A practice in the Tendring area

4. Ms A complains about the care and treatment she received from the Practice between July and August 2022. Ms A complains the Practice failed to:

• assess the rectal bleeding symptoms she presented with in July 2022 and discuss safety netting advice • document a test result telephone conversation in August 2022 • arrange a rectal examination and colonoscopy to further investigate her symptoms of rectal bleeding • arrange repeat blood tests to check whether her low iron level had improved.

5. Ms A says if the Practice had fully investigated her symptoms of rectal bleeding and low iron back in July and August 2022, then it would have been able to determine why she had rectal bleeding. Ms A was diagnosed with rectal cancer in February 2024, and she believes she would have received the cancer diagnosis sooner if these failings had not occurred.

6. Ms A now lives with permanent severe bowel dysfunction and relies on transanal irrigation every day, which takes several hours each morning. Ms A says she lives with a constant fear of recurrence, and she’s had a significant decline in her mental health.

7. Ms A is currently unable to work in any capacity. She says her trust in medical professionals has collapsed, which is affecting her current care and has a direct impact on her ability to make safe medical decisions.

8. Ms A would like the Practice to make service improvements, apologise for its failings and provide a financial remedy.

9. Ms A had a consultation at the Practice at the end of July 2022 to investigate her symptoms of rectal bleeding. The GP who assessed Ms A ordered blood tests and stool investigations. Around mid-August 2022, all of Ms A’s test results came back normal, and the Practice took no further action.

10. Later in August 2022, Ms A says she received a call from a nurse at the Practice. During the call she says the nurse shared her test results were normal and told her no review or follow-up was required. Ms A says the nurse advised her to purchase iron tablets from a pharmacy, which was on the advice of the GP, to manage her iron levels.

11. In mid-January 2024, Ms A attended hospital due to an anal prolapse. The hospital examined Ms A, and it advised her to liaise with her GP for further investigation.

12. The following day Ms A visited the Practice as her bowel had popped out again. The Practice carried out an examination and made a fast-track referral for suspected lower gastrointestinal cancer and it ordered blood tests. In mid-February, the Practice diagnosed Ms A with rectal cancer.

16. At the primary investigation stage of any complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this, and we have not seen any indications that something has gone seriously wrong.

Rectal bleeding

17. Ms A says the Practice failed to assess the rectal bleeding symptoms she presented with.

18. The GMC’s Good Medical Practice (section 15) says doctors must adequately assess the patient’s condition, taking account of their history, examine the patient and arrange investigations or treatment where necessary.

19. The NICE Suspected Cancer guidance (section 1.3.1) says to offer a quantitative faecal immunochemical testing (FIT) for suspected colorectal cancer in adults with a change in bowel habit. A FIT test is a screening tool used to detect tiny, invisible amounts of human blood in stool samples. It acts as an early indicator for potential colorectal cancer.

20. The records show at the appointment in July 2022, the Practice noted Ms A’s symptoms as ongoing irritable bowel syndrome (IBS). Ms A said she had altering bowel habits, which can be diarrhoea with occasional blood and switches to constipation. Ms A said it felts like she had IBS all the time. Ms A advised the Practice she had multiple investigation carried out at a hospital about ten years ago and was diagnosed with food and other allergies.

21. The records show Ms A said the symptoms eased if she ate plain foods like rice and chicken and flared up if she ate everything else. Ms A confirmed she had no fever, no abdominal pain and no weight loss.

22. The records also show the Practice also carried out an examination of Ms A’s abdomen and no abnormality was detected. The Practice therefore arranged blood tests and a FIT test.

23. The records show the Practice advised Ms A to trial Mebeverine. Mebeverine is an antispasmodic medication used to treat symptoms of IBS. The Practice agreed to review with the test results if no better.

24. The Practice’s actions appeared to be in line with the GMC’s Good Medical Practice (set out in paragraph 18) and the NICE Suspected Cancer guidance (set out in paragraph 19). The Practice noted Ms A’s presenting symptoms, examined her abdomen and arranged blood tests and FIT test to investigate her symptoms further. The Practice also initiated a trial of Mebeverine to address and manage the IBS symptoms.

25. We understand Ms A is concerned her cancer diagnosis could have been reached sooner, and we acknowledge the distress this causes her. Based on the evidence we have considered, we have not seen any indication of a failing in the Practice’s assessment of Ms A during this consultation.

26. We have therefore decided not to consider this part of her complaint any further. We realise our decision here will be upsetting for Ms A and we are sorry for any upset or distress our decision may cause.

Documentation of test results call

27. Ms A says a nurse at the Practice failed to document a test result telephone conversation in August 2022.

28. We considered whether there is any indication a nurse at the Practice failed to document the tests results telephone conversation. We did this by looking at what guidance sets out when telephone consultations should be documented.

29. Our nursing advisor said there is no specific guidance about recording telephone consultations, however, nurses should refer to the NMC Code. The NMC Code says nurses should keep clear and accurate records relevant to their practice, and they should complete all records at the time or as soon as possible after an event.

30. Our nursing advisor said all consultations or encounters with patients, whether this be on telephone, video or face to face require recording in the patient’s records, at the time or as soon as possible.

31. Ms A says she received a call from a nurse at the Practice in August 2022 to confirm her test results. Ms A says the nurse told her she needed iron tablets, and she could buy them over the counter, no prescription was needed. She also says the GP told the nurse to tell Ms A no follow up was required for her iron levels.

32. Ms A also says the nurse told her no follow up was required regarding her rectal bleeding symptoms. She says the GP had told nurse to tell Ms A she did not need to be seen again. Ms A says there was no safety netting during this telephone conversation.

33. In line with the NMC Code, the nurse should have documented this discussion in Ms A’s medical records. This did not happen, which is an indication of a failing in the nurse’s actions.

34. Based on the evidence we have considered, it clear there is an indication of a failing in the nurse’s actions. The nurse did not document the consultation in Ms A’s records in line with NMC Code. We have now considered what impact this had on Ms A.

35. We do not think there is a clinical impact on Ms A. Given the advice she was given, there was no further action to be taken, so this did not impact the care she received. Our GP adviser has said Ms A’s iron level was borderline, but not abnormal. We can also see Ms A’s iron level in January 2024 was normal, which has reassured us that there was no indication something was missed.

36. We appreciate this caused Ms A frustration and uncertainty, but we cannot say the impact went beyond this. Given the relatively low impact this had, we do not consider it would be proportionate for us to use our resources to consider this part of the complaint further. We know our decision here will cause Ms A upset and we are sorry for any further distress this may cause Ms A.

Further investigations

37. Ms A says the Practice failed to arrange a rectal examination and a colonoscopy to further investigate her symptoms of rectal bleeding. We recognise why this is important for Ms A, as she is concerned that if these investigations had been undertaken, her diagnosis could have been reached sooner.

38. We considered if there is any indication of a failing in the Practice not arranging a rectal examination and a colonoscopy to further investigate Ms A’s rectal bleeding symptoms, when the initial tests did not explain the presentation of rectal bleeding.

39. We did this by considering what guidance sets out when a rectal examination and a colonoscopy should be arranged to investigate rectal bleeding.

Rectal examination

40. Our GP advisor confirmed there is no specific guidance on carrying out a rectal examination when a patient presents with rectal bleeding. The GMC’s Good Medical Practice says doctors should promptly arrange suitable investigations where necessary.

41. Our GP advisor said a rectal examination should have been offered during the July 2022 consultation. This is because the cause of the bleeding may have been apparent on examination. We therefore think there is an indication of a failing here.

42. However, our GP advisor said it is impossible to know on the balance of probabilities what would have been found if a rectal examination had been completed.

43. We now know Ms A’s tumour was located 10cm from the anus, according to the sigmoidoscopy report. A sigmoidoscopy report is a medical document detailing the findings from an examination of the rectum and lower third of the colon using a flexible camera tube.

44. This means an examining clinician would need to feel with their finger 10cm inside Ms A’s anus when doing the examination in order to have been able to feel the tumour. Our GP adviser said some clinicians would be able to feel this far, but others would not, as it would depend on the length of their finger.

45. We can also see Ms A did have a rectal examination by a clinician at a hospital in January 2024. The hospital clinician recorded the rectal examination was normal. This indicates to us the clinician did not feel the tumour at that time.

46. It is therefore possible that even if the Practice had undertaken a rectal examination in July 2022, the Practice would also not have been able to have felt the tumour. We also have to consider that, if present, the tumour would have been smaller in 2022.

47. We also have to consider that it may also have not been there at all. This would be supported by Ms A’s FIT test result, which was normal. For most people, a normal result means they do not have cancer, although it cannot be complete ruled out. This indicating she likely did not have rectal cancer during the July 2022 consultation.

48. Given Ms A’s later cancer diagnosis, we acknowledge why she is worried something was missed here. Based on the evidence we have considered it is not possible to say if the Practice had carried out a rectal examination on Ms A in July 2022, her cancer would have been detected. We acknowledge our decision leaves Ms A with uncertainty here and we recognise this may be distressing for her.

Colonoscopy

49. The NICE Suspected Cancer guidance (section 1.3.1) sets out the criteria for when a FIT should be offered to guide a referral for suspected colorectal cancer. This includes adults with a change in bowel habit, or iron-deficiency anaemia, adults with rectal bleeding and abdominal pain or weight loss.

50. In line with this, the Practice arranged a FIT for Ms A. The records show Ms A’s FIT test came back normal.

51. The NICE Suspected Cancer guidance (section 1.3.2) says 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. Our GP adviser said at this stage, the further investigation will usually be a colonoscopy.

52. We understand Ms A’s concern about whether the diagnosis could have been reached sooner if she had had a colonoscopy, and we acknowledge this is distressing for her.

53. We hope she is reassured that we have seen no indication the Practice needed to refer Ms A for a colonoscopy, as her FIT test result was normal. Based on the evidence we have seen, we have seen no indication of a failing in the Practice’s action of not referring Ms A for a colonoscopy, as it had arranged the test as set out in the NICE Suspected Cancer guidance.

Unexplained rectal bleeding

54. Ms A complains the Practice failed to follow up the unexplained rectal bleeding she presented with.

55. We considered whether there is any indication the Practice failed to follow up Ms A’s unexplained rectal bleeding. We did this by considering what guidance sets out when to follow up someone with rectal bleeding.

56. The NICE Suspected cancer: recognition and referral guidance (section 1.3.3) says for people who have a FIT result below 10 micrograms of haemoglobin per gram of faeces, a safety netting process should be in place. Safety netting advice is guidance to help recognise when to seek further help if their condition changes, worsens, or does not improve.

57. The Practice documented it gave clear safety netting advice twice at the consultation. It documented that it advised Ms A to get back in touch if she had any worse or new symptoms, and that Ms A was happy with this plan. It also documented it advised Ms A to contact the Practice back if any worse or new symptoms.

58. We acknowledge this is different to Ms A’s reallocation of the consultation. She says there was no safety netting discussed during this consultation.

59. Before we investigate further, we look at whether an investigation would be practical. We have done this and consider it is unlikely we could make a robust decision about what is more likely to have happened. This is because what Ms A and the Practice told us are contradictory.

60. We have conflicting evidence here about whether or not the Practice gave safety netting advice. We consider it is unlikely we could make a robust decision about what is more likely to have happened.

61. We acknowledge Ms A’s account of events, and do not doubt her recollection. Given her concerns, and the ongoing difficulties she has, we acknowledge why she is so concerned about this.

62. As an independent organisation we rely on her and the Practice’s evidence, and in this situation, we are unable to give more weight to either piece of evidence. This is because there is no practical way to investigate what was said and, just as importantly, what was understood.

63. We acknowledge the importance of this issue for Ms A, and we do not want her to think we are discounting what she is telling us. Unfortunately, because of the evidence available to us, we do not think we would be able to reach a view on this if we pursued this further. We recognise this will be disappointing for Ms A. Based on the above, we will not consider this part of the complaint further.

Low iron

64. Ms A complains that given her unexplained rectal bleeding, the Practice failed to arrange repeat blood tests to check whether her low iron had improved.

65. We considered whether there is any indication the Practice failed to arrange repeat blood tests to check whether her low iron had improved. We did this by looking at what guidance sets out when repeat blood tests should be taken to monitor iron levels, particularly in patients with unexplained rectal bleeding.

66. Our GP advisor confirmed there is no guidance to follow up on low iron levels. The GMC’s Good Medical Practice says doctors must promptly arrange suitable investigations were necessary.

67. Our advisor went on to say the August 2022 test results showed Ms A’s iron level was 13, which is borderline. They explained anything lower than 13 would be abnormal. Our advisor said it is also common in females to have low iron levels while they are still menstruating.

68. The records show the blood test carried by the Practice in January 2024 was also normal. Therefore, we think there was no indication anything was wrong with Ms A’s iron levels at that time either.

69. Based on the evidence we have considered, we have seen no indication of a failing in the Practice not carrying out further blood tests. We think the Practice appears to have acted in line with the GMC’s Medical Practice. Ms A’s result was borderline, but not abnormal. There was no indication based on this result that further testing was needed.

70. We recognise it must be very worrying for Ms A to have concerns about the care she received in relation to her iron levels. As we have seen no indication of a failing here, we will not consider this part of the complaint further.

Summary

71. In summary, based on the evidence we have seen, including the clinical advice we have received, we have not seen any serious indications of failings in most of the actions of the Practice. In reaching our decision, we must consider relevant guidance and if it appears the guidance was followed. In this instance we have seen the Practice seems to have acted in line with most guidance as set out above.

72. We can see the Practice failed to act in line with GMC Good Medical Practice in relation to the rectal examination. The Practice also failed to act in line with NMC guidance in relation to the recording of the test results consultation. However, as we have been unable to link a clinical impact on either failing, we have decided not to consider these parts of the complaint any further.

73. We do not wish to underestimate how difficult this has been, and continues to be for Ms A. We recognise it must be very worrying and upsetting for Ms A to have concerns about the standard of care she received, and whether things could have been different for her. As we have seen nothing to indicate the Practice got anything seriously wrong, we will not be taking any further action on this complaint. We hope our work will being some reassurance to Ms A about her concerns.

1. We have carefully considered Ms A’s complaint about a GP Practice in Essex (the Practice).

2. We were sorry to hear Ms A’s concerns about the care and treatment she received. We recognise she has suffered with difficult symptoms and has been diagnosed with rectal cancer, which has been a distressing experience for her.

3. We have reviewed all the relevant evidence. We have seen no indication that anything went seriously wrong. We recognise Ms A may be disappointed by this decision. We hope this statement will help her understand how we reached our decision.