Decision Report 201303870

Summary

Mrs C's stepfather (Mr A) was diagnosed with advanced bowel cancer and received chemotherapy (a treatment where medicine is used to kill cancer cells). Mrs C said that he attended the medical practice regularly over the two years leading up to his diagnosis, during which time his health deteriorated. Mrs C believed that his symptoms were indicative of cancer and that he should have been investigated for this sooner. She also complained that the GP made a routine - instead of an emergency - referral for a colonoscopy and gastroscopy (a fibre-optic telescope looking into both the upper and lower parts of the bowel). After Mr A was diagnosed with bowel cancer, he attended the practice with a sore leg. His wife contacted the oncology department (who specialise in treating patients who have cancer) at the local hospital (the first hospital), who arranged a scan that showed that he had a blood clot in his leg and lung, and the following year his health began to deteriorate significantly.

Mrs C said that there was a failure by healthcare professionals in the community to provide a discussed and implemented care plan about support throughout Mr A's illness and end of life care. Mr A wanted to receive end of life care at home but at no time was he consulted about his wishes or preferred place to die. He had a number of admissions to hospital due to blood clots and his deteriorating condition. In the last month of his life, it was noted in the GP records that chemotherapy treatment had stopped due to progression of the disease. During his last admission to the first hospital, Mrs C said a doctor told them surgical intervention was not possible and the aim was to get Mr A's pain under control and discharge him home. However, Mr A's wife received a phone call several days later saying that her husband would be transferred to a second hospital where he would be under the care of his GP practice. Mr A remained unresponsive for several days, and his GP said Mr A was dying, but did not tell the family that he had decided that Mr A should no longer be given oral medication. Several days later, the family became distressed at Mr A's condition, and his GP told the family it was difficult to say how much longer he had to live. Mr A died shortly after.

Mrs C complained that the practice failed to refer Mr A to a specialist consultant within a reasonable time, failed to diagnose the blood clots he developed and that the communication and support was not reasonable. In relation to her complaint about the care provided by GPs when Mr A was a patient at the second hospital, Mrs C said she had concerns about prescription of medication and that Mr A was unresponsive for an unreasonable length of time.

After taking independent advice from one of our medical advisers, we found it was unlikely that Mr A would have had bowel cancer symptoms until around 18 months before his diagnosis, and there was no evidence that his medical problems were not reasonably assessed and dealt with. However, the medical adviser said that Mr A should have been referred urgently to hospital at one point in light of his warning symptoms and we upheld this complaint. We found that the practice's management of Mr A in relation to his blood clots was reasonable. We upheld the complaint about end of life care, as our adviser said that while it was not the sole responsibility of the GP to have such discussions with patients, they should ensure it was done within a reasonable time. In this case, the practice's failure to coordinate an appropriate end of life care plan compounded Mr A's and his family's distress at what was happening.

Our adviser said that there was a shared responsibility between the practice and the consultant oncologist (a doctor who specialises in treating patients who have cancer) to ensure that Mr A and his wife understood why chemotherapy was stopped. While we found that communication was on the whole reasonable, particularly in relation to stopping all medication and likely timescale of death, the failing around the decision to stop chemotherapy was significant because it meant that later discussions about treatment involved palliative care (care solely to prevent suffering), and we upheld this complaint.

Finally, we did not uphold Mrs C's complaint that medical staff at the second hospital (which was provided by GPs from the practice) failed to provide Mr A with appropriate medical care, as we found that the care and treatment provided in relation to pain relief was reasonable.

Recommendations

We recommended that the practice:

• review their process for referrals where referral symptoms are present in light of the medical adviser's comments;
• bring the failures this investigation identified to attention of the relevant staff; and
• apologise for the failures this investigation identified.