A practice in the Chorley area

3. Mr A complains the Practice failed to diagnose his mother’s lung cancer. Specifically, he says:

• Mrs X complained of a persistent cough and shortness of breath between October 2023 and January 2025, but the Practice failed to diagnose her lung cancer.

• The Practice failed to always record Mrs X’s complaint of an ongoing cough in her medical records between October 2023 and January 2025.

• In August 2024 Mrs X’s white blood cell and neutrophil count were elevated but the Practice did not take further action. White blood cells help the body fight infection, and neutrophils are a type of white blood cell. The Practice diagnosed this as a cause of long-term steroid use rather than doing further investigations.

• The Practice misdiagnosed Mrs X’s cough as acid reflux and Barrett’s oesophagus, despite having received a gastroenterology report indicating the acid reflux was an unlikely cause, and confirming Mrs X did not have Barrett’s oesophagus. Barrett’s oesophagus is a condition where the lining of the lower oesophagus (food pipe) changes because of long-term acid reflux.

4. Mr A says the failings caused his mother’s death, which he believes was avoidable. He also says Mrs X’s family suffered significant emotional distress due to the circumstances around her death.

5. To resolve his complaint Mr A wants the Practice to acknowledge the failings set out above and to provide an apology.

6. The Practice reviewed Mrs X between October 2023 and January 2025 for various symptoms, including an ongoing cough.

7. Mrs X became acutely unwell in January 2025, and the Practice treated her for a chest infection.

8. Mrs X’s condition worsened on 21 January 2025 and she was admitted to hospital, where she received further treatment.

9. Mrs X was diagnosed with advanced stage lung cancer on 31 January 2025. She was discharged home on 11 February 2025 to start palliative care, i.e. care to make her comfortable at the end of her life.

10. Mrs X sadly died on 6 March 2025.

Failure to diagnose

14. Mr A says his mother complained of a persistent cough and shortness of breath between October 2023 and January 2025, but the Practice failed to diagnose her lung cancer.

15. Between October 2023 and January 2025, we can see from Mrs X’s medical records that she attended the Practice on 27 October 2023 with a cough that had been ongoing for around 12 months. The records describe the cough as ‘phlegmy’ and note that it was worse after eating. Mrs X also reported symptoms of reflux, which is where stomach acid travels back up into the throat or chest. The records further note that Mrs X had a short smoking history. Following this appointment, the Practice arranged a chest X-ray and a sputum sample test for further investigation.

16. According to the NICE NG12 guidelines referred to in our ‘evidence’ section, a chest X-ray should be offered to patients to assess for evidence of lung cancer who are over the age of 40 and who show specific symptoms. We can see by having a history of smoking and an unexplained cough, Mrs X met these criteria. She was appropriately offered a chest X-ray by the Practice, in line with the guidance. We understand from the evidence available that Mrs X’s chest X-ray was reported as normal. The sputum sample test did not take place and we understand from the medical notes this is because Mrs X was unable to cough up sputum for a sample to be taken.

17. We understand from our adviser and the NICE NG12 guidelines that after a chest X-ray is done a patient is only referred for a two-week cancer pathway to the specialist team if there is a high suspicion of cancer. The chest X-ray was reported normal, and we understand there was another possible explanation for the cough from Mrs X’s history of her experiencing reflux and the cough being worse after eating. The Practice considered she may be suffering from gastroesophageal reflux disease (GERD), which is a condition where stomach acid repeatedly flows back up into the food pipe and can cause a chronic cough.

18. We can see from the medical records that between the consultation on 27 October 2023 and 19 March 2024 Mrs X presented to the Practice on multiple occasions regarding unrelated symptoms, none of which we understand from our adviser would have raised concerns about possible lung cancer.

19. On 19 March 2024 Mrs X attended the Practice with her daughter complaining of a chronic cough. We understand from our adviser and Mrs X’s consultation notes that specific cancer red flags were ruled out, including her having no weight loss and not coughing up blood. An examination of her chest was carried out and reported as normal, and on assessment a provisional diagnosis of reflux was again made. Mrs X was referred to the gastroenterology team in hospital for a review of her reflux symptoms, and a sputum sample was requested again. Our adviser says on review of this presentation and assessment, there were no causes for an increased suspicion of lung cancer.

20. We can see from the available evidence Mrs X reported a cough to the Practice again on 11 December 2024. The medical records indicate this was reported alongside ear pain and nasal congestion. She had been treated for a recent ear infection with a course of antibiotics. Amongst other assessments, a chest examination was carried out and was reported as normal. We understand from our adviser the consultation was focused on the ear infection symptoms, Mrs X was given an antimicrobial ear spray and no concerns were identified.

21. On 23 December 2024 Mrs X was reviewed by the Practice again as her ear pain worsened and she also reported facial pain. She was diagnosed with sinus inflammation which we understand from our adviser, based on the recorded assessment, was an appropriate diagnosis. We can see from the medical notes, once again a chest examination was carried out and reported as normal.

22. On 6 January 2025 Mrs X had a telephone assessment and a face-to-face home visit from a Practice doctor because she was feeling unwell with a cough and temperature. We can see from the medical notes from this review that Mrs X’s assessment, including a chest examination, was showing signs she may have an acute chest infection. The doctor diagnosed as such and gave Mrs X a course of antibiotics and steroids. We understand from our adviser that Mrs X’s symptoms and examination findings were consistent with a chest infection, and there were no signs at that time to suggest or raise concerns about lung cancer. Based on the symptoms Mrs X presented with, we can see the diagnosis and treatment provided by the Practice were in line with the NICE CKS guidance on chest infections referred to in our ‘evidence’ section.

23. Mrs X was reviewed again on 10 January 2025. The medical records indicate she was feeling ‘marginally better’ but still had an ongoing cough, wheezing and shortness of breath on exertion. We understand from the notes that as she was showing some improvement, the Practice doctor decided to continue the same treatment with a further course of antibiotics and steroids.

24. Mrs X was then seen again at home on 17 January 2025 by a Practice doctor. The records show that she reported her chest symptoms ‘had improved a lot’. However, she still had a blocked nose and left-sided facial pain. On examination her chest was recorded as ‘clear’. She was therefore treated for a sinus infection and prescribed a different antibiotic. This was the last review by the Practice before Mrs X was admitted to hospital on 21 January 2025.

25. From the available evidence, we can see that the Practice reviewed Mrs X each time she presented with symptoms and she was provided treatment in line with the relevant guidance. In view of this, we have not seen anything to suggest the Practice failed to follow applicable guidelines in its assessment and management of Mrs X’s symptoms. We recognise the seriousness of Mr A’s concerns, and we hope our explanations provide some reassurance that appropriate clinical assessments and treatment were carried out in line with recognised guidance at the time.

Record-keeping

26. Mr A complains the Practice failed to always record Mrs X’s complaint of an ongoing cough in her medical records between October 2023 and January 2025. We can see from Mrs X’s medical record that she presented with a cough six times within this period. We can also see the Practice regularly reviewed her for other symptoms and we understand from our adviser these reviews were unrelated to her symptom of ongoing cough.

27. We recognise Mr A’s concerns that his mother may have mentioned her cough on more occasions than those recorded in the medical notes but that this was not always documented by the doctor. We have been unable to find anything to suggest that Mrs X’s complaint of cough was mentioned but not recorded. Therefore, on the balance of probabilities we are unable to provide a view on whether the Practice always maintained good record-keeping.

28. In the absence of any indication that the Practice failed to record Mrs X’s symptoms as fully as it should, we are not able to give a view on whether the Practice failed to act in line with the GMC guidance set out above. We appreciate this may be frustrating for Mr A, particularly given the understandable concerns he has about his mother’s care and the difficulty in now establishing exactly what was discussed at each appointment.

Blood test results

29. Mr A complains that in August 2024 Mrs X’s white blood cell and neutrophil count were elevated. The Practice diagnosed this as a cause of long-term steroid use and so did not carry out further investigations, which Mr A believes it should have done.

30. We can see from the available evidence that Mrs X underwent routine blood tests on 14 August 2024 as part of her diabetes review. These tests showed a raised white cell count and neutrophil count. Repeat blood tests on 28 August 2024 showed these levels had increased further, although a further blood test on 9 October 2024 showed improvement. Mrs X’s medical records show that, at the time, she was receiving long-term steroid treatment for another condition and had also reported bowel symptoms that could suggest inflammation. We understand from the Practice’s complaint response that it considered the raised white cell count could be explained either by the long-term steroid treatment or the possible bowel inflammation identified during later consultations.

31. We understand from our adviser that this was a reasonable explanation in the circumstances, as Mrs X’s white cell count was only marginally raised initially and had reduced on repeat testing two months later. Our adviser explained that, where there is concern about an underlying cancer, it would generally be expected that the white cell count would remain persistently raised and would likely be at a higher level. We also understand from both the Practice’s response and our adviser that a drop in haemoglobin levels and/or a raised platelet count would have increased the suspicion of cancer but Mrs X’s test results did not show either of these findings. Haemoglobin is a protein in red blood cells that carries oxygen around the body and platelets are small cells in the blood that help stop bleeding by forming clots.

32. The NICE NG12 guidelines explain what primary care clinicians like GPs should do when blood tests are abnormal and when those results may suggest a possible cancer that needs further investigation. For lung cancer, the guidance says one of the blood test findings that may increase suspicion is a higher-than-normal platelet count. Mrs X’s platelet count remained within the normal range in all blood tests carried out between August 2024 and October 2024, so this particular indicator for referral on the lung cancer pathway was not present.

33. In view of this, we cannot see any indication that the Trust failed to act in line with established clinical guidelines by not carrying out further investigations for cancer when Mrs X was found to have a raised white cell and neutrophil count.

Misdiagnosis of cough

34. Mr A complains the Practice misdiagnosed Mrs X’s cough as acid reflux and Barrett’s oesophagus, despite having received a gastroenterology report indicating the acid reflux was an unlikely cause and confirming Mrs X did not have Barrett’s oesophagus.

35. As set out earlier, Mrs X was referred to the gastroenterology team on 19 March 2024 because she had an ongoing cough which the Practice considered might be related to acid reflux. A gastroscopy was then arranged, which is a test where a thin tube with a camera is passed through the mouth to look inside the oesophagus, stomach and upper intestine to check for problems. The Practice received the gastroscopy report on 4 September 2024. We note that, although the report did not find Barrett’s oesophagus, it did show that Mrs X had a sliding hiatus hernia. This is a condition where part of the stomach moves up into the chest, making acid reflux more likely. Within this report the gastroenterology doctor commented that he was ‘not convinced’ Mrs X’s cough was related to acid reflux. We understand that, following receipt of the report, the Practice did not take any further action.

36. While the gastroenterology doctor was not certain, based on their clinical judgment, that acid reflux was causing Mrs X’s cough, we note that she was diagnosed with a sliding hiatus hernia. We understand from the NICE CG184 guidance referred to in our ‘evidence’ section that a sliding hiatus hernia can contribute to a chronic cough, as it can cause acid reflux or GERD. It also recognises that GERD can still be present even where a gastroscopy appears normal. Therefore, the gastroscopy findings not only support the possibility that Mrs X may have been experiencing acid reflux or GERD, they also do not rule acid reflux out as a possible cause of her cough.

37. We recognise this may appear inconsistent, as the gastroenterology doctor expressed the clinical view that acid reflux may not be the cause of Mrs X’s cough, while at the same time diagnosing a sliding hiatus hernia, which is recognised as being associated with acid reflux symptoms. However, when considering whether the Practice acted appropriately and in line with applicable guidelines, we look at the available evidence against the relevant clinical guidance and established standards of practice. In this case, the guidance recognises that a sliding hiatus hernia may contribute to acid reflux and that reflux-related symptoms can still be present even where investigations are not definitive.

38. We can see from the available evidence that Mrs X did not return to the Practice with an ongoing cough symptom at the time the Practice received the gastroscopy report in September 2024. We understand from our adviser, in these circumstances, the Practice would not usually begin further investigations where the patient had not returned with a cough and there were no red flag symptoms suggestive of lung cancer.

39. We noted earlier in this statement that Mrs X reported a cough on 11 December 2024, approximately two months after the Practice received the gastroscopy report. The cough was reported during an appointment about acute ear pain, which was treated as an infection. From the available evidence, we have not seen anything to suggest that the Practice should have concluded the cough at this time was a continuation of Mrs X’s earlier chronic cough symptoms. We have also not seen any indication that this assessment should have led the Practice to reconsider acid reflux as a possible cause of the earlier ongoing cough.

40. We recognise this may be frustrating for Mr A, particularly given his concerns about the progression of his mother’s symptoms and the understandable request for further clarity about her care. We know that it continues to cause Mr A worry that Mrs X’s underlying diagnosis was not established earlier and that earlier diagnosis might have made a difference to the very sad outcome. We hope we have explained how we explored all the evidence available and why we have not identified any indication of failings in the care provided by the Practice.

41. In light of the above we have decided to take no further action with this complaint. We are sorry to hear of the distress Mr A experienced, and we hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it. We hope our independent view offers some clarity and reassurance to Mrs X’s family. We would like to thank Mr A for bringing his concerns to our attention.

1. We have carefully considered Mr A’s complaint about a GP Practice in the Chorley area (the Practice). Mr A complains about the care and treatment provided to his mother (Mrs X). We are very sorry to hear about the circumstances of Mr A’s complaint and the sad loss of his mother.

2. We have considered the evidence available to us carefully, including obtaining independent clinical advice, and we have not seen any indications of failings by the Practice. Therefore, we have decided to take no further action. We explain further below.