A practice in the Cheshire East area

7. The following summary of the complaint has been agreed by all parties.

8. Dr P complains about aspects of the care and treatment she has received from The Practice (the Practice) between 2021 and October 2024. Specifically, Dr P says the Practice:

• in 2021 did not appropriately consider her raised GGT (gamma-glutamyl transferase - a blood test to diagnose liver problems) and instead marked this as ‘okay’ • in 2022 did not consider her concerns that she may have metastases when she attended the Practice on 8 March with back and hip pain • In 2022 did not refer her for an MRI scan when she reported these symptoms, and instead referred her for an x-ray which was inappropriate due to her symptoms and history of breast cancer • in 2024 did not refer her for an MRI scan when she attended May with severe hip and back pain

9. In addition to the above, Dr P also raises concerns about the Practice’s handling of her delay in referring her from May 2024 to October 2024, it has not considered what impact this will have had on her prognosis and treatment options. Dr P also feels the Practice has not appropriately considered the earlier opportunities for referral.

10. Dr P says the failings in the Practice’s care have left her wondering if she would have had a terminal diagnosis, had her symptoms been appropriately investigated sooner. She also says she would have had the opportunity for better pain management had her symptoms been diagnosed sooner.

11. Dr P says the delayed diagnosis has had a devasting impact on her overall life. She is limited as to what she can now do and has suffered financial hardship as she has needed to reduce her working hours. These events have also had a significant mental and emotional impact.

12. By bringing this complaint to the Ombudsman Dr P is seeking a formal apology from the Practice to recognise what went wrong, service improvements, and a financial remedy.

13. What follows is a brief summary of events to put the complaint in context. We do not include all the details as each party to the complaint are aware of these.

14. At the time of events Dr P is a patient at the the Practice

15. Dr P had previously been diagnosed with breast cancer around 2012, was showing to be 10 years clear in March 2022 and stopped taking Tamoxifen in Jan 2022. (Tamoxifen is a drug prescribed to help prevent certain cancers in individuals).

16. Dr P had raised GGT level from a blood test in March 2021 (a liver enzyme which is often used to indicate a person’s liver and bile duct health). This was categorised as ‘okay’ when it was above the usual normal category at 71 (normal level 10-53).

17. Dr P visited the Practice in March 2022 with symptoms of hip and back pain raising concerns that this may be a sign of metastases. At the time she was referred for an Xray and subsequently diagnosed with osteoarthritis.

18. Dr P re visited the Practice in May 2024 presenting with concerns regarding hip and back pain. Dr P was referred to the MSK team in October 2024 (MSK is an abbreviation for muscular skeletal teams who specialise in muscles, joints, bones, tendons and ligaments).

19. On 29 October 2024 the MSK team referred Dr P for an MRI (a type of imaging surveillance of the body) of the lumbar spine and pelvis. The MRI scan found bone metastases in the right hip and spine (metastases are the spread of cells or tumours from one site in the body to another). There was concern about the risk of a pathological fracture of the right hip and Dr P was therefore directly sent to A&E for an orthopaedic opinion.

20. A further clinic letter from the oncology team confirmed Dr P’s diagnosis of metastatic carcinoma of the breast, with bone and liver metastases (ER 8 PR 6 HER2 0).

21. Dr P received treatment under the oncology team and later received a terminal diagnosis.

22. Dr P raised her complaint about the delay in referring her from March 2022 as she says this delay has caused her cancer to progress to a stage where it cannot be treated. The Practice’s response says that ‘in hindsight’ the GP could have perhaps referred Dr P for an MRI rather than referral to musculoskeletal (in June 2024). But overall, the Practice felt it had given the appropriate care throughout.

28. When we look at a complaint we first consider what are the relevant standards or guidelines are, to inform us what should happen. Next, we go onto consider the version of events from all parties. We do so to identify if care fell so far below a standard to be considered a failing (often referred to as ‘maladministration’).

29. If we identify a failing, we consider the impact and injustice on the aggrieved and if we can link this to the failing. We refer to this as ‘flowing’ from a failing.

30. Following this we then look to establish what the organisation has done to put matters right for the failing (the ‘remedy’). We also note that not every failing will be maladministration. On occasions this could be a shortcoming. Where we identify so we will make this distinction.

31. If we consider more could be done, we may make a range of recommendations. To do so we consider the individual circumstances of each complaint and also other similar complaints and the remedies we have awarded and precedent set. It is for the Ombudsman to determine remedy that is fair, proportionate and reasonable.

In 2021 the Practice failed to appropriately consider raised GGT (gamma-glutamyl transferase)

32. There are two sets of standards which are relevant here.

33. The British Society of Gastroenterology Abnormal Liver Function Blood Test Guidelines (November 2017) states investigations are suitable where the presentation shows high levels for both Alkaline phosphatases (ALP) and Gamma-Glutamyl Transferase (GGT) but not singularly GGT.

34. Further to this The GMC’s Good Medical Practice guidance is also relevant in this situation. The GMC guidance states practitioners must adequately assess a patient’s condition and promptly provide or arrange suitable treatment (part C) referring to another practitioner when this is needed.

35. Dr P complains that in March 2021 the Practice failed to appropriately consider her raised GGT (gamma-glutamyl transferase - a blood test to diagnose liver problems) and instead marked this as ‘okay’ when it was at 71iu/L (normal range 0-50).

36. During their complaint handling the Practice noted this GGT to be 71, they considered this was indeed slightly above the normal range of tolerance (at the upper end of normal) and this was recorded in notes to be OK as other liver function tests were not of concern and they explained it is not uncommon to see mildly raised levels of GGT.

37. We sought clinical advice to better understand what should happen in this scenario.

Our adviser explained (aforementioned) guidance recommends further investigations when both alkaline phosphates (ALP) and GGT are of a concern. Our adviser notes this is not detailed needing investigation when GGT concern alone present.

38. We understand many laboratories do not routinely measure the GGT level when liver blood tests are requested. If the ALP level is raised the GGT can be checked to see if the raised ALP is from the liver, as it can come from bone instead.

39. We then sought to understand what Dr P’s presenting ALP level was. From clinical notes we can see this to be in a normal range as this was at 82iu/L and the normal range would be 30-130. Reassuringly we note her other blood tests results were normal.

40. From clinical advice we understand the level of GGT were given due consideration and there was no clinical need at the time to then seek further escalation. Our adviser considers action taken was also in line with GMC guidance.

41. Though we recognise Dr P’s concerns we have not identified an indication of failing regarding the Practice’s actions to appropriately consider GGT levels. As such, without being able to identify a failing we take no further action on this complaint part.

Failed to consider her concerns that she may have metastases when she attended the Practice on 8 March 2022 with back and hip pain

42. The following guidance is relevant here: NICE CKS back pain (without radiculopathy). This states there is no requirement to send a patient for an MRI for musculoskeletal pain. It does recommend an x ray for malignancy, when the red flags of a patient aged 50 or over, history of cancer and night signal pain preventing sleep are all present.

43. Regarding hip pain as we are not aware of guidance specific to this, we refer to the principles of the GMC guidance as mentioned in the previous section.

44. Dr P complains that The Practice in March 2022 failed to refer her back pain and hip pain for an MRI especially considering her previous medical history of breast cancer.

45. We understand The Practice did question the possibly of sending Dr P for an MRI after the x-ray if the x-ray picked up signs that needed investigation.

46. From this appointment, the Practice referred Dr P for an x-ray. On 11 April 2022 the x-ray report stated no bone cancer was present, and Dr P was signposted for physiotherapy.

47. In considering the records and the clinical advice sought we understand Dr P met the clinical red flags to refer for further surveillance with x-ray, we have seen the actions taken were in line with the expected standard.

48. Further we note our clinical adviser commented it was reassuring the Practice did put in place a plan for pain management with physiotherapy to support this.

49. The x ray did show evidence of wear and tear in the lower back, but no hip issue and Dr P was given safety netting advice to return if pain in back and hip worsened.

50. Therefore, we find that the actions taken by the GP were in line with the GMC’s Good Medical Practice guidance with regards to arranging suitable onward investigations and arranging referrals and treatment where necessary.

In 2022 did not refer her for an MRI scan when she reported these symptoms, and instead referred her for an x-ray which was inappropriate due to her symptoms and history of breast cancer

51. The following guidance is relevant here: GMC guidance on good practice which states further referral must be made when needed.

52. We note the Practice responded stating (regarding suitability for MRI over x-ray) that Dr P attended the Practice 8 March 2022 with hip and back and a discussion took place, there were concerns of metastases raised and referral for prior x-ray which did not show any issues but did show osteoarthritis in the spine, but no indication of secondary bone cancer.

53. The practice noted Dr P was taking Ibuprofen which seemed to be helping. Dr P was signposted to the physiotherapist, and we can see safety netted occurred to return if the symptoms worsening. From the complaint response we understand on 10 May 2022 a Physiotherapist appointment took place and advised to book again if symptoms worsened.

54. Dr P considers this to be a failing that given her presentation and symptoms an MRI referral should have happened.

55. From clinical advice received we consider at the time it was appropriate and in line with the GMC’s Good Medical Practice for the Practice to not refer Dr P for an MRI in 2022.

56. Our adviser noted the referral for an x ray could have possibly picked up metastatic disease. We understand an absence of referral to MRI specifically is not indicating a failing. We recognise also pain management was put in place with a referral to a physiotherapist and safety netting advice. We can see Dr P attended the surgery later October 2023 for a mental health and wellbeing matter and February 2024 for a skin lesion, on both these occasions there was no mention of hip or back pain.

57. We have not been able to identify the choice of x -ray instead of an MRI to be a failing regarding this complaint part and therefore take no further action.

In 2024 did not refer her for an MRI scan when she attended with severe hip and back pain and concerns about her referral from May to October

58. The GMC’s Good Medical Practice guidance is also relevant in this scenario. The GMC guidance states practitioners must adequately assess a patient’s condition and promptly provide or arrange suitable treatment (part C) referring to another practitioner when this is needed.

59. Dr P had a consultation with the Practice May 2024 complaining of severe hip and back pain. Dr P states that the Practice failed to refer her for an MRI and instead referred her to musculoskeletal services. She complains that an early diagnosis could possibly have prevented her from emergency surgery to her femur and considers this potential delay in diagnosis has also led her to a point where her cancer cannot be treated.

60. We understand following this Dr P then attended a face-to-face appointment on 11 June 2024

61. We further note upon an MRI conducted by Musculoskeletal in October 2024, Dr P needed surgery in her femur performed 10 December 2024 due to the advancing of the metastases. Sadly, at this time Dr P was informed that her cancer had spread to her liver and bones.

62. In the Practice complaint response dated 25 March 2025 it is noted in section 5, ‘that with hindsight, he (the GP) felt that he could have referred you for an MRI scan following your appointment 11 June but that at the time he believed that the plan that was in place was sufficient, and he stated in the consultation record “review if recovery stalls”’.

63. From the clinical advice received, we recognise Dr P’s general health was of concern and in poor state for treatment when she was diagnosed and saw the oncologist in November 2024. She then commenced the standard of care for first line treatment for oestrogen receptor -positive metastatic breast cancer shortly afterwards.

64. We have identified the actions of the Practice were not in line with GMC’s Good Medical Practice here regarding taking full account of her presenting condition during this consultation, her health history and taking prompt action to arrange the most suitable and necessary investigations. It is our consideration this is an indication of failing that an opportunity was missed to refer Dr P for an MRI in May 2024.

65. We recognise it would be hard to say how much wait time there would have been had the referral been made earlier, but we make a distinction this also has an impact on the uncertainty Dr P would have faced in not knowing and the missed opportunity for this to commence sooner.

66. Having identified this as a failing we discuss the impact and present a remedy later in our report.

Impact and remedy

67. We have identified a missed opportunity from May 2024 to 27 October 2024 for a better clinical outcome. We recognise on 27 October 2024 an MRI of pelvis showed no left leg involvement but to the right leg extensive involvement. This is representative of a six-month period where to opportunity for a better outcome was missed.

68. We sought further clinical advice to better understand what this impact means. From the advice sought it is our understanding though a missed opportunity this would not have changed the intent of treatment (as regrettable to note a cure would not have been possible).

69. We understand although there is no certainty, had an earlier referral occurred the disease in the hip /femur would not have been advanced as to lead to the possibility of surgery actually being avoided, there is no evidence that we have seen which, on a balance, and from clinical advice and experience that would support that thinking. We are minded of this when considering remedy.

70. It is our view a delay in diagnosis meant Dr P experienced additional pain before metastatic disease was diagnosed and cancer treatment started. From the advice we consider it is probable the surgery helped the pain more quickly than her other cancer treatments would have and there was no delay to these starting. However, prior to surgery taking place we do not seek to diminish concerns that Dr P’s pain would have been worse due to missed opportunity for a better outcome.

71. From clinical advice we understand a delay of this period could affect prognosis if it meant that a patient’s condition had deteriorated so much that they were no longer fit enough to receive the necessary anti-cancer treatment. We sought to understand this better and form the clinical advice note reassuringly this was not the case for Dr P.

72. In further consideration of prognosis we note it would only be affected if during the delay period cancer had metastasized (spread) to the liver (prognosis could be shortened by that). The prognosis of bone only metastatic disease in breast cancer is better than that of liver metastases. Incidentally we consider that in 2021 it is very unlikely the mildly elevated gamma was due to liver metastases.

73. We note untreated liver metastases grow more quickly and are reassured that Dr P’s gamma GT in October 2024 was still only showing to be mildly elevated (130). When considering impact, it is our view that if liver metastases had been present since 2021, from the clinical advice sought, we would have expected significantly more disturbance of liver function at the time of diagnosis in 2024 (or more likely an earlier presentation with symptoms from her liver).

74. We further note the liver metastases were not visible on the CT scan performed at diagnosis but were seen on a dedicated liver MRI and were noted to be multiple in number. Therefore, there probably would have been liver involvement at this point during the missed opportunity. Finally, we consider the disease hip, and surgery would not have an impact to life expectancy.

75. We recognise this has been an ongoing and significant health challenge for Dr P who faces a very serious diagnosis at this moment in time. We seek to reassure from the findings we have made that what we have identified is a missed opportunity to act sooner regarding the MRI and moving onto considering remedy we base our recommendations on this.

76. In terms of management of pain, this means that we find Dr P endured an additional five to six months of pain before the metastatic disease was diagnosed and the cancer treatment started owing to the Practice not referring Dr P for an MRI in May 2024.

77. We find that this delay would not have affected the prognosis of Dr P’s condition as Dr P was still fit enough to receive anti-cancer treatment.

1. In issuing our final report we have found that The Practice acted appropriately in not referring Dr P for an MRI scan in 2022. We identify a referral for an x-ray and to a physiotherapist was also in line with relevant guidance.

2. We had identified there was a delay in identifying and investigating Dr P’s symptoms of metastases breast cancer and therefore there was a delay in diagnosis, due to Dr P’s ongoing hip pain the Practice should have made a referral for an MRI in 2024.

3. We have found that prior to surgery taking place Dr P would have endured additional pain for around six months and uncertainty resulting from the delayed diagnosis and thus a missed opportunity for a better clinical outcome.

4. We are unable to say with confidence if Dr P would have avoided surgery to the femur but the lack of certainty on this, we have viewed this as a potential injustice.

5. We can state that this six-month delay did not affect the prognosis as Dr P was still able to have cancer treatment after her surgery.

6. We recognise this has been a very difficult and uncertain time for Dr P regarding their health. Based on the findings, we are recommending that the Practice takes action to remedy the failing identified. We provide reasoning to our recommendations later in this detailed investigation statement.