Cambridge University Hospitals NHS Foundation Trust

3. Mrs E complains that a GP from the Practice ignored her mother’s symptoms for three months and incorrectly diagnosed constipation. She says her mother had pancreatic cancer and the delay meant Mrs M and her family could not prepare properly for her death.

4. Mrs E complains that doctors in the emergency department at one of NWA Trust’s hospitals (Hospital A) failed to carry out a CT scan on 19 February 2024. She also says doctors carried out an unnecessary rectal examination but dismissed Mrs M’s concerns. She says Mrs M experienced unnecessary distress and discomfort.

5. Mrs E complains that clinicians at one of CUH Trust’s hospitals (Hospital B) were poor at delivering bad news to Mrs M and her family on 28 February 2024. She also says clinicians left Mrs M in the discharge lounge on 5 March for several hours and failed to provide a care package when they discharged her. She says these incidents caused avoidable distress and discomfort for Mrs M and her family.

6. Mrs E wants the organisations to take action to ensure there is learning from her complaint. She also wants there to be disciplinary action against one of the GPs at the Practice.

7. On 17 January 2024 Mrs M handed a letter to staff at the Practice which referred to her concerns about abdominal pain, poor appetite and vomiting episodes. She then called the Practice and spoke to a GP on 29 January 2024. She said she had been constipated for around one month. The GP diagnosed constipation due to a urine infection, based on earlier test results. They recommended a urine test and additional laxatives.

8. Mrs M attended the Practice and saw the GP in person on 8 February 2024. She explained that she was still constipated despite taking laxatives. The GP examined her and did not have any significant concerns. The GP called her a week later and noted she was able to pass stools, and she was feeling a little better.

9. On 19 February 2024 Mrs M attended the Practice and saw the GP again. She said she felt she was improving. The GP was concerned she might have had a bowel obstruction and advised her to attend the emergency department at Hospital A. She had an X-ray there which did not show any concerns.

10. Mrs M had a conversation with her GP on 22 February 2024. They noted Mrs M had episodes of vomiting and the GP planned to review her the following week. On 28 February an advanced nurse practitioner from the Practice visited Mrs M at home. She recommended that Mrs M should attend Hospital B.

11. On 28 February 2024 doctors at Hospital B diagnosed that Mrs M had pancreatic cancer. They said this had spread to other parts of her body and that she was terminally ill. Mrs M remained in Hospital B until 5 March 2024. Sadly, Mrs M died on 14 March.

The Practice

15. Mrs E complains that Mrs M’s GP failed to properly investigate her symptoms of pancreatic cancer.

16. The Practice sent a detailed response to Mrs E’s complaint. It accepted there were some failings in care. It acknowledged the delay in acting on Mrs M’s handwritten letter. It also accepted the GP could have done more to consider the possibility of cancer.

17. We can also see the Practice arranged a meeting with Mrs E and her family to discuss her complaint. The Practice agreed it should have been mindful of the fact that patients may understate or downplay their symptoms. It agreed this would be considered in future consultations and that GPs would keep an open mind to other possible diagnoses.

18. The Practice accepted the GP should have considered weight loss. It explained how it had shared the complaint across the organisation so ensure clinicians learnt from what happened. It also changed the way it processed mail so that letters are opened and assessed for urgency.

19. We do not consider it would be proportionate for us to start a detailed investigation about the Practice. This is because Mrs E told us that the most important thing for her was to ensure there was learning from her complaint. We are satisfied the Practice has already taken appropriate action to show there has been learning.

20. Mrs E told us she also wanted there to be disciplinary action against the GP. We cannot make recommendations for organisations to take disciplinary action. We have discussed the role of the GMC with Mrs E and provided her with contact details.

21. We recognise Mrs E and her family want reassurance that the Practice has put the learning into practice. This is not something we can monitor, as we are not a regulator. We believe the Practice has treated the complaint seriously and has learnt from what happened to Mrs M.

NWA Trust

22. Mrs E complains that doctors at Hospital A did not carry out a CT scan on 19 February 2024. She also says they carried out an unnecessary rectal examination and dismissed Mrs M’s concerns.

23. The Clinical Adviser told is there is no absolute guidance about when emergency department clinicians should carry out a CT scan. Doctors should have followed Good Medical Practice.

24. Good Medical Practice says doctors must provide a good standard of care. This includes carrying out adequate assessments, taking account of the patient’s history and examining them if necessary. Doctors should also arrange timely treatment and appropriate investigations or referrals if needed.

25. The clinical records show Mrs M told doctors she had not had a proper bowel movement for around two weeks despite taking laxatives. She felt bloated, but all of her observations appeared normal. A doctor assessed her and arranged an X-ray to exclude any bowel obstruction. The X-ray did not show any evidence of a bowel obstruction. Mrs M’s blood test results were normal, as was a rectal examination. Mrs M had signs of a urine infection and was already taking medication for that.

26. Doctors sent Mrs M home with advice to see medical attention if her symptoms worsened. They also made recommendations about the laxatives she was using.

27. The Clinical Adviser told us doctors could have carried out a CT scan. But they chose to use an abdominal X-ray instead. There was then no reason for them to arrange a CT scan because the X-ray showed no signs of obstruction. The Clinical Adviser said doctors appear to have managed Mrs M to an acceptable standard.

28. We can see no indication of any failings relating to the CT scan decision. Neither can we see evidence that doctors dismissed Mrs M’s concerns.

29. We note that the rectal examination was distressing for Mrs M. We do not intend to investigate this incident. This is because we have decided to focus on the more serious complaints that people bring to us, where they may have faced a big impact. For example, these may be about a potentially avoidable death or where someone has suffered prolonged pain. These types of complaints are where we can often make the biggest difference. This means we are not looking into complaints where we can see there has been a smaller impact.

CUH Trust

30. Mrs E complains about the way a doctor gave Mrs M her prognosis on 28 February 2024. She also complains that no support was put in place when Mrs M left Hospital B and that she was left to wait for several hours in the discharge lounge.

31. The Trust’s representatives at the complaints meeting accepted the way the doctor gave Mrs M bad news was not private or dignified. It apologised for failings in communication. It explained how the incident would be fed back to the doctor concerned.

32. The representatives also explained how there was an assessment of whether Mrs M needed a care package and this was in line with the therapy and nursing assessments that took place in hospital. A referral was made to Age UK for welfare checks to take place. Mrs M was very keen to go home as soon as possible and staff were facilitating this. They were clear that this was her own decision and there was nothing to indicate she would not be able to manage at home. There is no indication of any failing in this respect.

33. Mrs M waited for around four hours in the discharge lounge before her transport arrived. The Trust has recognised this was distressing for her and has explained how its discharge lounge process was under review.

34. We are satisfied with the action CUH Trust has taken to address the failings relating to communication and the wait in the discharge lounge. We recognise these were distressing incidents for Mrs M and her family. We do not consider we would be able to add anything more by carrying out a detailed investigation of these issues.

Conclusion

35. Clearly Mrs M’s sudden illness was incredibly distressing for Mrs E and her family. We have seen indications that there were some failings in care. But we are satisfied the organisations in question have done enough to ensure there has been learning from her complaint. We have decided not to start a detailed investigation.

1. We have carefully considered Mrs E’s complaint about three NHS organisations. She complains about the care they gave to her stepmother, Mrs M, between December 2023 and her death in March 2024. We can see how devastating these events have been for Mrs E and her family. We offer our sincere condolences to them for their loss.

2. We have seen no indication that anything went seriously wrong relating to the care NWA Trust provided to Mrs M. We have seen indications of failings by the other two organisations. We consider the Practice and CUH Trust have already done enough to put things right for Mrs M. We have decided not to start a detailed investigation.