A practice in the Wandsworth area

5. Mrs O complains that, between June and September 2022, the Practice did not fully explore her daughter’s symptoms which included a persistent cough, shortness of breath and rapid weight loss, despite her history of breast cancer.

6. Mrs O says because of the failings the Practice provided her daughter with inappropriate treatment such as a nasal drip, inhalers and antibiotics and her daughter continued to suffer with her symptoms which had an impact on her day-to-day life. Mrs O says this was traumatic to witness her daughter’s health decline and for her to suffer in pain.

7. Mrs O says because of the failings her daughter unknowingly suffered with a large pleural effusion (excessive fluid in the lung) which required draining. She says this was significantly distressing to experience and caused her significant worry.

8. Mrs O also says because of the failing there was a delay in her daughter being diagnosed with metastasized breast cancer. Sadly, Ms S died from metastatic breast cancer in August 2023. Mrs O says she was devastated by this loss. She says she believes earlier diagnosis could have resulted in a better prognosis for her daughter.

9. Mrs O says the experience has a worsened her bereavement. She says her daughter was angry and distressed that because of the failings she had missed an opportunity for a better clinical outcome. Mrs O says this in turn caused the family anger and distress. She says the family, including her daughter’s partner, believe her daughter’s life was shortened because of the delay in diagnosis and treatment.

10. Mrs O is seeking an apology.

11. Ms S was first diagnosed with breast cancer in 2016. She had chemotherapy and radiotherapy at the time, as well as a bilateral mastectomy (removal of both breasts), prophylactic bilateral oophorectomy (removal of both ovaries as a precaution against ovarian cancer), followed by breast reconstruction. She also had a clinical history of asthma from 2009 onwards, various allergies, and was an ex-smoker.

12. In June 2022, she attended the Practice with a lump on her elbow that had grown in size. The records show this had been diagnosed by dermatologists as scar tissue from a catheter used in chemotherapy.

13. Ms S next attended the Practice for a cervical smear in early July. The records note her history of breast cancer and ‘patient [is] breast aware’ (aware of the signs of breast cancer to look out for). She was recorded as having gained weight since her last reading.

14. Later that month, Ms S attended the Practice with a persistent dry cough, upper chest tightness, rhinitis, and ongoing posterior nasal drip (excess mucus) which she had previously received treatment for. The GP recorded that her chest was clear on examination. They prescribed her a steroid nasal spray and advised she start steam inhalation.

15. In early August she attended the Practice again as her cough had worsened over the past two weeks. She reported she had tested negative for COVID-19. The GP prescribed her amoxicillin (antibiotics) and arranged for a blood test. The results from the blood tests were all recorded as within the normal range.

16. Ms S then tested positive for COVID-19 in mid-August. She attended the Practice as she was having trouble breathing, coughing, and occasional vomiting. The GP recorded that her inhaler was not bringing her relief and steam inhalation was not really helping.

17. In early September Ms S had a phone consultation with a Practice GP. She reported that she still had two more days of antibiotics to take, and her COVID-19 symptoms were ‘much better’ although she still had a cough. The GP arranged to see her face-to-face the next day.

18. During this appointment, the GP recorded that she had had a cough for more than six weeks and antibiotics had not helped. They noted that she had an elevated respiratory rate and reduced air intake. The GP arranged for an urgent chest X-ray at a hospital.

19. Ms S had the X-ray two days later. This showed ‘moderate sized left-pleural effusions’ (fluid buildup between the layers surrounding the lung). The radiologist suggested a CT scan ‘in view of the time span of the symptoms’ and to ‘exclude an underlying mass abnormality.’

20. The CT took place later that week. This found ‘extensive malignancy’ indicating stage four metastatic breast cancer or primary central lung cancer. Metastatic/stage four means the cancer has spread beyond the place it started. A GP at the Practice informed Ms S of the possible diagnosis and arranged an urgent referral to hospital. They recorded that she had ‘lost a stone of weight in [the] last weeks’ and was unable to eat. Two days later they submitted a fast-track referral to a hospital for further investigation.

21. Ms S’s cancer diagnosis was confirmed in mid-September. She sadly died from the disease in August 2023.

25. Mrs O complains the Practice did not fully explore her daughter’s symptoms which included a persistent cough, shortness of breath and rapid weight loss, despite her history of breast cancer. Ms S’s initial complaint to us explained that she first contacted the Practice about her cough in June 2022, but the GP did not offer her an X-ray.

26. Ms S explained that despite then having repeat appointments and her symptoms not clearing, the Practice did not refer her for an X-ray until early September.

27. We were sorry to hear how Mrs O and her family have been affected since the sad loss of Ms S. We understand this has been a significantly distressing time for the family.

28. In responding to the complaint, the Practice and its GPs explained Ms S first presented with a cough in late July. They explained that they focused on her active symptoms of rhinitis at the time, and that there were no red flag symptoms of cancer like weight loss, coughing up blood, or shortness of breath.

29. Practice GPs also explained that because of Ms S’s COVID-19 diagnosis and history of asthma, they decided to increase her inhaler prescription prescribe antibiotics (in case she had a secondary infection from coronavirus). They explained they promptly referred her for further investigation after her other COVID-19 symptoms cleared, but her cough remained.

30. When we investigate a complaint, we first consider what should have happened. We do this by looking at what the relevant guidance says. We then consider what did happen, and whether this fell short of the relevant guidance.

31. GMC guidance states that, to provide a good standard of practice and care, doctors must:

• adequately assess the patient, taking account of their history/symptoms, and examine the patient where necessary (15a) • promptly provide or arrange suitable advice, investigations or treatment where necessary (15b).

32. NICE CKS explains that clinicians should offer an urgent chest X-ray (to be performed 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

33. From Ms S’s records, we can see that the first time she presented to the Practice with a cough was in late July 2022. She did attend the Practice in June, but this was linked to scar tissue around her elbow.

34. Records from the July appointment show Ms S had a persistent dry cough, nasal drip, and upper chest tightness. They also show the GP examined her chest and found this was clear.

35. Our adviser gave their view that her symptoms at this point were linked to her upper airway and potentially allergy related. They explained there was no need for a chest X-ray at this point and gave their view that the appointment was conducted in line with GMC guidance and the decision to prescribe antihistamines and nasal steroids was appropriate.

36. Considering this advice and the available evidence, we consider the GP acted in line with guidance at this appointment. Although Ms S had a cough and was an ex-smoker, her symptoms were not unexplained and appeared to be linked to her airway and allergies.

37. Ms S next attended the Practice in early August. Her cough had become worse, and she was having trouble breathing. The records note that she had been in contact with people who had tested positive for COVID-19 but had herself tested negative.

38. Our adviser gave their view that Ms S’s symptoms at this point were indicative of a lower respiratory tract infection and were not ‘unexplained’. They explained that these are commonly seen symptoms and there was no indication for a referral for an X-ray at this point.

39. Later that month, Ms S tested positive for COVID-19. She attended the Practice with more coughing, difficulty breathing, and some vomiting. Our adviser again felt that these symptoms could be explained (by her COVID-19 diagnosis), and they did not feel referral was needed at this point.

40. The records show Ms S’s clinical picture had changed at her next appointment in early September. Her COVID-19 symptoms had eased but her cough remained. Our adviser gave their view that the cough became unexplained at this point, and the GP’s decision to refer for a chest X-ray was therefore in line with the NICE CKS.

41. Considering the available evidence and advice received, we consider the Practice’s GPs acted in line with GMC and NICE guidance. We consider they appropriately assessed Ms S (in line with GMC 15a). Although she had a persistent cough between July and August 2022, these symptoms were not ‘unexplained’ and appeared to have common causes. We cannot see evidence in the records that she reported weight loss to the Practice in July and August.

42. We also feel the GP acted in line with GMC and NICE when her symptoms became unexplained. They submitted a fast-track referral for further investigation (as per GMC 15b) which led to an X-ray and then CT scan.

43. Despite the GPs acting in line with guidance, Ms S was still sadly diagnosed with stage four metastatic cancer. We recognise that this will have been an incredibly difficult moment for her and her family. We also recognise that the knowledge there was not a missed opportunity to refer her will not lessen the impact of their loss. We are sorry to hear of the significant impact this has had on them.

1. Mrs O complains about aspects of the care and service Ms S, her daughter, received at a medical practice in the London Borough of Wandsworth area (the Practice) between June and September 2022.

2. We have not seen anything wrong in how the Practice explored Ms S’s symptoms. The Practice acted in line with the relevant guidance during each consultation.

3. We understand Mrs O believes if the Practice had done more during its consultations, it may have changed her daughter’s prognosis and prolonged Ms S’s life. We recognise the lasting effect the loss of a loved one has and do not wish to diminish the upset and distress Mrs O and her family have experienced. We were sorry to hear about this tragic situation.

4. We thank Mrs O for bringing her complaint to us and we hope she will find our decision useful in confirming we have not seen any indications that something went wrong with her daughter’s care.