accessing cancer care, and him experiencing avoidable symptoms and distress associated with his cancer as a result.

60. Therefore, we have seen the Practice has done what we would expect and made improvements to prevent similar incidents happening again in future. This means there is nothing more we would expect it to do and no reason to consider the matter further.

61. We thank Ms C for bringing this complaint to us. We understand Ms C went through a very distressing and traumatic time when there was uncertainty around her husband’s care and treatment. We also recognise how painful it has been for Ms C to lose her husband and how difficult it has been for her.

62. We hope our explanation provides Ms C some reassurance on what happened during Mr C’s care and treatment, and that we have reached this decision following careful consideration. We recognise this decision may be difficult for Ms C, as well as recognising how it may be hard to revisit these events.

1. We have carefully considered Ms C’s complaint about the care the Practice gave her husband, Mr C.

2. Considering the failure to categorise a test result, we have decided we cannot link this event to a delay in Mr C’s oesophageal and colorectal cancer treatment.

3. Considering the alleged failure to refer for a cancer diagnosis in the same month, we have seen no indications the Practice got things wrong.

4. Regarding Ms C’s complaint the Practice did not escalate matters appropriately when Mr C called the Practice about his test results, we have seen this event does not link to the impacts she describes.

5. We want to thank Ms C for bringing the complaint to us. We were saddened to hear of the events Ms C complains about and recognise the distress her and her husband went through. We also recognise how difficult it has been for Ms C following her husband’s death and how painful the experience has been for her after they were together for 24 years.

6. We hope our explanation provides Ms C with some reassurance as to what happened during her husband’s care and treatment.