A practice in the Cannock Chase area

5. Miss Y complains the Practice failed to consider her father’s symptoms collectively from September 2023 to November 2024.

6. Specifically, Miss Y says the Practice did not: • explore if Mr Y’s headaches in September 2024 were part of a neurological condition • explore Mr Y’s symptoms of erectile dysfunction and low back pain in August 2024 alongside his other recently reported symptoms.

• correctly treat Mr Y’s low back pain in August and September 2024 despite worsening pain • take seriously Mr Y’s concerns on 19 September about his blood cancer having returned • correctly treat or consider Mr Y’s newly reported confusion on 30 September 2024 alongside his other recently reported symptoms.

7. Miss Y says the Practice missed opportunities to investigate her father’s deterioration sooner and therefore Mr Y’s brain tumour was discovered at a very late stage. Miss Y feels an earlier diagnosis would have meant they would have had more time to ensure her father’s comfortable and dignity at the end of his life. She tells us how she and her family did not have time to process Mr Y’s diagnosis because of the missed opportunities.

8. By bringing her complaint to us, Miss Y is seeking service improvements to stop the same circumstances happening for other families. She is also seeking an apology from the Practice.

9. Mr Y had a past history of blood cancer. From September 2023 to October 2024, he attended the Practice with a number of different symptoms. These included concerns about:

• an increase in migraines in September 2023 • skin lesions in October 2023 • an irregular heart rhythm in February and March 2024 • a rash on his back in August 2024 • erectile dysfunction in August 2024 • lower back pain in August 2024 • new onset confusion in August and September 2024 • new onset forgetfulness in October 2024.

10. Mr Y’s symptoms from September 2023 to August 2024 were considered and investigated by the Practice. Mr Y was referred for scans of his back in August 2024, and was found to have lumbar spondylosis with multilevel disc and degeneration of lumbar intervertebral disc.

11. His new onset confusion was initially felt to be caused by medication for his back pain. However, this persisted even when the medication was stopped.

12. The Practice referred Mr Y for a scan of his brain to consider the symptoms of confusion and new onset forgetfulness in October 2024. Sadly, this identified that Mr Y had a neoplasm of the brain (a brain tumour).

13. Mr Y died shortly after this diagnosis in November 2024. We cannot underestimate the shock and distress this will have caused his family. We are very sorry for their loss.

Practice did not explore Mr Y’s headaches

18. Miss Y says Mr Y attended the Practice in September 2023 with reports of worsening headaches. She says the Practice did not explore whether Mr Y’s headaches were part of a neurological condition. Miss Y believes the Practice should have fully investigated Mr Y’s headaches given his history of blood cancer.

19. The records from the Practice say Mr Y attended the Practice with concerns about migraines and a visual aura. It states Mr Y reported the headaches happening more frequently, ‘since June five times a month and once weekly for the past month.’

20. The Practice took Mr Y’s blood pressure and prescribed him with almotriptan (migraine medication) to be taken for a migraine attack. The records also state a GP discussed preventative tablets, but Mr Y declined these at the time.

21. The GMC guidance ‘Good medical practice’ explains clinicians should promptly provide suitable advice, investigations or treatment where necessary. It states clinicians have a duty to ‘adequately assess’ their patients. This includes considering their clinical history, symptoms and where necessary, examine a patient to form a diagnosis.

22. We asked our GP adviser what should have happened in Mr Y’s situation, particularly because of his previous diagnosis of blood cancer. Our adviser noted the records from September 2023 say Mr Y’s migraines were not a new symptom and were instead a long-term problem. It was therefore appropriate for the GP to treat the migraines with medication.

23. Our adviser also noted the medication Mr Y was taking for his erectile dysfunction can cause an increase in headaches. Our adviser explained it was logical given Mr Y’s recurring migraines to attempt to treat it with medication in the first instance.

24. We appreciate how headaches can be a symptom of blood cancer and retrospectively why Miss Y feels the Practice should have considered if her father’s headaches were more serious.

25. In this case it appears the Practice appropriately considered Mr Y’s clinical history and presenting symptoms. It also appears it reached a reasonable diagnosis of continued migraines based on his symptoms and side effects to medication he was already taking. We consider these actions were in line with the above GMC guidance.

26. The NICE migraine guidance states clinicians should advise patients to return and consider alternative medication and treatment if migraines persist or worsen. The records do not indicate Mr Y returned to the GP with concerns of migraines or headaches following this consultation.

27. We consider the actions taken by Practice staff was in line with the above guidance as the records indicate Mr Y was advised to return and discuss alternative treatment and investigations if his migraines persisted. We therefore see no indication the Practice should investigated Mr Y’s migraines further at this point.

Practice did not explore symptoms of erectile dysfunction and low back pain alongside headaches

28. Miss Y says the Practice did not explore her father’s new symptoms of erectile dysfunction and low back pain in August 2025, alongside his other recently reported symptoms.

29. The Practice said it referred Mr Y for psychosexual input. It also referred him to the Practice physiotherapist for chronic back pain on 22 August and he was seen on 23 August for a normal neurological assessment. The Practice then put a referral in for Mr Y to have an MRI lumbar spine (non-invasive imaging test that provides detailed pictures of the lower back) given his symptoms were ongoing.

30. The NICE erectile dysfunction guidance states patients should be referred to psychosexual services if there is a suspected psychogenic (physical or psychological symptoms that come from the mind) cause of the symptoms.

31. We asked our adviser if the care and treatment for Mr Y’s erectile dysfunction and low back pain was appropriate and in line with this guidance.

32. Our adviser explained the records state Mr Y said he felt his erectile dysfunction was a mindset issue and so it was appropriate for psychosexual input to be considered first.

33. From the evidence available to us, we can see Mr Y was seeing a private physiotherapist for recurring back pain for the previous three years. Our adviser explained it was appropriate for the GP to refer Mr Y to the Practice’s physiotherapist for a neurological assessment. This is in line with NICE guidance for low back pain which states a neurological assessment should be carried out.

34. Our adviser said the records show the Practice examined Mr Y’s back and ruled out any red flags (a symptom or change which suggests a serious underlying condition) in line with NICE guidance on low back pain.

35. We asked our adviser to consider his previous blood cancer as Mr Y had raised concerns about his blood cancer returning. They explained NICE guidance sets out types of cancer low back pain could be a symptom of. They explained blood cancer is not a specific cancer NICE guidance says clinicians should consider as a cause of back pain.

36. The NICE erectile dysfunction guidance states clinicians should refer patients for an MRI if there is no symptomatic improvement in four to six weeks. The Practice decided to refer Mr Y for an MRI scan (magnetic resonance imaging which is a non-invasive imaging technique that uses strong magnetic fields and radio waves to create detailed images) given his concerns before waiting to see if his symptoms improved within four to six weeks. This shows the Practice were prompt in its investigation.

37. We asked our adviser if the Practice should have done anything further in relation to Mr Y’s erectile dysfunction and low back pain given his other recent medical concerns. They explained Mr Y did not return to the GP with concerns over headaches and so there was no clinical need for the Practice to consider this in line with his erectile dysfunction and low back pain.

38. Based on the evidence we have seen, we can see no indication the Practice missed an opportunity to explore Mr Y’s symptoms of erectile dysfunction and low back pain alongside his other recently reported symptoms.

Practice did not correctly treat Mr Y’s low back pain in September 2024

39. Miss Y says her father’s low back pain was persistent during August and September 2024. She says Mr Y expressed his concern of his blood cancer having returned. She says painkillers, physiotherapy and a lumbar MRI was not enough, and she feels the Practice should have investigated his symptoms more broadly.

40. The Practice says an urgent care practitioner (UCP) reviewed Mr Y for ongoing chronic back pain on 19 September 2024. It says said the UCP carried out basic observations and noted Mr Y expressed his concerns his blood cancer had returned. By this point Mr Y was already booked in for routine blood testing and had been referred for an MRI scan. The Practice say it gave Mr Y nefopam (a non-opioid, centrally acting painkiller) for the pain and safety netted to return if he had new or worsening symptoms.

41. On 25 September 2024, the Practice carried out Mr Y’s blood tests and marked them as unremarkable with no further action needed.

42. The Practice also explains explained the MRI report on 29 September 2024 showed lumbar spondylosis with multilevel disc and facet degenerative changes with mild nerve root irritation but no significant canal compromise. Lumbar spondylosis is a term used to describe general wear and tear in the lower back (the lumbar spine). Over time, the discs (the cushions between the bones in the spine) and the facet joints (the small joints that connect the bones in the spine) can begin to wear down and change, which is referred to as ‘degenerative changes’.

43. The Practice’s response states there was no clinical evidence to suggest that the chronic low back pain was an indication of a pathology, such as a brain tumour.

44. The GMC guidance states clinicians should adequately assess a patient’s condition, considering their symptoms and views. It also states clinicians should promptly provide investigation and treatment where necessary.

45. The NICE back pain guidance on haematological cancers (blood cancers) states persistent back pain can be a symptom of blood cancer and states clinicians should offer a full blood count.

46. As above, Mr Y had already been referred for an MRI scan and blood tests at the time of the appointment on 19 September 2024. These actions were in line with the above guidance. We therefore consider the UCP acted appropriately in giving further pain relief and providing advice on what to do if his symptoms worsened.

47. Overall, we see no indication the Practice did not promptly act on Mr Y’s low back pain and will not be considering this part of the complaint further.

Practice did not correctly consider if Mr Y’s newly reported confusion

48. Miss Y says the Practice did not correctly treat or consider Mr Y’s new concerns of confusion on 30 September 2024. She feels this should have been considered and acted on alongside his recent medical concerns over the last year.

49. In its response, the Practice says Mr Y saw a nurse practitioner on 30 September 2024 for his low back pain. It says Mr Y told them he had started to experience confusion since he began the nefopam. The nurse practitioner advised Mr Y to stop taking the nefopam as they thought his confusion was related to this medication. They added a note to Mr Y’s medical record stating his reaction to the nefopam and safety netted Mr Y to return if the symptoms continued.

50. The NMC guidance states nurses should ensure any information and advice given is evidence-based. The BNF guidance ‘Nefopam hydrochloride’ lists confusion as a frequent side effect.

51. We asked our nurse adviser if the Practice acted within guidelines when providing care and advice to Mr Y at this consultation. Our nurse adviser explained the nefopam had been prescribed on 19 September 2024, 11 days earlier, and there were no reports of confusion before starting this medication. Given Mr Y had started new medication and was experiencing new symptoms of confusion, our nurse adviser explains it was an appropriate pathway to explore.

52. We consider the Practice nurse has appropriately referred to the BNF guidance around possible side effects of nefopam and correctly safety netted Mr Y to return to the Practice should the confusion continue once he stopped the medication.

53. We have seen no indication the Practice did anything wrong in its care and treatment of Mr Y’s newly reported confusion on 30 September 2024.

Consideration of collective symptoms

54. We appreciate Miss Y is concerned that collectively Mr Y’s symptoms should have been considered. We are sorry to hear she feels the Practice did not provide appropriate care and treatment.

55. The GMC guidance states clinicians should promptly provide or arrange suitable investigations or treatment where necessary. It also states clinicians should refer a patient to another suitably qualified practitioner when this serves their needs.

56. Our GP adviser explains Mr Y did not present with any other symptom of a brain tumour other than the migraines in September 2023 and the confusion in September 2024. It did not seem likely that these were related, as Mr Y’s migraines appeared to resolve and he did not return with further concerns about this after this time.

57. The records indicate Mr Y presented at the Practice on 4 October 2024 with continued confusion despite having stopped taking nefopam. The records also state Mrs Y shared her husband had new onset forgetfulness as well. The GP sent Mr Y to hospital for an emergency assessment of his confusion and related symptoms. At the hospital, Mr Y had a CT scan (computed tomography which uses X-rays and computer technology to create detailed cross-sectional images of the body) which sadly revealed neoplasm of the brain (a brain tumour).

58. We are satisfied the Practice has carried out care and treatment of Mr Y in line with the above guidance. When Mr Y showed concerning symptoms, the GP made a prompt decision to send him to the hospital where the correct investigations could be carried out by specialists.

Conclusion

59. We are deeply sorry to hear that Mr Y passed away from an aggressive brain tumour, which was diagnosed at a late stage. We understand how difficult it must have been for the family, having had so little time to come to terms with his diagnosis. After reviewing the circumstances, we have not seen any indication the Practice missed opportunities to diagnose him sooner or indications they failed to consider his symptoms collectively.

1. We have carefully considered Miss Y’s about the care and treatment her father, Mr Y, received from the Practice.

2. We are sorry to hear Mr Y died in November 2024 after being diagnosed with neoplasm of the brain (a brain tumour). We understand this was a very distressing and difficult time for Miss Y and her family, particularly given his late diagnosis. We also appreciate how difficult it must have been for Miss Y to discuss the circumstances of her complaint with us.

3. We would like to reassure Miss Y we have not seen any indication the Practice missed an opportunity to diagnose her father’s brain tumour sooner. From the evidence we have considered, it appears the Practice made appropriate decisions about Mr Y’s treatment and investigations. .

4. We hope our explanation below goes some way to provide Miss Y and her family some closure for their concerns.