A practice in the City of Plymouth area

6. Mrs K complains about the following aspects of her deceased husband’s, Mr K, care and treatment from Wycliffe Surgery (the Practice) between July 2024 to January 2025. Mrs K said the Practice: • did not properly investigate her husband’s COPD symptoms • did not make appropriate referrals or make urgent referrals when needed • did not conduct its complaint handling appropriately.

7. Mrs K says Mr K died prematurely and would still be alive if he had been given adequate care and treatment.

8. Mrs K says she and family have been through trauma and grief from losing Mr K too early. She said it has also affected her mental health, and she suffers from stress and anxiety.

9. She also said her and husband were not taken seriously and felt dismissed through the time period. This caused a lot of stress having to fight for care and treatment.

10. Mrs K would like service improvements for care and treatment for patients with long-term and life-changing conditions, as well as the way in which the Practice conduct face to face meetings relating to complaints.

11. This background is intended to place the key events related to this complaint in context, not to provide a detailed chronological account of everything that happened.

12. COPD is the name for a group of lung conditions that cause breathing difficulties. It is a common condition that mainly affects middle aged or order adults who smoke. The main symptoms of COPD are shortness of breath, a persistent chest cough with phlegm, frequent chest infections and persistent wheezing.

13. In mid-July 2024, Mr K received a diagnosis of COPD due to the results of his chest CT scan with contrast. A CT contrast scan is an examination of a person’s chest using X rays and an iodine-based solution often known as X-ray dye. The Practice had arranged this because of a lung cancer suspicion, which his CT scan did not confirm.

14. During August 2024, unfortunately Mr K’s conditions continued to deteriorate, affecting his quality of life.

15. Between August and September 2024, to ensure he received a comprehensive and extensive investigation, the Practice referred him to several examinations and hospital clinics under the non-site-specific two week wait pathway.

16. These further investigations included a visit to the dietician clinic, an endoscopy (a flexible tube with a camera used to look inside a person’s body), heart examinations and a CT abdomen/pelvis with contrast, and ENT referrals (ear, nose, throat tests) to exclude other conditions. While Mr K remained very concerned about his decreasing health, none of these scans confirmed any cancer or obvious reason for his symptoms.

17. On 27 August 2024, the Practice’s COPD nurse reviewed Mr K’s ongoing respiratory symptoms and referred him for a spirometry test (pulmonary function examination).

18. In early September, a thoracolumbar X-ray (an X-ray of a person’s chest and lower back), initiated by the Practice, revealed no abnormality.

19. On 30 September 2024, Mr K attended a local Express Diagnostics centre for his spirometry test. The result came back negative. The report also noted Mr K had some difficulty in completing it due to his decreased respiratory functions.

20. Between early and late October, the Practice’s COPD nurses reviewed him and prescribed him a couple of different sets of inhalers to try and soothe his COPD symptoms. About a month later, on 25 November 2024, another COPD nurse reviewed Mr K’s second inhaler and stopped it, as it was not providing any relief.

21. On 28 November a GP noted Mr K was awaiting heart investigations, and if the results were unremarkable the Practice would consider referring him to the respiratory team for further investigations.

22. Throughout the months detailed above, Mr K’s respiratory functions felt worse as he struggled to breathe normally. He became less active and less interested in life. He also started to lose weight due to loss of appetite.

23. On 10 December Mr K had an electrocardiogram (a test of the heart’s electrical activity) which was reported as abnormal. On 12 December the Practice referred him for an echocardiogram (a scan of the heart). On 24 December the Practice reviewed Mr K who was feeling very unwell and breathless. The Practice prescribed a different inhaler and noted it would review him after his echocardiogram.

24. In early January 2025, Mr K was rushed to the hospital. He was in critical conditions on account of his rapidly declining respiratory symptoms.

25. On 12 January 2025, Mr K very sadly died.

29. 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. We have done this and have not found any indications of failings. We will explain the reasons for our decision in detail below.

The Practice did not thoroughly investigate Mr K’s COPD symptoms

30. Mrs K is concerned the Practice did not thoroughly investigate the causes of her late husband, Mr K’s, COPD symptoms between August 2024 and January 2025.

31. NICE COPD guidance sets out how symptoms of COPD should be assessed, diagnosed, and treated within the NHS. Paragraph 1.1 says ‘The diagnosis is suspected on the basis of symptoms and signs and is supported by spirometry.’

32. Paragraphs 1.1.4 and 1.1.12 of NICE COPD guidance go on to explain that spirometry should be performed at diagnosis, when reconsidering the diagnosis, and to monitor disease progression. The guidance also says clinicians should consider primary care respiratory review and spirometry for people with emphysema (a lung condition that damages the air sacs in the lungs) or signs of chronic airways disease on a chest X-ray or CT scan.

33. From Mr K’s available medical records, we can see he first reported signs of COPD in July 2024 when he reported a three week history of breathlessness. The Practice referred Mr K for urgent tests to rule out lung cancer. Mr K had a CT scan on 12 July which was reported as showing signs of emphysema.

34. Mr K was having other tests throughout July and August to explore the possibility of cancer elsewhere in the body. On 12 August hospital staff asked the Practice to carry out a primary care COPD review. This review took place on 27 August. Following the review the Practice referred Mr K for a spirometry. It was in line with NICE COPD guidance for the Practice to carry out a COPD review and refer Mr K for spirometry at this time.

35. Mr K had the spirometry test on 30 September 2024. We asked our adviser to examine the results of his report.

36. Our adviser informed us his FEV1/FVC (a measure of how much air someone can exhale in one second compared to a full breath) result of 82.4% is significantly higher than the diagnostic threshold for COPD (typically less than 70%). Because of this, the spirometry did not appear to support a diagnosis of COPD.

37. With regards to Mr K’s further tests and treatment the Practice referred him to and prescribed between August and end of November 2024, we see evidence it properly and accurately investigated his COPD symptoms.

38. NICE COPD guidance says in addition to spirometry, clinicians should investigate other potential causes for the symptoms. It says at the time of their initial diagnostic evaluation all patients should also have a chest X-ray, a full blood count, and body mass index calculated.

39. In terms of chest X-ray, we note on Mr K’s GP records the X-ray dated 11 July was normal but given his symptoms the hospital also organised a CT scan (a scan that uses X-rays to create detailed cross-sectional images of the body). The CT scan was done on 12 July 2024. This confirmed long-term, smoking-related damage to his lungs and emphysema. Our adviser drew our attention to the fact emphysema is a radiological finding rather than an indication of a definitive COPD diagnosis. We can see Mr K had chest imaging in line with NICE COPD guidance.

40. We can also see the Practice arranged several blood tests in July 2024, including a full blood count as indicated in NICE COPD guidance. The full blood count was reported as normal.

41. Mr K’s records also show that after he had the CT scan which indicated he may have COPD, the Practice calculated his BMI in line with NICE COPD guidance.

42. With regards to the Practice’s management of Mr K’s COPD symptoms whilst he went through all the other investigations, we note COPD nurses prescribed a range of inhalers in line with NICE COPD guidance.

43. Our adviser highlighted that the Practice stopped Mr K’s inhalers in November 2024 due to lack of effectiveness. Our adviser explained this supports the clinical view COPD was not the primary cause of his respiratory symptoms. If Mr K’s symptoms were caused by COPD, inhalers would usually be an effective treatment to ease his symptoms.

44. We asked our adviser if another spirometry would have been recommended after his September 2024 test given Mr K’s lack of response to inhalers. In our adviser’s clinical opinion, repeating this test would have not shed any further diagnostic clarity on Mr K’s shortness of breath. While COPD was the initial suspect for his symptoms, other underlying pathologies (health issues) might have been the cause and Mr K was awaiting the results of other investigations.

45. We can see Mr K had several hospital investigations into his symptoms including suspected cancer investigations from the non-site specific, ENT and head and neck teams. In November 2024 when it was apparent Mr K was not responding to inhalers as would be expected for someone with COPD. The Practice also considered whether a heart condition may be the cause of his breathlessness. The Practice subsequently referred him for tests of his heart. Sadly, these could not be completed before Mr K died in January 2025.

46. Taking into account our adviser’s clinical views on Mr K’s medical records and test results, and the NICE COPD guidance, we do not see the Practice should have taken any further action in investigating Mr K’s symptoms. It has acted in line with clinical standards. We recognise how distressing it was to not have a clear diagnosis or treatment plan for Mr K’s symptoms. We have not seen this was due to any failings on the Practice’s part.

Lack of urgent referrals to other NHS services

47. Mrs K complains the Practice did not make the appropriate or adequately urgent referrals to other services to assess her late husband’s respiratory symptoms. She said she had to repeatedly requests other referrals from the Practice.

48. We note from Mr K’s GP records the Practice made two referrals to two-week-wait pathways. These are fast-track cancer investigation referrals. We can see the referrals were made for suspected lung cancer on 4 July 2024, and non-site specific cancer on 2 August. These referrals were in line with NICE suspected cancer guidance.

49. After investigations on the non-site specific cancer pathway, hospital staff also referred him to ear nose and throat two week wait pathway on 19 August, and to the head and neck two week wait pathway on 22 August.

50. These referrals from the Practice and hospital staff led to Mr K having a variety of tests including an endoscopy examination, which came back on 23 August 2024 and did not show any evidence of any remarkable findings.

51. Mr K’s GP records also show the Practice examined his blood tests, taken on 8 November 2024, and found an abnormal result, warranting a routine referral for a heart ultrasound scan, in line with NICE heart failure guidance.

52. The result causing this cardiac investigation referral is Mr K’s NT-proBNP blood level being 461.0 ng/L. NT-proBNP is a protein, one of the ‘ingredients’ to produce the BNP hormone. The heart makes and releases BNP into bloodstream when it is working harder than normal to pump blood. Similarly to BNP, higher than normal amounts of NT-proBNP indicate the heart is making an extra effort to pump blood.

53. NICE heart failure guidance paragraph 1.2.4 says to refer people with suspected heart failure and an NT‑proBNP level between 400 and 2,000 ng/l to have specialist assessment and transthoracic echocardiography (heart scan) within six weeks. We can see Mr K had heart scans within this timeframe following the Practice’s referral.

54. We asked our adviser to review Mr K’s available medical records. In their clinical opinion, they told us the Practice investigated Mr K’s symptoms appropriately, following the clinical guidance valid in 2024 and 2025. They added, all the results obtained were still not sufficient to point out to a unifying diagnosis. We need to consider the challenges of diagnosing Mr K’s condition due to the complexity of his symptoms.

55. We understand Mrs K’s concerns about the Practice not making other urgent and suitable referrals for his COPD symptoms. We have carefully considered evidence throughout Mr K’s GP records, the Practice’s account, relevant NICE guidelines, and clinical advice. Having done so, we do not consider the Practice should have referred Mr K for further investigations any differently than what they did.

Complaint handling

56. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has not taken appropriate measures to clearly communicate with the complainant and provide clear reasons for the events raised in the complaint. Having done so, we have found the Practice has done enough to address Mrs K’s concerns.

57. Mrs K says she feels the Practice’s complaint handling has not fully addressed her concerns, and its responses have not adequately answered her questions. She says she also had to chase up the Practice a few times to request referrals to other NHS services to explore other possible causes for Mr K’s COPD symptoms.

58. Section 8.21 of our NHS Complaint Standards says organisations must clearly address all the issues raised in their investigations.

59. Upon reviewing Mrs K’s initial letter of complaint dated 2 June 2025, we can see she considered the treatment the Practice had offered her husband in his last months was inadequate and contributed to the rapid decline of his health and premature death in January 2025.

60. Mrs K also indicated she and her family now felt let down by the NHS and she requested service improvements in the way the Practice investigates and cares for patients with long-term health conditions, so other families would not have to go through what they did.

61. We can see the Practice responded to Mrs K’s complaint three days after she made it, on 5 June 2025. In this letter, the Practice’s GP provided a clinical account for the care of Mr K in his last months, stating clinicians at the Practice extensively investigated Mr K’s condition through referrals to the chest clinic, cardiology, gastroenterology, and the non-specific symptoms clinic. While this team identified no malignancy, they also facilitated a two-week wait referral to the ENT service, where an endoscopy subsequently confirmed Barrett’s oesophagus (a condition where the lining of the oesophagus is damaged by stomach acid).

62. The GP’s letter recognised Mr K’s family expressed concerns regarding pulmonary rehabilitation. However, it was their clinical opinion Mr K did not meet the criteria for referral. The Practice said even if it had sent one, the pulmonary clinic would have rejected it. The letter also confirms the Practice is unable to influence hospital waiting times for urgent tests.

63. Continuing the account of clinical events, the GP confirmed the Practice strictly followed relevant NICE guidelines for COPD management throughout the events complained about. They explained that recent and past cardiology test results did not clarify the cause of Mr K’s shortness of breath and weight loss.

64. The GP’s letter ends offering the Practice’s condolences for Mr K’s death, notes Mrs K and her family’s understandable frustrations at how events unfolded and apologises Mrs K was under the impression it had not investigated her husband’s symptoms thoroughly. The Practice also reassured her its medical team consistently processed Mr K's referrals, and records show no clinician ever denied him an onward referral to the respiratory team.

65. Both the GP and Practice Manager also recognised Mrs K’s wish to have a face-to-face local resolution meeting to address her concerns in person and asked Mrs K to call them on the phone to arrange this.

66. From the Practice’s minutes taken during the meeting of 14 July 2025, we note two doctors, Mrs K, and a relative were in attendance. We also note one of the doctors explained to Mr K’s family his COPD was diagnosed based solely on a CT scan radiological finding. A subsequent spirometry returned normal values, despite Mr K having difficulties tolerating it.

67. The doctor at the meeting went on to explain the trial of inhalers their nurse prescribed to address Mr K’s COPD symptoms had been ineffective, which is an unusual result for this condition. The Practice said had the inhalers provided relief indeed, this would have been an indication Mr K’s COPD was present, but that was not the case.

68. We note Mrs K’s frustration at the demeanour and answers the doctor provided during the meeting and the perceived lack of compassion, given the sad circumstances. She had wanted the Practice to just apologise and promise service improvements in any future case similar to Mr K’s long-term, complex health presentation. Although she understood the cause of her husband’s death was pulmonary embolism, Mrs K left the meeting still unsatisfied with its outcome and was further distressed.

69. We appreciate that a meaningful and satisfactory Practice response is personal. While we have assessed the response against our NHS Complaint Standards, we remain mindful it may still have felt insufficient to Mrs K.

70. Our complaint standards say that if the organisation found that the service provided was in line with what should have happened, it should apologise and reassure the person. We can see this happened.

71. Overall, we can see the Practice answered Mrs K’s questions and responded to her complaint in line with our complaint standards. For these reasons, we will not be investigating this part of the complaint further.

72. We thank Mrs K for taking the time to bring her complaint to our attention. We hope our explanation brings some additional clarity about the care and treatment Mr K received.

1. We are very sorry to learn of Mrs K’s complaint on behalf of her deceased husband, Mr K, about the care and treatment he received at his GP practice for suspected chronic obstructive pulmonary disease (COPD) between July 2024 and January 2025. We acknowledge the importance of having Mrs K’s concerns addressed and we have carefully considered all of them.

2. We recognise how difficult this time has been for Mrs K and the distress she and her family have felt during these events. We are sorry to hear of her sad loss and the impact this has had.

3. We have reviewed Mr K’s relevant records about the Practice’s care and treatment offered and we have seen the medical team made the correct clinical decisions in investigating his COPD symptoms and referring him to other clinics for further tests in line with the relevant guidelines.

4. We also think there is evidence of good communication with Mr K and his family about the updates on his treatment and potential other causes of his respiratory symptoms. We note the medical team listened to his and his family’s concerns and provided explanations and in-person resolution meetings to explain its actions.

5. We have therefore decided we do not need to take any further action on the complaint. We understand our decision may be disappointing to Mrs K and we acknowledge this may add further distress to an already challenging time.