A practice in the Fenland area

3. Mr U says his wife had head pain and pressure which had been ongoing for around a year.

4. He says when she saw practitioners at the Practice in March and April 2024 she was referred to an ear, nose and throat specialist with tinnitus (a condition characterised by changed perception of noise such as a ringing or bussing sound).

5. He complains this was the wrong specialism and that his wife should have been directed a brain cancer specialist.

6. Mr U says the referral to an incorrect specialism resulted in a ten-month delay in her diagnosis of a terminal cancerous brain tumour.

7. He says this has had a major financial impact on them as well as an emotional impact. They did not have time to plan for his wife needing to stop working and that he needed to take time off work and eventually stop working to care for her.

8. To put things right, Mr U would like the Practice to apologise to his wife and that it makes improvements to procedures and management of patients to prevent recurrence.

9. He would like some financial remedy because of the financial impact of not being able to plan for his wife not working and him needing to give up working to care for her.

10. Mrs U is in her late forties.

11. She was sadly diagnosed with a temporal tumour (an abnormal growth in the temporal lobe of the brain) in early 2025.

12. She underwent a re-sectioning procedure (removal of part of the tumour) which resulted in a diagnosis of a glioblastoma, an incurable, aggressive cancerous tumour which limits life span.

Referral to the wrong specialism delaying diagnosis

16. Mr U complains his wife was seen at the Practice on two occasions with the same symptoms. He says she was incorrectly directed to a hospital to see an ear, nose and throat specialist but this was not the correct specialism as she needed to have been referred to a cancer specialist.

17. He says this resulted in a ten-month delay in her seeing the correct specialist who diagnosed her as having a terminal cancerous brain tumour. Mr U says this reduced their opportunity to actively plan for the impact this would have on their day-to-day life as both he and Mrs U have needed to stop working.

18. In its responses to Mr U, the Practice says the clinicians who saw Mrs U did not assess her as having any ‘red flag’ symptoms of anything other than ENT issues, and that based on her symptoms the referral was correct.

19. 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.

20. In reaching our decision, we have considered the NICE CKS on sinusitis (a condition that affects the sinuses behind the cheeks and forehead). In the section ‘how should I diagnose chronic sinusitis’ it says,

‘Diagnose chronic sinusitis if sinonasal (anything related to the nasal cavity) inflammation lasts 12 weeks or longer, with a combination of at least two diagnostic symptoms and objective evidence of sinonasal inflammation.

In adults, diagnostic symptoms are:

•Nasal blockage/obstruction/congestion or nasal discharge (anterior (at the front) /posterior (behind) nasal drip (excess mucus causing irritation)).

•Facial pain/pressure (or headache).

•Reduction (or loss) of the sense of smell.

Examine the person.

•Inspect and palpate the maxillofacial area (upper jaw and central midfacial bones) to elicit swelling or tenderness’.

21. The NICE CKS also explains when a patient needs an urgent referral to hospital. This is required where the patient shows symptoms including ‘nasal obstruction…crusting or facial swelling’, ‘periorbital oedema (swelling round the eye) or cellulitis (bacterial skin infection), a displaced eyeball (where the eyeball moves from its normal position), double vision…reduced visual activity’ and ‘signs of meningitis (inflammation of the protective membranes covering the brain and spinal cord) …reduced consciousness’. These are known as red flag symptoms.

22. The brain tumour charity explains ‘different parts of the brain control different functions, so the symptoms you experience will depend partly on where the tumour is within your brain’. It says some of the symptoms of glioblastoma are:

• ‘headaches, caused by pressure in the brain • personality changes • trouble remembering things • trouble speaking or understanding • tiredness • depression • trouble thinking • seizures • sight problems’.

23. NeuroLaunch.com, a site that provides information on neuro conditions, says,

‘Early symptoms like persistent headaches, new-onset seizures, and cognitive changes often overlap with benign (not likely to result in death) conditions, which frequently delay diagnosis by months…The location of the tumour within the brain shapes which symptoms appear first, there is no single universal presentation’.

First appointment

24. The medical records show Mrs U attended the Practice mid-March 2024 and had a faceto-face appointment with a specialist nurse practitioner (SNP). The records say she had symptoms of pain in her head and that in certain positions, for instance when she sleeps on her front, she felt pressure and throbbing which stopped on changing position.

25. She told the SNP she had seen a private clinician who had prescribed a nasal spray (Nasonex, a spray used for sinusitis) and that she had found it harder to take in one nostril compared to the other. She said the private clinician had recommended she attend the Practice after four weeks if this did not work.

26. The medical notes say the SNP noted Mrs U did not experience any dizziness, no changes to hearing or other symptoms. The SNP noted her to have slight inflammation in both nasal passages.

27. Mrs U was prescribed a different nasal spray and given a follow up appointment in four weeks. The SNP noted a referral to ENT should be considered if the nasal spray did not resolve the symptoms.

28. We asked our clinical adviser about this appointment and whether the assessment and treatment provided was appropriate given Mrs U’s presentation.

29. They confirmed the checks and examination carried out had been appropriate but said the medical records do not show the SNP to have documented which side of the face was affected or how long the spray prescribed by the private clinician had been used. In addition, there is nothing in the medical records to show the SNP examined Mrs U’s face to determine whether this showed any signs of swelling or tenderness, something our clinical adviser would have expected to see.

30. Despite the records of the examination not showing this to have covered all areas, our clinical adviser said the prescribing of a different nasal spray and making a follow up appointment was the correct thing to have done. This is because the symptoms described (pressure and pain in the head when leaning forwards, blocked and inflamed nasal passages) were indicative of sinusitis.

31. This is supported by the NICE CKS as Mrs U presented with a headache and facial pain and referred to a potential nasal blockage as she said she had had trouble in using the nasal spray in one nostril. In addition, she was only experiencing one of the nine symptoms of glioblastoma as listed by NeuroLaunch.com which in isolation did not raise any concerns of a more sinister diagnosis.

Second appointment

32. The medical records of the second appointment where Mrs U was seen by an advanced nurse practitioner (ANP) say she had recently shown symptoms of tinnitus which has since cleared. The ANP carried out some checks on her hearing and confirmed this to appear normal.

33. The ANP also noted in the medical records that Mrs U continued to suffer headaches around the right eye and forehead and that she had a pulsating noise with pressure at the top of her head.

34. As the second nasal spray had not helped Mrs U, the ANP referred her to an ENT specialist for further investigation. The ANP did not mark this as an urgent referral as there were no ‘red flag’ symptoms such as cellulitis around the eye, reduced vision and reduced consciousness. The ANP also noted there were no ‘neurological symptoms’.

35. We asked our clinical adviser about this appointment and whether the ANP had taken the correct action in referring Mrs U to an ENT specialist.

36. They said in this instance that the ANP examined Mrs U’s ears due to her mentioning tinnitus and the tests found nothing of concern. In addition, notes of symptoms and their location were made.

37. Our clinical adviser says whilst there is no reference to Mrs U’s sinuses being palpated, something that ought to have happened, they do not consider this would have made a difference to the decision to refer her to an ENT specialist. All symptoms pointed to this being the correct specialism.

38. Our clinical adviser also says it was wrong to say there were ‘no neurological symptoms’ as headaches are defined as a ‘neurologic’ symptom. They went on to say this would not have made a difference to the referral to ENT as this symptom alone does not suggest a glioblastoma. As Mrs U’s symptoms were indicative of sinusitis, the next step was a referral to an ENT specialist.

39. This is again supported by the NICE CKS and NeuroLaunch.com’s guidance as Mrs U had two of three symptoms of chronic sinusitis and only one of nine symptoms of glioblastoma.

40. After consideration of the evidence and clinical advice, our decision is that there appear to have been shortcomings in the assessment of Mrs U’s condition but that these are not so far below the expected standard to be seen as failings or maladministration.

41. Neither the SNP nor ANP palpated the sinuses in their assessments. The NICE CKS lists this as one of the checks needed when assessing a patient for sinusitis.

42. In addition, at the second appointment the ANP referred to ‘no neurological symptoms’ when this was not the case as a headache is a neurological symptom. We are pleased to see this has been acknowledged and the Practice apologised for this in its response to the complaint.

43. Our clinical adviser did not find it likely the shortcomings would have made a difference to the referral to an ENT specialist as all symptoms indicated chronic sinusitis that did not respond to nasal sprays. The headaches and pulsing indicated pressure in the sinus area and the nasal inflammation supported this as these are the symptoms listed by NICE for this condition.

44. Whilst there are indications that the Practice did not fully meet the requirements of guidance and standards, this do not appear to have made a difference to the treatment path. This is because it is unlikely Mrs U would have been referred to a different specialism at this time as she did not present with symptoms of glioblastoma.

45. NeuroLaunch.com explains glioblastoma usually presents as other conditions and is often not diagnosed for a long period of time because it does not have one specific presentation. Mrs U was only displaying one of nine symptoms of glioblastoma but was displaying two of the three main symptoms of sinusitis.

46. Guidance suggests referral to an ENT specialist where two symptoms are displayed. As such, we have not seen any indication of the Practice making an incorrect referral to ENT or delaying the diagnosis of glioblastoma.

47. We realise this has been and continues to be an extremely difficult and stressful time for Mrs U and her family. The diagnosis will have been a shock and very upsetting. We thank Mr and Mrs U for sharing details of their experience with us.

1. We have carefully considered Mr U’s complaint raised on behalf his wife, Mrs U, about ​a GP Practice in the Fenland area (the Practice). We are saddened to hear of Mrs U’s diagnosis and the distress and upset this has caused.

2. After our consideration we have not seen any indication of the Practice doing anything wrong in its referral to an ear, nose and throat specialist (ENT). We have also not seen any indication of this delaying Mrs U’s diagnosis for ten months.