Mr M complained about severe delays in sending his mother for tests. He felt that the delays meant that by the time his mother was diagnosed with cancer, she had only two weeks left to live. He also complained about a long delay in a visit by an out–of–hours GP when his mother was in pain.
What happened
Mrs T saw a number of GPs in the twelve months before she died. Some initial blood tests were normal but she continued to experience pain. The Practice eventually referred her to the Trust for investigation and tests, but there was a delay in carrying out the tests because staff did not read the request for them properly. This meant that the need for one of the tests was not spotted at first.
The GP Practice would not refer Mrs T for specialist cancer support until it had received the results of all the investigations, even though it was already clear she had the disease. Mrs T was then finally diagnosed with advanced cancer to her bones.
After the tests, Mrs T was in extreme pain and needed a GP to visit her at home outside normal surgery hours. The out–of–hours GP did not arrive for several hours.
Mrs T died two weeks after receiving her diagnosis.
What we found
The GP Practice missed opportunities to thoroughly explore Mrs T's symptoms; to refer her to a specialist when cancer was strongly suspected; and later to refer her for palliative support when she was struggling with pain. There were also administrative failings in how the GP Practice referred her to the Trust for investigations. This was because the referral was made by a nurse who was not authorised to do so (it should have been made by a GP), and the referral did not accurately reflect the clinical picture. Additionally, an appropriately qualified member of its staff did not keep Mrs T sufficiently updated about her referral.
There were also administrative failings by the Trust when it received the referral from the GP. This resulted in a delay in arranging some of Mrs T's tests. Also, when initial investigation results showed that Mrs T had cancer, the Trust missed an opportunity to speed up further investigations it had planned, and to recommend referring her to a specialist doctor.
Had it not been for the failings of the GP Practice and the Trust, an earlier diagnosis could have been made. However, because of the type of cancer Mrs T had, the outcome would not have been any different.
The out-of-hours GP service had already acknowledged that a fault with its computer software had told the assigned doctor that a home visit had already been made. This led to an unacceptable delay in Mrs T receiving a home visit, and left her in pain for several hours. However, the doctor could not have known the information on the computer was inaccurate.
Putting it right
The GP Practice and the Trust both acknowledged and apologised for the impact of their failings, and drew up plans which described how they would learn from Mrs T's experiences. The GP Practice and Trust both paid compensation (£700 and £400 respectively) to Mrs T's family in recognition of the distress caused to them.
The out-of-hours GP service apologised to Mr M for the unnecessary pain his mother suffered as a result of the delayed home visit. We noted that it took action to address the software problem as soon as it became aware of it.
A GP practice
A GP practice
An out-of-hours GP service
West Yorkshire
Did not apologise properly or do enough to put things right
Apology
Compensation for financial loss
Recommendation to learn lessons or draw up an action plan