A practice in the East Riding of Yorkshire area

4. Mr D complains the Practice missed multiple opportunities to diagnose his mother, Mrs W with a gastric cancer from May 2021. He says it did not act on concerning blood test results and dismissed her concerns over her symptoms due to her weight and other health issues.

5. Mr D said his mother sadly died shortly after her diagnosis of metastatic cancer in December 2021 and although he believes an earlier diagnosis would not have changed this outcome, he says it would have allowed for her to spend quality time with her family in her final months. He told us his mother's final months were traumatic spent in pain and with untreated gastric symptoms. He says she also felt dismissed due to her weight which was distressing for both her and her immediate family. Mr D said he continues to feel this impact.

6. He wants an acknowledgment of failings, an apology, service improvements and a financial remedy.

7. Mrs W attended the Practice on multiple occasions from May 2021 with ongoing gastric symptoms. She received a diagnosis of breast cancer following a routine mammogram in June 2021 and started treatment for this. She sadly died in December 2021 shortly after her diagnosis of metastatic cancer.

10. Mr D complains the Practice missed multiple opportunities to diagnose his mother, Mrs W with a gastric cancer from May to December 2021. Mrs W sadly died in late December. He told us, that although an earlier diagnosis would not have changed this outcome, it would have allowed his mother to spend quality time with her family in her final months.

11. Mrs W attended the Practice on several occasions from May until her diagnosis in early December. Due to the nature of the complaint, we have looked at each appointment individually to see what happened.

12. In early May, Mrs W attended the Practice with worsening reflux symptoms (indigestion). This is when stomach acid comes back up from the stomach into the oesophagus, the tube connecting the mouth to the stomach. She was still experiencing symptoms despite already taking medication to reduce the amount of acid the stomach makes.

13. NICE guidance on an unidentified cause for dyspepsia (indigestion) says a clinician should assess for any alarming symptoms, such as vomiting blood, black or bloody stools, unexplained weight loss, or changes in bowel habits. This is because this may suggest a complication or other serious underlying condition.

14. Our clinical adviser explained the GP’s examination of Mrs W noted only mild tenderness in the upper stomach area, with no red flag symptoms (serious warning signs) such as those described above.

15. The Practice planned for Mrs W to switch her antacid medication and arranged blood tests and a FIT test (a stool test used to check for hidden blood in stools). Depending on the results, it then planned to refer her to gastroenterology for further tests.

16. It therefore appears this consultation with the Practice was in line with NICE guidance in that the GP assessed for any red flag symptoms and arranged further investigations based on its examination.

17. Our clinical adviser explained the results of Mrs W’s blood tests showed she had iron deficiency anaemia. This is a common condition that happens when the body does not have enough iron to produce enough levels of haemoglobin, the substance in red blood cells that enables them to carry oxygen around the body. Her FIT results also showed blood.

18. NICE guidance on managing iron deficiency anaemia says a clinician should urgently refer people with iron deficiency anaemia using a suspected cancer pathway (two week-wait referral) for colorectal cancer if they have a FIT result that shows blood in faeces. The Practice referred Mrs W to a lower gastrointestinal clinic on a two-week wait (urgent) referral to rule out any sinister causes in mid-May. She also started taking an iron supplement.

19. It therefore appears the Practice acted in line with NICE guidance when managing Mrs W’s results and ongoing investigations into her continuing symptoms.

20. Mrs W had a telephone appointment with the Practice in early July. She had symptoms of constipation, a condition where a person has difficulty emptying their bowels, often experiencing infrequent, hard, or painful stools. She told the Practice she thought this was due to taking the iron supplement, so she had reduced the amount she took daily.

21. BNF guidance on iron supplements says common side effects to this drug include constipation, diarrhoea, gastrointestinal discomfort and nausea.

22. During the appointment the Practice noted a local Trust had given Mrs W a diagnosis of colonic polyps (growths in the lining of the colon) following a recent colonoscopy to investigate her FIT results. She had yet to have these removed due to her being on the medication warfarin which prevents the blood from clotting. Sadly, Mrs W had also received a breast cancer diagnosis following an abnormal mammogram in June and she was awaiting treatment. The Practice reduced Mrs W’s iron supplement medication as it considered the constipation she presented with could be due to the levels she was taking in line with the BNF above. It also arranged for repeat blood tests and to review if required.

23. We consider the Practice acted in line with BNF guidance when it considered Mrs W’s presenting symptoms to be consistent with a common side effect to taking an iron supplement. The Practice appears to have acted to manage this by reducing the dose she took and by organising further monitoring of her symptoms.

24. A GP at the Practice, next spoke with Mrs W in mid-September following an appointment with a nurse in early September where she advised she had worsening symptoms including abdominal pain and bloating. She also described persistently loose stools with mucus. During this appointment, Mrs W told the GP that the symptoms had started when she began taking letrozole (a breast cancer medication).

25. BNF guidance on letrozole says common side effects to this drug include abnormal appetite, constipation, diarrhoea, and gastrointestinal discomfort. The GP told Mrs W to stop taking letrozole. Our clinical adviser explained the Practice also safety netted her by arranging a follow up in a weeks’ time and gave her advice on where to seek help if her symptoms deteriorated.

26. GMC guidance says a clinician should adequately assess a patient’s conditions taking account of their history, including symptoms, the patient’s views, needs, and values.

27. It appears the Practice acted in line with BNF guidance when it considered Mrs W’s presenting symptoms to be consistent with a common side effect to taking letrozole. It also acted in line with GMC guidelines in assessing and monitoring her condition.

28. The following week, the Practice contacted Mrs W, and she reported her abdominal pain, and other symptoms had settled and improved since she stopped taking letrozole. The Practice advised her to speak with her cancer nurse about an alternative hormonal treatment and gave her ongoing safety advice relating to any abdominal symptoms.

29. We therefore consider the Practice acted in line with GMC guidance as it considered the decision-making regarding Mrs W’s ongoing therapy, and safety netted her should her abdominal symptoms deteriorate.

30. Mrs W’s next appointment with the Practice was in late October where Mrs W sought lifestyle advice on losing weight in case she needed breast cancer surgery in the future. The Practice referred her to a local living well programme.

31. The Practice also noted she had told it her bowel symptoms had continued. The GP noted Mrs W’s symptoms relating to her bowel had initially improved after stopping letrozole and she was now on new treatment. The GP noted Mrs W had type two diabetes and was taking the medication metformin which could be contributing to her symptoms. This was because her last test for glucose in the blood indicated her diabetes was unmanaged and this can cause the bowel symptoms Mrs W described.

32. NICE guidance on type 2 diabetes in adults says when reviewing metformin, a clinician should switch to modified-release metformin if the patient cannot tolerate the standard-release metformin. In Mrs W’s case the GP reduced the metformin dose and switched Mrs W’s medication to modified-release preparation with a review in one month or sooner if the symptoms persisted.

33. It therefore appears the Practice acted in line with NICE guidance when it considered metformin as a factor in Mrs W’s symptoms. It also planned to closely monitor her symptoms in line with GMC guidance as explained above.

34. At an appointment with the Practice in late November, Mrs W reported a partial improvement in her bowel symptoms after switching medication. However, she explained she still had intermittent diarrhoea with urgency and occasional faecal incontinence. She also reported reduced appetite and ongoing fatigue, possibly related to the medication exemestane (breast cancer treatment).

35. Our clinical adviser explained, that in view of her persistent symptoms, the Practice organised blood tests for Mrs W, as there appeared to be no other causes for her symptoms such as infection.

36. It appears this action by the Practice was in line with NICE guidance on chronic diarrhoea that says a clinician should consider blood tests if they have excluded infection and the other causes of acute diarrhoea and suspect that the episode of acute diarrhoea is due to a chronic cause.

37. We can see the Practice discussed the results of her blood tests with her three days after she had the bloods taken. Our clinical adviser explained the results of these tests showed a vitamin B12 deficiency with associated anaemia. It also showed a newly impaired renal function and raised CRP (C-reactive protein), which is a substance produced by the liver in response to inflammation in the body.

38. The Practice therefore arranged for repeat blood tests in line with NICE guidance on chronic kidney disease (CKS) which says if a clinician suspects CKS it should request further investigations including bloods.

39. Mrs W had the blood tests the following day and the Practice contacted with her with results the next day as her urea and electrolytes showed raised potassium levels. The GP arranged for her to attend hospital. This action appears to be in line with GMC guidance which says clinicians must act promptly when results indicate potential risks to a patient's health.

40. Mrs W had further investigations at a hospital Trust and sadly received a further cancer diagnosis. She sadly died in late December.

41. After careful consideration of all the consultations Mrs W had with the Practice in relation to her bowel symptoms between May and December 2021, we have found the Practice acted in line with relevant guidance when managing her ongoing issues including the results of her blood test.

42. We also consider it provided investigations and changes in medication based on Mrs W’s presenting symptoms, and we did not find evidence it disregarded her symptoms because of her weight. We understand how upsetting and difficult it must be for Mr D to feel there were missed opportunities to diagnose his mother’s cancer earlier, particularly given the impact this had on Mrs W and her family. We hope our explanation gives him some reassurance that we have carefully considered his concerns. However, we have not found that the Practice got anything wrong in its actions, so we will take no further action on this complaint.

1. We have carefully considered complaint about the Practice in Beverley (the Practice). We were sorry to hear of Mr D’s experience, and we would like to express our sincere condolences for the sad loss of his mother.

2. We have looked at all the evidence provided to us by Mr D and the Practice. We have seen that the Practice followed relevant guidance in relation to the actions it took when managing Mrs W’s presenting symptoms between May and December 2021.

3. We hope that our explanations about your mother’s experience below give some reassurances about what happened and why and explain how we have fully considered this complaint.