A practice in the Norwich area

3. Dr A complains about the care and treatment provided by the Practice to his brother, Mr B. He says the GP Practice:

• Failed to refer his brother for tests for oesophageal cancer in January 2023 • Failed to refer his brother for tests for oesophageal cancer in January 2024

4. Dr A says his brother’s cancer may have been diagnosed sooner if the practice had referred him for investigations on these occasions. He says this late diagnosis of his brother’s cancer meant that it could not be treated and may have led to his early death. He says learning of his late diagnosis had a devastating impact on his brother and his whole family.

5. Dr A would like the Practice to acknowledge the failings, apologise and improve its service to ensure all of its medical staff learn from this incident, are made aware of the cancer guidelines and adhere to them in future.

6. Mr B attended the Practice on 11 January 2023. The doctor who assessed him diagnosed reflux and prescribed treatment with lansoprazole (a medication for acid reflux and heartburn).

7. Mr B attended again on 16 January 2024 as his symptoms had continued. The doctor increased the dose of his lansoprazole medication and requested a chest Xray which came back as normal. Mr B returned on 19 February 2024 as his symptoms had not improved and the doctor referred him for an endoscopy (where a camera on a thin flexible tube is inserted through the mouth to allow the clinician to see inside the throat, oesophagus and stomach) which was performed 14 March 2024.

8. The endoscopy found a tumour which was later confirmed as cancer of the oesophagus. By the time it was diagnosed the cancer was too advanced to be treated. Mr B was placed on a plan of palliative care and sadly died in July 2025.

12. The GMC guidance states:

‘You must provide a good standard of care. If you assess, diagnose or treat patients, you must:

• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary

• refer a patient to another practitioner when this serves the patient’s needs.

In providing clinical care you must:

• provide effective treatments based on the best available evidence • consult colleagues where appropriate.’

13. The NICE guidance says:

‘Refer people using a suspected cancer pathway referral for oesophageal cancer if they:

• have dysphagia (difficulty swallowing), or • are aged 55 and over, with weight loss, and they have any of the following: • upper abdominal pain • reflux • dyspepsia.

Consider non-urgent, direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people with haematemesis (vomiting blood).

Consider non-urgent, direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people aged 55 or over with:

• treatment-resistant dyspepsia, or • upper abdominal pain with low haemoglobin levels, or • raised platelet count with any of the following: • nausea • vomiting • weight loss • reflux • dyspepsia • upper abdominal pain, or

• nausea or vomiting with any of the following: • weight loss • reflux • dyspepsia • upper abdominal pain.’

January 2023

14. Dr A says the Practice did not fully consider his brother’s symptoms and based their decision not to refer him for tests to investigate possible cancer solely on the basis that he had not lost any weight. In its response the Practice said the doctor did not refer Mr B as his presenting symptoms were not suggestive of a possible cancer diagnosis.

15. The note in the records of the attendance on 11 January 2023 says:

‘Gastrointestinal symptoms, reflux symptoms, indigestion ongoing, no weight loss, no lump or bump in any part of his body, he is otherwise at his baseline, cutting down on alcohol and smoking, no haematemesis.

Plan – hydrate, lansoprazole return if symptom worsens.

Differential diagnosis – suspected reflux.’

16. Our adviser said Mr B was at risk of oesophageal cancer due to his previous history of heavy alcohol use. The records indicate he attended with gastrointestinal symptoms of reflux and indigestion and was still drinking alcohol and smoking albeit at a reduced level than previously.

17. Our adviser said the key question for the doctor to ask during this consultation, in accordance with the NICE guidance, is whether he was suffering dysphagia and whether he had experienced food getting stuck in his throat when swallowing. Dysphagia is the first symptom referenced in the NICE guidance which illustrates the significance of this symptom and the impact it would have on care planning.

18. There is no evidence in the records to indicate the doctor asked Mr B whether he had experienced dysphagia and no consideration of this aspect of his condition is recorded in the note of the assessment.

19. Our adviser said discussing dysphagia is important under such circumstances as it would guide the next steps in the plan of care. Dysphagia alone would meet the criteria for immediate referral under the urgent cancer pathway which is why it is such an important aspect of the patient’s condition to ask them about.

20. The symptoms the doctor did record would suggest no need for a referral under the urgent cancer pathway. However the omission of any questioning or information about dysphagia is a significant failing in the assessment indicating it was not carried out in line with the GMC or NICE guidance. Establishing whether Mr B had suffered with dysphagia is key information and the records indicate it was overlooked by the Practice at the time of the assessment.

21. We carefully considered Dr A’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we have received. We found the Practice failed to consider and document key elements of Mr B’s condition during this attendance.

22. We cannot say whether or not a referral should have been made at this time as this key information is missing. Had Mr B been asked by the Practice about dysphagia and advised he didn’t have any problems then a referral would not have been warranted. If he had been asked and said he had experienced difficulty swallowing, a referral under the urgent cancer pathway would have been warranted.

23. We found the Practice should have asked Mr B about swallowing problems and recorded this information during this assessment. We think this is a failing in the assessment given his history and the symptoms he attended with. This failing has now left doubt which we cannot resolve about whether or not the Practice should have referred Mr B at this time for investigations under the urgent cancer pathway. We think the doubt that now remains is a significant injustice for Dr A.

January 2024

24. Dr A says despite his brother reporting that his symptoms had worsened, the Practice did not refer him for tests to investigate possible cancer as he had not lost any weight. In its response the Practice said:

‘We are sorry that you felt we had ruled cancer out purely on (Mr B) not having lost weight. We asked this as the cancer pathway asks for either dysphagia, which (Mr B) didn’t report, or weight loss with abdominal pain, reflux or dyspepsia (heartburn) or iron deficiency amenia with new heartburn, which (Mr B) didn’t have either. We had to hence proceed along the endoscopy pathway for treatment resistant dyspepsia.’

25. The notes in the records for January 2024 say:

16 January 2024 ‘ongoing chest/back pains – feel quite consistent with episodes of worsening, not associated to any clear pattern. Seen in Rapid Access Chest Pain Clinic who were happy not cardiac, Lansoprazole 30mg probably helped, not controlled on 15mg alone. Helicobacter (bacteria that can infect stomach) negative.

No unintended weight loss – anxious, has googled and come up with cancer. Chest Xray requested.’

24 January 2024 ‘Chest Xray report says – Lungs clear, no hilar or mediastinal mass, no pleural effusion. Satisfactory, no further action’

29 January 2024 ‘Patient called to advise lansoprazole has not helped. Famotidine prescribed in addition to lansoprazole.’

26. Mr B did not attend again until 19 February 2024 when he said his symptoms had continued despite the additional medication provided by the Practice. It is at this point the Practice referred him for an endoscopy to investigate treatment resistant dyspepsia. The endoscopy was carried out on 14 March 2024 and identified a lump in his oesophagus suggestive of cancer. From this point his investigations were requested under the suspected cancer pathway.

27. As we have seen in the attendance 12 months earlier Mr B was at risk of oesophageal cancer and by January 2024 he was still suffering with gastrointestinal symptoms of reflux and indigestion that had not resolved with treatment. Our adviser said, similar to the assessment in January 2023, the key question to ask during the consultations in January 2024 is whether he was experiencing dysphagia in addition to his ongoing symptoms and whether anything had changed with his ability to swallow food.

28. There is no evidence in the records to indicate the doctor asked Mr B whether he had experienced dysphagia and no consideration of this aspect of his condition is recorded in the notes of the assessments in January 2024. However it is recorded in the assessment by the Hospital Trust’s Gastroenterology Department which states:

‘I first met Mr B after his endoscopy on 14 March 2024 where he was having symptoms of reflux, pain on swallowing and dysphagia. He had been managing a sloppy to soft diet avoiding breads as well as other tough meats.’

29. The records indicate Mr B advised the doctor in January 2024 that he was anxious his symptoms may be due to cancer. Our adviser said in light of his ongoing symptoms and lack of improvement despite treatment, such concerns should prompt questions from the doctor about the possible red flags for oesophageal cancer, the main one being dysphagia.

30. The symptoms the doctor did record during the consultations in January 2024 would suggest no need for a referral under the urgent cancer pathway. However the omission of any questioning or information about whether he was experiencing dysphagia is a significant failing in the assessments indicating they were not carried out in line with the GMC or NICE guidance. Establishing whether Mr B had suffered with dysphagia is key information and the records indicate it was overlooked by the Practice during this period.

31. We carefully considered Dr A’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we have received. We found the Practice failed to consider and document key elements of Mr B’s condition during this period.

32. We cannot say whether or not a referral should have been made at this time as this key piece of information is missing. Had Mr B been asked about dysphagia and advised he didn’t have any problems then a referral would not have been warranted. If he had been asked and said he had experienced difficulty swallowing, a referral under the urgent cancer pathway would have been warranted.

33. We found the Practice should have asked Mr B about swallowing problems and recorded this information during the assessments in January 2024. We think this is a failing in the assessments performed by the Practice. This failing has now left doubt which we cannot resolve about whether or not the Practice should have referred Mr B for investigations under the urgent cancer pathway. We think the doubt that now remains is a significant injustice for Dr A.

1. We partly uphold Dr A’s complaint. We acknowledge how upsetting this incident was and that it continues to cause him considerable distress.

2. We partly uphold a complaint where we find failings but do not think they led to the injustice being claimed. We found the Practice failed to consider and document key elements of Mr B’s condition during the attendances in question. This has left doubt which cannot now be resolved about whether he should have been referred for tests for oesophageal cancer earlier.

34. We make recommendations in line with our Principles for Remedy which are reflected in the NHS Complaint Standards. These say organisations should identify instances where things have gone wrong, take responsibility for these and find ways to put things right for those involved. They should learn from complaints to improve services.

35. We have identified failings in the assessments carried out by the Practice when Mr B attended in January 2023 and January 2024. These failings have left Dr A with doubt which we cannot resolve about whether or not the Practice should have referred his brother for investigations under the urgent cancer pathway sooner.

36. With that in mind, we recommend the Practice writes to Dr A to: • acknowledge the failings we have identified and apologise for the impact they had • explain what action it will take, or has taken, to address these failings – it should do this in the form of an action plan which should be shared with us, the complainant, and the Care Quality Commission.

37. The Practice should send this to Dr A within one month of the date of our final report. The Practice should send us evidence it has completed all of the recommendations. We will check the action plan includes the reason for the failing, what the organisation does or will do differently in future, who is responsible for each action, the timescale for completion, and how it will be monitored.