A practice in the Croydon area

6. Mrs A is complaining about the care and treatment she received from GP Practice in the Croydon area. Specifically, she complains:

• the Practice did not investigate her lower abdomen pain between August 2021 and February 2023 which delayed her stage four bowel cancer diagnosis • The Practice did not respond appropriately to test results and investigation requests from the eye hospital which delayed her diagnosis.

7. Mrs A says she has been through an incredibly difficult and painful time which could have been avoided. Mrs A says she experienced significant blood loss before her cancer diagnosis which caused permanent damage to her right eyesight. She also says she has physical scars from the surgery to remove the tumour.

8. Mrs A says she has been mentally impacted by the whole experience and lives in fear that she and her loved ones may experience similar treatment.

9. Mrs A would like an apology, service improvements and a financial remedy.

10. Mrs A has a history of anaemia and stage four bowel cancer.

11. Mrs A reported urinary symptoms in October and November 2021 and heaviness in her lower abdomen on 12 October and on 30 December 2021.

12. Mrs A underwent an ultra-sound scan on 2 February 2022 which revealed a liver cyst which required monthly monitoring. The GP noted her bladder appeared low and referred her to gynaecology.

13. The gynaecology department investigated Mrs A’s pelvic pain on 24 August 2022, diagnosing musculoskeletal pain and she began gynae-physiotherapy treatment.

14. Mrs A attended the neuro-ophthalmology clinic at Moorfields Eye Hospital on 30 August 2022 with damage to the optic nerve in her right eye (right optic neuropathy), unexplained loss of vision, and underwent blood tests.

15. On 1 September 2022, a consultant from the eye hospital wrote to the Practice confirming the results which revealed a low red cell count, with elevated CRP levels (C reactive protein, indicates inflammation in the body, with higher levels suggesting more significant inflammatory activity or infection). The results also showed she was anaemic and had low folate levels (folate levels indicate the concentration of vitamin B9 in the blood, reflecting the body’s ability to produce healthy red blood cells).

16. Mrs A underwent further investigations in January 2023 and, following a positive FIT test, the Practice referred her via the urgent two-week cancer referral pathway.

17. Mrs A was diagnosed with stage four bowel cancer on 9 February 2023. She had surgery to remove the tumour and underwent a ten-month period of intensive chemotherapy.

Assessment

23. Mrs A complains the Practice did not investigate her symptoms of lower abdomen pain between August 2021 and February 2023 which led to a delayed diagnosis of stage four bowel cancer. She says she was treated for gynaecological and urology issues which were not present.

24. Mrs A has told us she now has permanent damage to the sight in her right eye which she believes is due to the blood loss she experienced whilst she waited for a diagnosis.

25. We reviewed this issue with the help of our GP adviser using Mrs A's medical records.

26. NICE’s suspected cancer guidance says patients over 60 with unexplained abdominal pain or any anemia should have a FIT test and/or investigations for gynecological cancer including CA125 blood tests (measures the level of cancer antigen 125, a protein that is often elevated in women with ovarian cancer).

27. A faecal immunochemical test (FIT) tests for blood in the stool which cannot easily be seen and is used as a screening tool for bowel cancer and other gastrointestinal issues. It tests for elevated levels of haemoglobin (red blood count) which is an early sign of bleeding in the gastrointestinal tract and can be an indication of cancer.

28. In its response, the Practice said there were reasonable grounds to initially suspect a urine infection as Mrs A’s symptoms were related to passing urine and improved with antibiotics. It also said her pain improved after treatment with the gynaecology and physiotherapy teams. The Practice acknowledged that abdominal pain can be a symptom of bowel cancer and said Mrs A had not reported a change in bowel habit or weight loss.

29. Mrs A had nine consultations between August 2021 and December 2021 where she reported various symptoms including pain in her lower abdomen and groin and urinary symptoms. Our GP adviser said the consultations during this period were appropriate and that one of the urine tests had led to a reasonable diagnosis of suspected UTI infections.

30. Mrs A attended the Practice on 30 December 2021 reporting lower abdomen pain. The GP arranged an ultrasound of Mrs A’s abdomen and pelvis. Our GP adviser said it was clear at this consultation something else was causing Mrs A’s pain and that as well as arranging ultrasound investigations the GP should have arranged a full blood count and CA-125 tests in line with NICE guidelines.

31. A CA-125 blood test measures the level of a protein known as cancer antigen 125 and is used for ovarian cancer surveillance. The healthy range is from 0 to 35 units/ml and levels above this can be an indication of ovarian cancer with NG12 guidelines recommending an ultrasound scan of the abdomen and pelvis. Our GP adviser said this test would have revealed whether Mrs A was at risk of gastrointestinal cancer.

32. The GP contacted Mrs A on 6 February 2022 to discuss the results. The scans revealed a cyst in her liver which the GP explained was very common and that otherwise her abdomen and pelvis were normal. Our GP adviser said the results of the pelvis ultrasound showed the chance of gynaecological cancer was low and at this stage there was another opportunity for GPs to make further investigations into Mrs A’s symptoms by ordering blood tests.

33. Our GP adviser said the Practice did not follow NG12 guidelines on diagnosing suspected cancer as clinicians did not arrange relevant blood tests and consider Mrs A’s clinical history.

34. Mrs A should have had blood tests when the source of her abdominal pain could not be identified, and ultrasound scans had not suggested a gynaecological cause. This suggests if she had undergone blood tests from December 2021 ovarian cancer could have been ruled out and further investigations undertaken. We consider this to be a failing.

Ophthalmology test results

35. Mrs A complains blood test results from the ophthalmology department on 9 September 2022 showed her inflammation markers were elevated, and this was not acted on which led to a delay in her cancer diagnosis. She says she felt she was only taken seriously by the ophthalmology team who had taken blood tests to investigate her vision issue.

36. We reviewed this issue with the help of our GP adviser using Mrs A's medical records.

37. The Practice acknowledged it had received contact from the eye hospital explaining Mrs A’s inflammation markers were elevated. It said the Practice should evaluate the need for further investigation without making clear any specific concerns or investigations.

38. Mrs A attended the neuro-ophthalmology clinic at Moorfields Eye Hospital on 30 August 2022. She had damage to the optic nerve in her right eye (right optic neuropathy), unexplained loss of vision, and underwent a series of blood tests.

39. A consultant wrote to Mrs A’s GP on 1 September with the results which revealed a low red blood cell count and elevated CRP levels (an indication of inflammation). The results also showed she was anaemic and had low folate levels. The consultant asked the Practice to prescribe folate oral supplements and to evaluate the need for further investigation in view of the blood test results.

40. Mrs A attended the neuro-ophthalmology clinic for follow-up in October and December, they wrote to her GP advising investigations had still not revealed the cause of her right optic neuropathy (damage to the optic nerve in the right eye, which can lead to vision loss and other visual disturbances).

41. Our GP adviser said the September 2022 letter from the ophthalmology clinic states Mrs A has a haemoglobin level of 91 g/L which is significantly low. The healthy range for adult women is between 120 to 150 g/L.

42. Our GP adviser said when clinicians at the Practice received the ophthalmology letter they should have linked the low haemoglobin level with Mrs A’s abdominal pain.

43. Mrs A was seen at the Practice for ongoing pain in her pelvis and abdomen on 8 and 15 November where she was prescribed painkillers and advised to continue with her physiotherapy exercises. Our GP adviser said clinicians missed further opportunities at these two appointments to link Mrs A’s symptoms with her haemoglobin levels.

44. Our GP adviser said the Practice should have acted when it received the ophthalmology letter in September 2022 which reported a highly abnormal result that was unrelated to Mrs A’s eye condition. The significantly abnormal test result and Mrs A’s abdominal pain could have resulted in a FIT test being arranged three months earlier. Our GP adviser said had this been arranged it is likely Mrs A would have been diagnosed at least three months earlier. We find this was a failing.

Impact of failings identified

45. We sought advice from our oncologist adviser, and ophthalmology adviser to consider the impact of the failings we have identified in the care provided by the Practice.

46. We consider the Practice should have arranged for Mrs A to have blood tests from December 2021, when the source of her abdominal pain could not be identified, and ultrasound scans had not suggested a gynaecological cause.

47. We also think the Practice should have acted and arranged a FIT test when it received the ophthalmology letter in September 2022 which reported a highly abnormal result that was unrelated to Mrs A’s eye condition. We consider if this had been arranged it is likely Mrs A would have been diagnosed with cancer at least three months earlier.

48. Mrs A says she experienced significant blood loss before her cancer diagnosis which caused permanent damage to her right eyesight. She also says she has physical scars from the surgery to remove the tumour.

49. Our oncology adviser explained Mrs A’s blood loss could not have been avoided if she had been diagnosed with cancer three months earlier. This is because she was already anaemic. She had low haemoglobin levels (91 g/dl), which were not dissimilar in September 2022 to what they had been in January 2022 (88 g/dl). This shows the blood loss was already present, manifesting in the low haemoglobin.

50. On 1 September 2022 Moorfields Eye Hospital wrote to the GP and explained Mrs A was anaemic. It asked the GP to prescribe folate oral supplements and evaluate the need for further investigations in view of the results. The GP did not act on this, this was not in line with NICE guidance on suspected cancer recognition and referral. As above, we say a FIT test should have been arranged at this point.

51. Ovarian cancer was ruled out in February 2022, when an ultrasound scan of Mrs A’s pelvis was performed and did not show ovarian cancer. Our oncology adviser explained Mrs A did not present with any bowel issues at this time that would have warranted a two-week GP suspected cancer referral.

52. Our oncology adviser explained a three-month delay in cancer diagnosis is too short to have made any difference to Mrs A’s prognosis. Treatment would have been very likely to have been the same (including the surgery), as the tumour was already large. Our adviser explained based on human tumour volume doubling times it would usually be a nine month to one year delay for there to be a difference in prognosis/treatment.

53. Our oncology adviser explained it is very difficult to say if Mrs A’s blood results would have been abnormal in December 2021 as this was so long before her diagnosis. Our adviser says they suspect the results would have been normal, as when someone is losing blood it takes a long time before iron stores are depleted and blood tests become abnormal. December 2021 was around 13 months before Mrs A’s blood results showed as abnormal.

54. Our oncology adviser explained it is likely that if the Practice had carried out blood tests in December 2021 and subsequently Mrs A had been diagnosed with cancer at that time, she may have not needed to have chemotherapy prior to surgery but would have needed it afterwards. Our adviser explained on a balance of probabilities, her prognosis probably would have been quite similar to what it is now.

55. Our ophthalmology adviser helped us to look at the Mrs A’s claimed impact relating to damage in her eye.

56. Mrs A has weakness in her right eye caused by problems with her optic nerve.

57. Our ophthalmology adviser explained it is unclear if the damage to Mrs A’s right eye was caused by blood loss. Mrs A went to her optician for a routine check. They found she had reduced vision and referred her to Moorfields Eye Hospital. Moorfields saw her in the cataract clinic. Mrs A had no acute history of her vision changing. At the cataract clinic it was found that reduced vision was due to weakness of the right optic nerve as well as cataract.

58. Investigations took place to see why her optic nerve was weaker. There are many causes for a weak optic nerve including a poor blood supply, such as occurs with anterior ischaemic optic neuropathy (sudden vision loss caused by insufficient blood flow to the front portion of the optic nerve), inflammation or demyelination (a condition that affects the protective cover around nerve calls).

59. Imaging suggested the problem was most likely due to an ischaemic event (reduction in blood flow to the eye) but as there was no exact time course of onset and she lacked the typical presentation of an acute event it is hard to be sure. Risk factors for optic nerve ischaemia do include anaemia but also increased inflammatory markers and smoking. It is not clear from the records at what point Mrs A became anaemic. It is also not clear at what point she lost her vision.

60. Guidance from the Clevland Clinic explains optic nerve risk can happen spontaneously. Mrs A also smoked which this guidance highlights is a risk factor for optic nerve damage.

61. Blood tests eventually showed colon cancer was the cause of her anaemia. We cannot say for certain that Mrs A’s optic nerve not working properly and being damaged is directly related to her anaemia. It could be linked to this but could also be linked to her smoking or something else.

62. Guidance from the National Library for medicine explains relating anaemia to iscahemic optic neuropathy suggest additional factors can be required such as low blood pressure, more associated with acute blood loss or as in this case smoking.

63. We cannot say Mrs A's anaemia caused the problem with her optic nerve and we do not know when the optic nerve problem developed and when she became anaemic. Therefore, we cannot say Mrs A’s cancer being diagnosed sooner would have made a difference to the problem with her optic nerve.

64. We cannot link the failings we have identified to Mrs A’s claimed impact. We can however say Mrs A would have experienced an element of distress and uncertainty during the delayed cancer diagnosis as she did not know what her prognosis was.

65. We have not seen these failings and the impact have been fully recognised by the Practice.

1. Mrs A complains a GP Practice in the Croydon area (the Practice) did not carry out adequate investigations into her symptoms between August 2021 and February 2023 which resulted in a delayed stage four bowel cancer diagnosis.

2. It is our view that the Practice should have carried out blood tests when the source of Mrs A’s abdominal pain could not be identified, and ultrasound scans had not suggested a gynaecological cause. We consider this to be a failing.

3. We have also found the Practice should have acted when it received the ophthalmology letter in September 2022 which reported a highly abnormal result that was unrelated to Mrs A’s eye condition. The significantly abnormal test result and Mrs A’s abdominal pain could have resulted in a FIT test being arranged three months earlier, and in turn Mrs A could have been diagnosed with cancer three months earlier.

4. We cannot say Mrs A being diagnosed with cancer three months earlier would have made a difference to her prognosis. We also find treatment would have likely to have been the same, including surgery. We can say Mrs A experienced a degree of distress and uncertainty due to the Practice’s actions.

5. We partly uphold this complaint and have set out the recommendations we have made at the end of this report.