A practice in the Eastbourne area

The Practice

5. Mrs C complains that between 8 March and 10 April 2024, when her mother attended the Practice despite her symptoms and worsening condition, each time the Practice told her it was viral related. She says doctors should have considered lymphoma or another serious cause for the symptoms and referred her mother to the hospital sooner.

The Trust

6. Mrs C complains that when her mother attended an emergency department (ED) at the Trust on 6 April 2024, the doctor did not adequately assess or examine her mother and disregarded the blood test results. She says the doctor should have admitted her mother to hospital as she was seriously ill.

Both organisations

7. She says this caused a delay in her mother being diagnosed with lymphoma, which meant it had already infiltrated the liver. This meant she could not have treatment. She says earlier diagnosis may not have cured the lymphoma but would have given her mother time to fight it, get her affairs in order, say her goodbyes and understand what was happening to her.

8. She says these events and her mother’s death have been devastating and has left them in shock and disbelief. She says it is upsetting that they trusted what the doctor said and that her mother was struggling so much at home when she should have been in hospital being cared for.

9. In bringing this complaint, she wants an independent review of the events and service improvements.

10. Between 8 March and 11 April 2024 Mrs P had several telephone and in person consultations with GPs at the Practice. During these consultations she was experiencing many symptoms at various times, including cough, weight loss, fevers, shortness of breath, and bloating.

11. GPs considered Mrs P had a chest infection which they treated with antibiotics. They also completed blood tests and other tests with a view to ruling out a more serious cause for her symptoms.

12. On 6 April, Mrs P attended an ED at the Trust. The doctor considered she likely had a viral chest infection and discharged her home.

13. At an appointment on 11 April, the GP noted she was looking very unwell and had yellow discoloration of the skin and eyes (jaundice). They were concerned she may have a pulmonary embolism, which is a clot in the lung. They also suspected she had an underlying upper gastrointestinal malignancy (a cancer in the top part of the digestive system). They referred her to the ED.

14. At the ED Mrs P was diagnosed with B Cell lymphoma, a type of cancer of the lymphatic system, which is part of the immune system. Sadly, Mrs P died the following month.

Complaint about the Practice

18. NICE cancer guidance sets out when different types of cancer should be suspected and what investigations or referrals should be made. For lymphoma, the guidance says to consider a suspected cancer pathway referral in adults presenting with unexplained swollen lymph nodes or enlarged spleen. When considering referral, doctors should consider any associated symptoms, particular fever, night sweats, shortness of breath, itchy skin or weight loss.

19. It sets out what investigations to complete depending on individual symptoms, including those which are non-specific, such as unexplained weight or appetite loss. For these symptoms in women it says to complete tests for ovarian cancer.

20. When Mrs P first went to the GP on 8 March, she had recently tested positive for COVID-19. Our GP adviser said there was nothing to be concerned about at that stage, particularly considering the short history. Her symptoms and presentation were suggestive of someone recovering from COVID-19.

21. When Mrs P returned on 22 March she did have some symptoms which could potentially be ‘red flags’ for serious illness. However, these must be considered in context of the clinical picture as the symptoms could also be due to someone being unwell, for example with infection.

22. The GP thought Mrs P likely had a lower respiratory tract infection (LRTI), an infection of the lungs and airways. However, they did not rule out the possibility or disregard Mrs P’s concern that there may be a more serious cause. In completing a CA125 and blood tests, they took a cautious approach by investigating the possibility of ovarian cancer.

23. This was in line with the NICE guidance for when women are experiencing unexplained weight loss or appetite loss and people experiencing unexplained fever.

24. By the time Mrs P returned to the Practice on 28 March, the CA125 test result had returned as normal. Blood tests showed she was slightly anaemic (low red blood cells), and her ferritin (iron stores) and CRP (substance produced by liver in response to inflammation) were high.

25. Our GP adviser said, although ferritin and CRP can be raised with cancer, they are non-specific symptoms and can equally indicate infection or inflammation. Although with hindsight we know Mrs P had cancer, our adviser said that at the time with Mrs P’s short history, the results did not tend to point towards cancer.

26. The records show the GP considered it likely Mrs P had an ongoing LRTI as it would explain all the symptoms, but they remained cautious about the possibility of cancer. Due to Mrs P being anaemic, they arranged a FIT test to check for colorectal cancer. They also arranged chest X-ray to check for infection or cancer, and an ultrasound to check Mrs P’s abdominal organs. These actions were in line with the NICE guidance.

27. However, at this stage it appeared to the GP that Mrs P had a LRTI which was not improving. Our adviser said considering the lack of improvement there should have been a concern of sepsis at that time. Sepsis is a life threatening condition in which the body’s response to infection injures tissues and organs.

28. NICE sepsis guidance says to think ‘could this be sepsis’ if a person presents with symptoms or signs that indicate possible infection. It says if sepsis is suspected, to use a structured set of observations to assess people. They should assess temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation levels.

29. Two doctors reviewed Mrs P on 28 March. Each of them took some but not all her physiological observations. This is not in line with the above guidance.

30. NICE sepsis guidance says to consider using an early warning score to assess people suspected of having sepsis in community settings. NEWS2 is a commonly used early warning score system from The RCP guidance.

31. Although the NICE sepsis guidance does not say an early warning score must be used, they are an effective way of considering the potential risk of deterioration. Therefore, we have calculated Mrs P’s NEWS2 score here as it allows us to consider her clinical presentation even though we were not present at the time.

32. We can see that even though the observations were incomplete, with each doctor on 28 March Mrs P had a NEWS2 score of at least five. According to the RCP guidance, this means she was at medium risk of deterioration.

33. The RCP guidance says this would require an ‘urgent assessment by a clinician or team with core competencies in the care of acutely unwell patients.’ Our GP adviser said this meant Mrs P needed to be reviewed at hospital, either through the ED or a direct referral to the medical team, as her observations indicated she may have sepsis.

34. The NICE sepsis guidance also sets out risk criteria for patients with suspected sepsis. We can see Mrs P met between one and three of the medium to high-risk criteria, depending which doctor’s observations were the more accurate.

35. The guidance says to assess people who meet any moderate to high-risk criteria to make a definitive diagnosis of their condition and decide whether their condition can be treated safely outside hospital. It says if a definitive diagnosis is not reached or the person’s condition cannot be treated safely outside an acute hospital setting, refer them urgently for emergency care.

36. On 28 March, doctors had not reached a definitive diagnosis for Mrs P. Considering her clinical presentation suggested she may have sepsis, they should have referred her to the hospital.

37. Further when considering whether her condition could be treated safely outside of hospital, they should have considered her observations. As set out in paragraph 33, her incomplete observations indicated she was at medium risk of deterioration and needed to be assessed by a doctor specialising in acutely unwell patients.

38. The Practice did adequately assess Mrs P’s condition or refer her to the hospital on this occasion. This was not in line with the NICE sepsis guidance. This was a failing. We have considered the impact of this later in the report.

39. When Mrs P returned to the Practice on 2 April, her observations were stable and her condition had not deteriorated since the last appointment. The GP advised as her chest was clear and the antibiotics had not improved, it may be a viral infection. They planned to await the chest X-ray result and repeat the blood tests in two weeks.

40. On this occasion, as in the others, Mrs P did not have any signs or symptoms which would have prompted the doctor to suspect she had lymphoma. Mrs P had many nonspecific symptoms and the GP was investigating whether there was a serious cause for these. At this stage, there was no indication to complete further tests as a chest X-ray and ultrasound of abdomen were already planned.

41. On 11 April, the GP saw Mrs P looked very unwell and was jaundiced. They noted the slightly raised D-dimer result from the ED, which is a test that can identify a PE. Due to this, the GP was concerned Mrs P may have a pulmonary embolism and the jaundice may indicate an upper gastrointestinal cancer. The GP arranged Mrs P’s visit to hospital.

Impact of the failing

42. We found that on 28 March the GP should have been concerned Mrs P may have sepsis and referred her to the hospital.

43. With hindsight, we know Mrs P did not have sepsis as, when she returned to the Practice on 2 April, her condition had not deteriorated. However, Mrs C is concerned that a referral may have led to an earlier diagnosis of lymphoma for her mother. We have therefore considered what would have happened had the Practice referred Mrs P to hospital on 28 March.

44. Our ED adviser said the ED would have repeated the physiological observations and done blood tests, many of which had been completed by the GP. They said beyond this it is difficult to predict what would have happened.

45. One of the blood tests which should be completed for suspected sepsis is a venous blood gas (VBG). This gives insight into the body’s chemical balance and respiratory function.

46. If this test had shown a lactate level of less than two then doctors would have likely considered Mrs P was not at high risk of sepsis and she only had a LRTI. Alternatively, they may have diagnosed post-COVID syndrome given her recent positive COVID-19 test.

47. If the lactate level had been over two, doctors would have considered Mrs P was at high risk for severe illness and death from sepsis. This would have prompted investigations to identify the source of infection.

48. Our ED adviser explained considering her symptoms and the investigations already completed, the next step would have been a CT scan. They said a CT scan would have diagnosed the lymphoma.

49. Unfortunately, we are unable to say what the result of VBG test would have been. This means we do not know if referral to ED on 28 March would have led to Mrs P being diagnosed with lymphoma at that time.

50. Sadly, we are unable to give Mrs C a definitive answer to her concern about the impact of this failing on her mother’s condition. This leaves Mrs C with uncertainty around whether her mother may have been able to have some treatment or at least have known about her illness sooner.

51. She has been left wondering whether her mother may have known of her diagnosis sooner and been better supported, rather than struggling and worried. Whether she would have had more chance to say her goodbyes, get her affairs in order and understand what was happening to her.

52. This is an injustice to Mrs C. We will make recommendations for the Practice to make service improvements to prevent this happening again. We have set these out below.

Complaint about the Trust

53. GMC guidance says doctors should adequately assess a patient’s condition(s), taking account of their history, including symptoms and the patient’s views and needs. They should carry out a physical examination where necessary and promptly provide or arrange suitable investigations where necessary.

54. The RCUK guidance sets out the standard emergency medicine practice for assessing a patient. This is known as the ABCDE approach, prompting doctors to consider the airway, breathing, circulation, disability and exposure. Our ED adviser said there should then be further focussed examination based on this initial assessment.

55. PRSB guidance says it is important to record suspected and possible diagnoses in the clinical notes, clearly identifying that they are not confirmed diagnoses or being treated as such. Our ED adviser said this would mean that following examination, the doctor should have identified a list of possible diagnoses which could account for the problems Mrs P presented with and the blood test results.

56. The records show following triage, an ECG and blood tests were done. A doctor reviewed Mrs P, noting some of the history and her presenting problems. However, the notes of their physical examination of Mrs P are minimal.

57. For example, in relation to her breathing, the notes only show the lungs are clear with equal air entry. They do not show the doctor considered all factors set out in the RCUK guidance when considering a patient’s breathing. Nor do they show the doctor considered all factors identified during triage, such as difficulty in completing sentences, noisy breathing, productive cough and high temperature.

58. Our ED adviser said considering the loss of appetite and weight loss, there should have been a thorough abdominal examination to rule out a gastro-intestinal cause. We consider that doing so would have been in line with the GMC guidance.

59. The records only show Mrs P’s abdomen was SNT, meaning soft and non-tender. This suggests there was some abdominal examination. However, in its complaint response the Trust said the doctor did not examine her abdomen as they did not consider it necessary. Mrs C also says the doctor did not examiner her mother’s abdomen on this occasion.

60. We therefore consider no abdominal examination was done. The absence of a thorough abdominal examination was not in line with the GMC guidance.

61. In line with PRSB guidance, doctors should document possible diagnoses. Our ED adviser said in this case, for the symptoms Mrs P was experiencing this could have included chest infection, heart failure or cardiac disease or a PE.

62. Although possible diagnoses have not been documented, we can see the blood tests completed included a D-dimer. NICE PE guidance explains that where there is a positive Ddimer, investigations should be completed to confirm or rule out a pulmonary embolism.

63. We have not seen any evidence the Trust considered this result or completed these investigations. This supports our view that the doctor did not adequately assess Mrs P or fully consider possible diagnoses, before concluding she had a viral chest infection.

64. Our ED adviser said although a viral chest infection would explain some of the symptoms Mrs P was experiencing, it would not fully explain the combination of these. Similarly, the other possible diagnoses would not explain the combination of symptoms and results.

65. The full blood count (FBC) showed Mrs P had low platelets, low lymphocytes and nucleated red blood cells. Tests showed her blood was taking a long time to clot.

66. In its complaint response, the Trust said the blood test results were not significantly abnormal. Our ED adviser said in isolation the results are not always alarming in the ED. However, they said this combination of results along with Mrs P’s clinical presentation should have prompted the doctor to suspect cancer and then aim investigations and examinations towards identifying the source of it.

67. Our adviser said depending on the clinical findings and physiological observations, this would have resulted in two possible outcomes for Mrs P.

68. Either, the doctor would have referred her as an outpatient under the two-week wait suspected cancer pathway. This means patients have investigations as outpatients and are referred to a multi-disciplinary team meeting and within a two-week timeframe. In this instance, Mrs P’s symptoms would likely have been investigated with a CT scan.

69. Alternatively, if Mrs P was too unwell to be discharged, she would have been admitted and the investigations done during that admission.

70. We have therefore considered whether Mrs P was well enough to be discharged. At around 4pm, Mrs P had a NEWS2 score of 3. We do not know which physiological observations led to this score but can see there was a plan to repeat these hourly.

71. Despite this plan we have not seen any evidence NEWS2 observations were repeated before Mrs P was discharged home at 1am. This was not in line with RCP guidance and means we do not know Mrs P’s physiological condition in the hours before she was sent home.

72. We have not seen any evidence the doctor considered or discussed with Mrs P her mobility or her ability to manage at home. These factors are particularly relevant due to Mrs P reporting she had been unable to walk to the bathroom or stand. The records show Mrs C also informed the doctor she was concerned about her mother being ‘quite worn out.’

73. This means that in addition to not adequately assessing Mrs P’s symptoms and considering cancer as a potential cause, the Trust also did not consider whether Mrs P was well enough to be discharged home. These are failings.

74. If the failing in assessment had not happened then it would have led to investigations for suspected cancer. When and how these would have happened depended on how unwell Mrs P was at that time.

75. Unfortunately, we do not know whether Mrs P would have been considered well enough to be discharged from the ED and able to manage at home. This means we do not know whether she would have been admitted to hospital or not. However, we have considered both scenarios.

76. Firstly, if Mrs P had been well enough, she would have been investigated for cancer under the two-week wait pathway. She would likely have been diagnosed by 20 April. Therefore, in this scenario, we can see she would not have been diagnosed any sooner than she was.

77. Secondly, if Mrs P had not been well enough for discharge from the ED and investigations were completed as an inpatient, it may have led to diagnosis of lymphoma around four days sooner.

78. We know that once Mrs P was admitted to hospital on 11 April, investigations were completed with a view to confirming the diagnosis of lymphoma and her potentially having treatment for it.

79. Although on 26 April doctors were able to give Mrs P a drug to target the cancer cells, due to her liver function she could not have the full planned chemotherapy regimen for lymphoma. On 2 May, doctors confirmed they had ruled out gastro-intestinal causes for the liver failure and they concluded it was due to lymphoma infiltrating the liver. It was not possible to reverse the liver failure and she was too unwell to have treatment for lymphoma.

80. Our ED adviser said when Mrs P attended ED on 6 April, her lymphoma was very advanced. Mrs P’s liver function was impaired when she was admitted on 11 April and continued to deteriorate. We also know from the records that when admitted on that day, she said she had been jaundiced for several days. This jaundice indicates there was likely liver dysfunction present shortly after Mrs P’s attendance at ED on 6 April.

81. Considering the evidence we have seen, even if Mrs P had been admitted to hospital on 6 April, the lymphoma would still have affected her liver, and she would have become too poorly for treatment.

82. This means that although we there was a failure to adequately assess Mrs P on 6 April, it did not affect her ability to have treatment. However, we recognise that despite this, it has left Mrs C with uncertainty about whether her mother might have been admitted to hospital and not had to struggle so much at home.

83. We have made recommendations for the Trust to make service improvements to prevent this happening again. Other than our independent view on her complaint, which is set out above, this is the outcome sought by Mrs C to resolve her complaint.

1. We have considered Mrs C’s complaint about the care provided to her mother, Mrs P, in the weeks before she was diagnosed with lymphoma. We were sorry to hear of her concerns and recognise how important they are to her.

2. We found the Practice failed to adequately assess and refer Mrs P to hospital on 28 March 2024 for suspected sepsis. This has caused uncertainty for Mrs C about whether her mother might have been diagnosed with lymphoma sooner.

3. We have found the Trust failed to adequately assess Mrs P on 6 April. This has caused uncertainty for Mrs C about whether her mother might have been diagnosed and admitted to hospital sooner.

4. We have partly upheld the complaint. We have made recommendations for the Practice and the Trust to take learning to prevent a repeat of these events.