A practice in the Kirklees area

3. Mr B complains about the care and treatment provided to Mr A by the Practice and the Trust between 17 September and 1 December 2024. Mr B says,

• the Practice did not address or treat the swelling on Mr A’s legs when he brought it up in his appointment on 17 September 2024 • the Trust did not manage Mr A’s pain effectively between 25 November 2024 and 1 December 2024 • the Trust did not act on the radiologist’s report of Mr A’s spleen scan on 29 November 2024

4. Mr B told us if the Practice had assessed Mr A’s swollen legs, he could have been diagnosed with cancer sooner and had more time to live. Mr B told us the pain Mr A experienced accelerated his death. Mr B said the Trust could have acted on the spleen clot to save Mr A’s life.

5. As an outcome, Mr B is looking for service improvements to make sure this does not happen to anyone else in the future.

6. Mr A suffered with Chronic obstructive pulmonary disease (COPD). COPD is when the lungs get damaged and become inflamed and narrowed. COPD can cause shortness of breath and a persistent chesty cough.

7. Mr A attended the Practice on 17 September 2024 about a COPD flare up. Mr A had blood tests on 19 September 2024, and a chest X-ray on 26 September 2024.

8. On 11 October 2024, Mr A’s wife called 999 because Mr A had chest pain and was struggling to breathe. Mr A went to the Emergency Department (ED) at the Trust on 12 October. On 14 October Mr A returned to the ED complaining of the same symptoms. On 15 October 2024, Mr A had a CT scan of his lungs.

9. Mr A had a PET scan on 18 October 2024. On 25 October 2024 Mr A was told he had lung cancer and metastases in the bones, right peritoneum (lining in the abdomen), right adrenal gland (gland in the kidney) and multiple lymph nodes (organs of the immune system). Metastases is the spread of cancer cells from the primary tumour to other distant areas the body causing new tumours.

10. On 1 December 2024, the Trust ordered abdominal and chest x-rays for Mr A. While Mr A waited for these, he went into cardiac arrest. Chest compressions began at about 4.04pm and were attempted until 4.25pm when Mr A was sadly declared dead.

Issue 1 – The Practice did not address or treat the swelling in Mr A’s legs when he brought it up in his appointment on 17 September 2024

15. Before we decide if we should conduct a detailed investigation of a 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 have not found any indications that something has gone wrong.

16. Mr B told us Mr A went to the Practice on 17 September with concerns about his chest and his swollen legs. Mr B believes Mr A’s legs were an early sign Mr A had cancer. Mr B says if Mr A had a scan after this appointment, his fast-acting cancer could have been diagnosed and treated earlier.

17. Mr B told us Mr A called an ambulance on 11 October and told the paramedic about his legs. The paramedic was shocked the Practice had not done anything about Mr A’s swollen legs on 17 September 2024.

18. We considered the Practice records from 17 September 2024. The Practice notes are extremely detailed. They state Mr A presented with chest wheezing and more shortness of breath than was usual for him. The Practice booked Mr A into a COPD clinic to review his inhaler. The Practice records do not hold any evidence of Mr A reporting swelling to his legs.

19. Mr A was booked in for blood tests at the Trust on 19 September 2024. The records of this appointment are very detailed. There is no evidence Mr A reported swollen legs at this follow up appointment. Unfortunately, we cannot ask Mr A about this.

20. We asked Mr B if he had further evidence to corroborate his version of events, as he was not with Mr A at his Practice appointment. Mr B sent us an image of Mr A itching his legs. As we cannot see Mr A’s legs in this picture, we cannot confidently say his legs were swollen at this time. Even if the images did show swelling, we would still not be able to establish whether Mr A reported it to the Practice.

21. The Ambulance Trust provided us with its recording of the 999 call and its notes of its visit on 11 October. We also obtained a letter sent by the Ambulance Trust to the Practice after their visit.

22. The ambulance notes state Mr A had been experiencing shortness of breath for the past three days. The notes also say Mr A had bilateral lower leg pain with swelling for the past three days.

23. We know Mr A had shortness of breath for at least three weeks. If the Ambulance recorded the length of time Mr A had shortness of breath wrongly, there is a possibility it also recorded the symptom of leg swelling wrongly. There is a possibility the ambulance meant to write three weeks for both symptoms.

24. The Practice said Mr A could not have brought up his swollen legs on 17 September 2024 as the ambulance crew noted on 11 October, Mr A had only had this symptom for three days.

25. Mr A did not book another appointment at the Practice to discuss any concern about his legs.

26. We have weighed up all the evidence available to us. On the balance of probabilities, we consider it is more likely Mr A did not bring up his swollen legs on 17 September 2024. Even if the Ambulance records meant to say Mr A had swollen legs for three weeks, this does not mean he told the Practice. Given the detailed nature of the Practice record from 17 September 2024, it is likely the Practice would have noted Mr A’s legs in the record if he had mentioned them.

27. As we have found, on the balance of probabilities, Mr A did not raise concerns about his legs to the Practice, we have not found any indications of a failing in the Practice’s management of Mr A’s legs.

Issue 2 – the Trust did not manage Mr A’s pain effectively between 25 November 2024 and 1 December 2024

28. Mr B told us Mr A was in severe pain between 25 November and 1 December 2024. Mr B says the Trust did not manage Mr A’s pain effectively, and the pain Mr A was left to suffer accelerated his death.

29. On 25 November 2024, Mr A’s wife called the Oncology Ward on his behalf as he had extreme stomach pain. Trust records show Mr A rated his abdominal pain a 10/10 and he felt extremely bloated. Mr A described the pain as a burning and stabbing sensation.

30. On the call, the Trust used a marker system of red, amber and green to assess Mr A’s symptoms. Amber symptoms mean the Trust should follow up with the patient in 24 hours. If there are two amber symptoms, this turns into a red, which means the Trust should assess the patient. The Trust marked Mr A’s pain as an amber symptom. It also marked Mr A’s rash as an amber symptom. The records state this made Mr A a red rating.

31. Mr A was told to attend the Trust where he had an abdominal x-ray. He was told his bowels were loaded with stools. Mr A was given 1g of paracetamol to be taken four times a day. Mr A was also given 30mg of codeine to be taken three times a day. Mr A was also given 1g of IV paracetamol four times a day for his stomach cramps.

32. At 10pm on 28 November 2024, Mr A called the Oncology Helpline. He said he had pain in his left arm, back, and his abdomen. Mr A felt his stomach was burning or going to burst. The Trust again used the red, amber and green system. Mr A was rated an amber for pain, and an amber for a rash. This made him a red rating. Mr A was asked to attend the Trust.

33. Mr A arrived at the Trust at midnight on 29 November. Mr A reported worsening abdominal pain and left arm weakness. Mr A was given 5mg of morphine every two hours starting at 1.52am. Mr A was given 1g of paracetamol at 6am, to be taken four times that day.

34. On 1 December 2024 Mr A told the Trust he had pain in his abdomen. The Trust records state Mr A was still in agony after his paracetamol and morphine.

35. Mr A’s morphine was increased to 10mg twice a day. It was first administered at 10am. Mr A continued to experience pain in his abdomen throughout the afternoon. Mr A died at 4.25pm.

36. Our Adviser referred to UKONS guidance. It tells practitioners how to respond to new symptoms cancer patients report. UKONS guidance says practitioners should use the Red, Amber, Green system to assess the patient’s symptoms. This guidance says if a patient is rated red, the patient should have their symptoms promptly assessed by a practitioner.

37. WHO guidance tells practitioners how to administer the correct amount of pain relief to cancer patients. It says the patient’s treatment should only be moved to the next step if the pain remains uncontrolled or worsens. It says pain relief should be given by the clock rather than on demand. This means the pain relief should be administered every few hours on a regular basis rather than when the patient requests it. The patient then has a steady stream of pain relief in their system.

38. The first step of WHO guidance is to use non-opioid pain relief, such as paracetamol. If the pain persists, a weak opioid such as codeine or tramadol can be introduced. The non-opioid and weak opioid are used together to allow for effective control of moderate pain. NICE pain guidance says the recommended dose of codeine is 30mg to 60mg of every four hours.

39. WHO guidance says if the pain continues to be treated as moderate or progresses to severe, the practitioner should progress to step two. This step involves introducing a strong opioid pain relief like morphine, oxycodone or fentanyl. The dosage of strong opioids is slowly increased until the pain is controlled.

40. We can see on 25 November 2024 and on 28 November 2024, Mr A called the Oncology helpline. His calls were both triaged using the red, amber, green system. On both occasions Mr A had two symptoms rated an amber. As UKONS guidance says, this should have made Mr A into a red rating which demands an assessment of the patient. Mr A was asked to attend the Trust so it could conduct a face-to-face assessment for his condition. We consider the Trust acted in line with UKONS guidance on both occasions.

41. We can see Mr A was prescribed paracetamol on 25 November 2024. Mr A reported increased pain, and the weak opioid codeine was started on this day. This is in line with step one of WHO guidance. Both the paracetamol and codeine were prescribed on a by the clock basis, also in line with WHO guidance. The 30mg of codeine prescribed was in line with the recommended dosage in NICE pain guidance.

42. When Mr A reported an increase in pain on 29 November his pain medication was altered further. Mr A was started on 5mg morphine by the clock; this is in line with step two of WHO guidance.

43. On 1 December, Mr A reported another increase in pain. Mr A was already being administered a non-opioid, paracetamol; a weak opioid, codeine; and a strong opioid, morphine. Mr A’s morphine prescription was increased to 10mg a day. This was in line with WHO guidance which says strong opioids should be slowly increased.

44. We appreciate it was extremely distressing for Mr B to witness Mr A in so much pain. We can see Mr A’s pain relief was administered on a by the clock basis in line with WHO guidance, and at a level consistent with NICE guidance and WHO guidance. For this reason, we do not see any indications of failings by the Trust.

Issue 3 - The Trust did not act on the radiologist’s report of Mr A’s spleen scan on 29 November 2024

45. The Trust told Mr B something may have been missed in one of Mr A’s spleen scans. Mr B told us Mr A kept having pain in his stomach and the Trust told him it was constipation. Mr B believes if a clot in the spleen was missed, there was a missed opportunity for intervention which could have saved Mr A’s life.

46. We considered the Trusts records of Mr A’s care. Mr A was put on the blood thinning medication apixaban on 15 October. Mr A paused this prescription from 25 October to 28 October to allow him to take his new medication tinzaparin. Mr A started taking apixaban again on 29 October, he was prescribed 5mg a day.

47. At midday on 29 November, Mr A had a CT scan and an X ray of his abdomen. The radiology report stated some areas on the edge of Mr A’s spleen were darker on the scan. This can be a sign of infarcts. Infarcts is tissue death which can be caused by a ruptured blood vessel and can lead to circulation failure.

48. A note was made on Mr A’s records that he was at risk of venous thromboembolism (VT). VT is when a blood clot can break loose and travel to the lungs which can cause a life-threatening blockage in circulation.

49. After Mr A’s death, the Oncology Report noted Mr A’s scan from 29 November had found possible splenic infarcts. Mr A’s proposed cause of death was cardiac arrest resulting from an acute thromboembolic event. This is the sudden formation of a blood clot inside a blood vessel which blocks blood flow.

50. We discussed Mr A’s care with our Adviser. They told us GMC guidance says practitioners should adequately assess a patient’s condition considering their history and symptoms. Practitioners should promptly provide or arrange suitable investigation where necessary.

51. Our Adviser told us it was appropriate for the Trust, considering Mr A’s diagnosis of metastases, to focus on managing his pain and other symptoms, rather than investigate the spleen infarcts. Our Adviser told us blood clots are extremely common in metastases, and a common cause of death. Our Adviser determined no intervention could have prevented Mr A’s death.

52. We can see why the Trust’s suggestion it might have missed something in the scan created concern and confusion for Mr B. We appreciate this would have been distressing to hear.

53. We note Mr A was prescribed a blood thinner, which is used to reduce the risk of blood clots. We consider no intervention by the Trust on the spleen infarcts would have changed the outcome for Mr A. We consider the Trust acted appropriately in the context of Mr A’s diagnosis of metastases. We can find no indications of failings in the Trusts actions.

Conclusion

54. In summary, we have found the actions of the Practice and the Trust were in line with national guidance. We found no indications anything went wrong in Mr A’s care. For this reason, we will take not further action on this complaint.

55. We were sorry to hear of the sad events surrounding Mr A’s death. We can see it was extremely distressing for Mr B and his mother to witness Mr A’s rapid decline. We hope our decision provides a clearer explanation of the care provided to Mr A.

1. We have carefully considered Mr B’s complaint about the care given to his father Mr A by Calderdale and Huddersfield NHS Foundation Trust (the Trust) and a GP Practice in Kirklees (the Practice).

2. We have seen no indication anything went seriously wrong in the care given to Mr A. We can see Mr B and his mother went through an extremely distressing time witnessing the decline and death of Mr A. We can see this was an awful time. We hope our investigation provides some closure to the events.