A practice in the Worthing area

5. Ms E complains about the care and treatment the Practice provided her mother, Mrs C, between 30 August and 17 September 2024.

6. She specifically states the Practice failed to provide her mother a face-to-face GP appointment and referred her for an endoscopy without an in-person examination.

7. She also complains a Practice paramedic, instead of the GP, gave her mother a likely cancer diagnosis over the phone without care or sensitivity.

8. Ms E says, in her final days, her mother’s condition deteriorated rapidly. Her stomach swelled dramatically, causing severe discomfort. At postmortem she has 6.5 litres of fluid build-up in her abdomen. Ms E says the Practice denied her mother comfort in her final days as she suffered physically and mentally.

9. Ms E says receiving her mother’s likely cancer diagnosis over the phone from the paramedic rather than the GP, added further to her shock and distress. She says the delivery lacked care and sensitivity, reinforcing her belief the GP had neglected her mother’s needs.

10. Ms E is looking for an apology and acknowledgment from the Practice.

11. Mrs C first presented with symptoms in August 2024. She had rarely seen a GP in previous years. On 30 August, Ms E became concerned about her mother’s symptoms and contacted the GP requesting a home visit.

12. Mrs C deteriorated rapidly and unpredictably within three weeks. From her initial reported symptoms, the Practice diagnosed her likely cancer 13 days later. Sadly, Mrs C died on 17 September.

The GP did not see Mrs C and referred her for an endoscopy without an in-person examination

16. 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

17. On 30 August 2024, Ms E telephoned the Practice and requested a GP visit her mother at home. She had concerns about her mother’s lack of appetite, weight loss, bloating and diarrhoea.

18. A Practice nurse visited Mrs C the same day. Mrs C’s medical records, say she reported her symptoms seemed to be present on taking alendronate (osteoporosis medication). She said the symptoms then subsided after two days and then started again on re-taking it.

19. The nurse considered Mrs C’s symptoms might be related to her osteoporosis medication, as she reported feeling unwell after taking it. The nurse advised her to stop her osteoporosis medication and arranged a follow up call in three to four weeks.

20. The Practice said the decision the Practice nurse made to ask Mrs C to stop taking her osteoporosis medication was a precautionary measure. This was to assess whether the medication was contributing to her symptoms.

21. Our adviser said the nurse’s decisions to stop the medication and monitor the patient were appropriate at this stage.

22. Ms E said the nurse was ‘useless’ and believes the GP should have visited her mother as she requested.

23. Our adviser said there is no specific national guidance on how the Practice should triage which clinicians see patients on such cases. They said decisions are based on local practice protocols and clinical judgement.

24. Ms E’s initial call to the Practice resulted in a same-day home visit, which our adviser said was reasonable. Based on the history provided at the time, our adviser said the nurse’s assessment and treatment plan were appropriate. Although, in hindsight, the diagnosis was not correct, the clinical decision-making was reasonable given the information available at the time.

25. Mrs C’s medical records show the nurse also provided appropriate advice about what to do if things got worse. Ms E’s follow-up call six days later reflects this. That the advice was given and acted on.

26. On 5 September, Ms E telephoned the Practice again to report her mother had not improved and her symptoms had worsened. She was also now having some abdominal cramps. She requested a GP to visit her mother for a second time.

27. The following day, a Practice paramedic practitioner telephoned Mrs C. They then arranged a home visit later the same day to review and examine her.

28. The Practice paramedic practitioner requested a CA125 blood test. A CA125 test is a specific blood test to measures a protein linked to ovarian cancer.

29. The paramedic practitioner also arranged a faecal immunochemical test (FIT) as they found Mrs C to have a swollen abdomen. A FIT test is a stool test used to check for hidden blood in the bowel.

30. Ms E believes the paramedic practitioner diagnosed her mother with constipation and prescribed her laxative. She said the laxatives caused her mother great pain. Ms E was not present during the examination and later acknowledged, in a phone call on 2 February, this account may be inaccurate, and she cannot confirm it.

31. In their response, the Practice reassured Ms E the paramedic did not diagnose constipation, as she initially thought. They assessed Mrs C for abdominal pain and suggested a short trial of laxatives for symptom relief, alongside Buscopan, which Mrs C already had. Buscopan is a medication used to relieve stomach and abdominal cramps.

32. We reviewed Mrs C’s records from the paramedic practitioner’s visit. They recorded a clear history and examination. They suspected a serious underlying condition and arranged appropriate blood tests to investigate this. This included a CA125 test, which led to a diagnosis of ovarian cancer. Our adviser confirmed this action was appropriate. They said it is unlikely the outcome would have been any different had a GP undertaken this visit.

33. GMC Good medical practice states:

In providing clinical care you must: adequately assess a patient’s condition(s), taking account of their history, including • symptoms relevant psychological, spiritual, social, economic, and cultural factors the patient’s views, needs, and values • promptly provide (or arrange) suitable advice, investigation or treatment where necessary • propose, provide or prescribe effective treatment based on the best available evidence • where appropriate refer a patient to another suitably qualified practitioner when this serves their needs.

34. Our adviser noted there also appears to have been a misunderstanding from Ms C about the roles of different clinicians. She felt that a GP would have been better and managed the situation differently. Our adviser said today’s NHS has changed. The GP would not have acted differently from the nurse or GP paramedic who reviewed Mrs C.

35. On 9 September, Ms E visited the Practice to arrange a blood test for her mother.

36. On 11 September, Ms E took her mother to the Practice for blood tests. Whilst she was there, she told the receptionist about her worrying concerns for her mother and her distressing bowel movements. The receptionist said they would request a GP visit her mother that afternoon.

37. The GP phoned Mrs C that afternoon, instead of visiting. As Ms E was with her mother, she spoke with the GP herself.

38. The GP discussed possible stomach issues and booked an endoscopy for her mother without an examination. The GP arranged an urgent referral for possible upper gastrointestinal cancer which refers to cancers that develop in the upper part of the digestive system.

39. Ms E believes this was wrong and that her mother’s issues were to do with the lower female reproductive area, not the stomach or digestion.

40. At the time of the GP telephone appointment, records show Mrs C’s blood test results were not yet available. The GP would have made a referral based on the information they had at the time and clinical judgement.

41. When the blood results became available the following day on 12 September, the Practice changed the referral from endoscopy to gynaecology, reflecting the new information. Our adviser said this was appropriate.

42. At this point, given the paramedic’s recent examination of Mrs C, the Practice said they felt the most appropriate and fastest course of action was to make an urgent referral rather than arrange a GP visit. This would allow her to receive specialist assessment and further testing. It then booked a scan for 19 September, eight days later.

43. We consider a GP could have visited and examined Mrs C on 11 September but would have been unlikely to change the outcome, as the tumour was already advanced. Our adviser also agreed a face-to-face GP examination at this stage would not have changed the outcome, as the findings would likely have been similar to those already identified by the paramedic.

44. NHS Sussex ICB looked at the complaint independently. As part of its review, it concluded from the practice response and clinical guidelines the Practice have acted appropriately in Mrs C’s care in some of Ms E’s concerns but might have acted differently in others.

45. It found the Practice carried out the correct investigations and referrals without delay, despite the absence of a GP examination. It found there were two missed opportunities a GP might have seen Mrs C in the Practice on the 9 and 11 September.

46. It said it would have been reassuring and comforting for Mrs C to know the doctor had seen her, although it would have been unlikely to have changed the outcome. By the time the paramedic saw her, this was an advanced tumour.

47. Given the seriousness of the situation, our adviser said at this stage the key question would be how best to investigate the underlying cause.

48. At this stage, the options were either hospital admission or an urgent two-week wait referral. Our adviser felt admission would probably not have been appropriate at the time, and the decision to arrange a two-week wait referral was reasonable. This involved an element of clinical judgement, given the uncertainty about the underlying cause.

49. On 17 September 2024, Mrs C sadly died at home. Ms E told us the ambulance crew who arrived after her mother had died, couldn’t believe the terrible state she was in in her own bed. We recognise this must have been difficult for Ms E.

50. Ms E says despite her three requests for a face-to-face GP appointment, the Practice failed to see her elderly mother in person between her first request and her mother’s death.

51. Ms E believes if the doctor had seen her mother straight away, they would have sent her to A&E.

52. On 2 February during our initial phone call, I asked Ms E why she did not take her mother to A&E with her concerns herself. She told me her mother did not want to go. She was frail and kept thinking the doctor would come out to see her.

53. The Practice said after reviewing Mrs C’s case, it feels all the decisions made were based on the best available information they had at the time. They said Mrs C received the appropriate care in response to her symptoms. They were deeply saddened by the rapid progression of her illness, as she had seemed to be doing relatively well when the paramedic saw her.

54. We are satisfied the Practice’s approach was in line with GMC Good medical practice. We consider the Practice acted in line with guidelines on this matter. The Practice may have missed opportunities to see and examine Mrs C. While this would not have changed the outcome, it may have provided comfort and reassurance.

55. We consider the Practice’s actions to be reasonable in the circumstances and find no indication of failings. Sadly, Mrs C deteriorated rapidly, in an unpredictable way.

56. This likely meant both the clinicians and Ms E were not expecting such a quick decline. We recognise this will have added to the family distress and grief.

Practice Paramedic, instead of a GP, gave a likely cancer diagnosis over the phone without care or sensitivity.

57. On 12 September, the Practice paramedic practitioner telephoned Ms E and her mother. They gave the news Mrs C’s blood tests results showed a raised CA125 level. They said it was likely ovarian cancer.

58. Ms E told us receiving her mother’s likely ovarian cancer diagnosis over the phone from the paramedic rather than a GP further added to their shock and distress. She said the delivery lacked care and sensitivity. This compounded her feelings of lack of care from the Practice.

59. In its response, the Practice said the paramedic practitioner received the blood test results and telephoned Ms C and Ms E to give the results. They apologised if Ms E felt they gave no care or consideration during this conversation. They said this was not their intention. They explained it is never easy to have difficult conversations which involve talking about a possible cancer diagnosis.

60. The Sussex ICB review states, when giving a diagnosis, it is best practice for a GP to deliver life-changing news. It said GP’s are trained to break bad news and explain what happens next.

61. It also states these conversations should take place face-to-face, as non-verbal communication is just as important as the words used. It recommended the Practice review its procedures for giving a potential cancer diagnosis to ensure they follow best practice.

62. Our adviser noted it is not necessarily the case these days, that a GP would be better trained than a paramedic in delivering difficult news.

63. Our adviser said there is no specific guidance on who should deliver bad news over the telephone. In this case, the Practice paramedic practitioner made the call. Our adviser said this may be because they had requested the blood tests and the results came back to them.

64. Our Principles of good administration says, public bodies must provide effective services, using appropriately trained and competent staff. Our principles also state public bodies must make reasonable decisions, based on all relevant considerations.

65. Our adviser said ideally, such conversations would take place face-to-face with the patient and their relatives. However, this can take time to arrange. In practice, when significant or concerning results are available, patients or families often wish to discuss them as soon as possible, which means these conversations frequently take place over the phone.

66. Taking our adviser’s view and the principles of good administration into account, we consider the Practice made its decision based on all relevant factors and used appropriately trained and competent staff.

67. The blood test results came back to the paramedic who had arranged them. There is no evidence they were less qualified than a GP to communicate this information. While face-to-face discussions are preferable, sharing the results by telephone was the timeliest option in the circumstances.

68. We recognise this did not help and may have increased Ms E’s concerns the Practice did not show enough care for her mother.

69. In this situation, there was no easy way to communicate the results. We consider the paramedic practitioner exercised appropriate clinical judgement, in line with our principles of good administration.

70. This means we found no indication of failings in the Practice’s actions and will not consider this case further.

71. Ms E told us she wanted reassurance she had done everything she could to seek answers for her mother. We hope this explanation provides some closure. We note she has since moved practices and hope she is now able to move forward.

1. We have carefully considered Ms E’s complaint about the care and treatment the Practice provided her mother, Mrs C.

2. We considered the Practice’s care of Mrs C and its decision to refer her for an endoscopy without a face-to-face appointment. We found the GP’s actions reasonable in the circumstances and saw no indication the Practice made errors in its decision making.

3. We also considered the Practice’s decision for the paramedic to telephone Mrs C to discuss her likely diagnosis. In the circumstances, we found the actions reasonable and saw no indication anything went wrong.

We want to thank Ms E for bringing this complaint to us. We are sorry to hear about the death of her mother and the circumstances surrounding her care and treatment. We recognise how difficult this has been for her and her family.

4. We hope our explanation reassures Ms E about the Practice’s actions. We recognise the importance of her complaint and the time she has invested in pursuing it. We hope this provides some closure.