Clinical treatment outside hospital; GP : A GP Practice in the area of Aneurin Bevan University Health Board Report Date 15/01/2025 Case Against A GP Practice in the area of Aneurin Bevan University Health Board Subject Clinical treatment outside hospital; GP Case Reference Number 202303356 Outcome Public Interest Report Ms D complained about the care and treatment provided to her grandmother, Mrs F. Specifically, the investigation considered whether, between June 2021 and June 2022, Mrs F’s GP Practice failed to take appropriate action which would have resulted in an earlier diagnosis of her bladder cancer.
My investigation found that Mrs F had ongoing urinary symptoms and a presence of blood in her urine without infection, which should have resulted in an urgent suspected cancer referral in July 2021. There were a number of missed opportunities to make this referral, and it was not made until May 2022. This was a significant service failing. I am saddened to conclude that had an urgent referral been made for Mrs F at an earlier stage, on balance, it is likely that the bladder cancer would have been diagnosed and treated sooner. Whilst I cannot be certain that this would have prevented Mrs F’s death, on balance, it is likely she would have survived longer. This is a grave injustice, not just to Mrs F, but as an enduring source of distress for Ms D and her family.
I recommend that the Practice, within 1 month of this report: a) Provides Ms D with a fulsome apology for the failings identified in this report. The apology should make reference to the clinical failings, the impact of these on Mrs F’s outcome and the impact on Ms D and her family.
b) Provides my office with confirmation that the new alert system for follow-up of patients with persistent blood in their urine is in use.
I recommend that the Practice, within 2 months of this report: c) Reviews this case, along with its original significant event analysis, and the opportunity for earlier suspected cancer referral in line with NICE guidelines, to identify any points of learning which can be applied in future care and when dealing with complaints.
d) Provides relevant clinicians with training on NICE guidelines for urinary tract infections in adults and bladder cancer diagnosis and management.