Selected Investigations Completed April - September 1999

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Part II - Full Texts of Selected Investigations

Complaint against: A GP in the Barnsley Health Authority area

Complaint as put by Mrs A

1. The account of the complaint provided by Mrs A is that, in January 1997, her father, Mr B, attended his general practitioner (GP), with a chest infection. The GP did not treat the chest complaint. He prescribed tablets to treat an ulcer, although Mr B had not been troubled by ulcers since the 1950s. Mr B continued to feel unwell and the GP arranged for him to have blood and urine tests, an x-ray and an electro-cardiogram [ECG] (a measurement of the heart's performance). When the GP received the results, he went to Mr B's home and told him that he had cancer and that he might have only weeks to live. Mr B was shocked and appeared to lose the will to live. He underwent further tests in hospital; but these did not detect cancer. On 28 July, the GP met Mrs A and Mrs A's sister to discuss their father's care. On 27 August, Mr B died in hospital as a result of bronchopneumonia.

2. In September 1997, Mrs A discussed with the practice manager the care and treatment which the GP had provided to Mr B. On 8 November, she wrote to the practice manager with questions about the GP's diagnosis and care of her father. The GP responded to her letter on 9 February 1998. On 18 February, Mrs A asked Barnsley Health Authority (the Authority) for an independent review of her complaint. The Authority's convener (the convener) recommended further local resolution and, on 27 April, Mrs A attended a conciliation meeting with the GP. Mrs A remained dissatisfied and, on 4 May, repeated her request for an independent review. On 9 June, the convener wrote to Mrs A again refusing independent review. Mrs A remained dissatisfied and complained that the GP had failed to answer her complaint satisfactorily.

3. The matter subject to investigation was that the GP did not provide Mrs A with adequate explanation of his diagnosis, care and treatment of Mr B.

Investigation

4. The statement of complaint for the investigation was issued on 21 August 1998. Comments were obtained from the GP and relevant documents were examined. The Ombudsman's investigating officer took evidence from Mrs A, Mrs B (Mr B's wife) and the GP. I have not put into this report every detail investigated, but I am satisfied that no matter of significance has been overlooked.

5. The focus of the Ombudsman's investigation has been the adequacy of the GP's handling of Mrs A's complaint and the explanations he gave of his actions and judgments. However, the clinical situation underlying Mrs A's complaint was complex and, perhaps, difficult for a lay person to comprehend, particularly in the sensitive and distressing circumstances of Mr B's illness and the GP's visit on 18 July 1997. I have, therefore, included as an appendix to this report, in layman's terms, the opinion given by the Ombudsman's professional adviser when, initially, she considered Mrs A's complaint, the GP's formal response to it and the documentary evidence, including Mr B's clinical records (Annex A). I have also appended the GP's account of his consultations with Mr B, drawn from the clinical records (Annex B). In summary, the Ombudsman's adviser was of the view that the GP's clinical examination of his patient and the investigations he commissioned were appropriate and suggested cancer as the most likely cause of Mr B's condition. The adviser also concluded that the GP had dealt with the breaking of bad news in a reasonably sensitive manner, given that fairly urgent decisions needed to be taken about the management of Mr B's illness, and that he had made appropriate arrangements for follow up. In the light of that advice I concluded that there was no clinical case to answer. Following Mrs A's complaint to the practice, the GP had opportunities to explain his actions and the judgments he reached and this investigation has concentrated on the adequacy or otherwise of his attempts to do so. Mrs A was informed of the terms of the investigation, by letter, on 21 August 1998. A glossary of medical terms used in the report is provided at Appendix C.

Relevant legislation

6. The Secretary of State for Health, in exercise of powers conferred on him by sections 15(1), 29 and 126(4) of the National Health Service Act 1977, issued the National Health Service (General Medical Services) Amendment Regulations 1996 which include that:

' .... a doctor shall establish and operate .... a "practice based complaints procedure" to deal with any complaints made by or on behalf of his patients and former patients .... '

7. The regulations also make clear that a practice based complaints procedure should be such as to ensure that all complaints are properly investigated and the complainant given a written summary of the investigation and its conclusions.

8. The regulations add that:

' .... A doctor shall cooperate with any investigation of a complaint by the Health Authority ....

' .... The cooperation required .... includes .... attending any meeting to consider the complaint .... if the doctor's presence at the meeting is reasonably required by the Health Authority.'

9. The Secretary of State for Health, in exercise of powers conferred by section 17 of the National Health Service Act 1977, also issued 'Directions to Health Authorities on dealing with complaints about family health service practitioners'. Section 12 of which confers powers on Health Authorities to provide conciliation services where both the complainant and the person subject to the complaint agree that this would be appropriate.

Documentary evidence

Autopsy

10. The report of the autopsy (post mortem) carried out on Mr B contained detailed information about the condition of his lungs and included the following information:

' .... There is a slight purpuric rash [purple in colour, does not blanch with pressure - usually indicating a low platelet count] over the upper chest ....

' .... there is no evidence of gastro intestinal neoplasm [cancer]

'I understand Mr B, a former coal miner, had been diagnosed as having emphysema and bronchitis in 1962 and retired at the age of 55 years because of his chest condition. He was not in receipt of any disability pension for his chest, although I understand a claim is pending ....

'Post mortem examination showed a very extensive bilateral bronchopneumonia superimposed on changes of emphysema and chronic bronchitis .... '

The cause of death was given as 'bronchopneumonia due to or as a consequence of chronic obstructive airways disease [industrial].'

11. On 9 October 1997, the consultant gastro-enterologist in charge of Mr B's care while he was in hospital wrote to the GP's practice with the following information:

'Diagnosis:

1) Bronchial pneumonia (terminal event)

2) High grade pyrexia [fever or temperature] of unknown origin

3) Thrombocytopenia [reduction of platelets which enable blood to clot] and bone marrow dysfunction.

' .... No evidence of malignancy was found, nor was an infective agent identified ....

' .... While we found many changes on our investigations they were mostly non-specific .... The initial presentation was certainly consistent with a malignancy [cancer] .... '

12. On 4 December, the hospital's chief executive wrote to Mrs A and said:

' .... Throughout the whole of his hospital stay .... investigations were trying to find a cause for his fever and to try and exclude the presence of any cancer ....

'Death certificates record the immediate cause of death, rather than always shedding light on the preceding illness. In Mr B's case, the bronchopneumonia set in very rapidly which led to his death and this is therefore what is recorded on his death certificate. This was not, however, the diagnosis of his previous ill health throughout July and August .... '

Correspondence related to Mrs A's complaint

13. On 28 July, the GP met Mrs A and Mrs A's sister. They had asked to see him to discuss the care he had provided to Mr B (see also paragraph 24). The GP recorded their discussion in Mr B's notes as follows:

' .... 2 daughters. Worried about father. Told "he had pneumonia". Yellow. Explained illness process .... Advised to fill in complaint. Also talked about

- quality of life

- telling bad news

- hospital problems

- treatment versus care'.

14. On 8 November, Mrs A wrote to the practice manager and confirmed the questions that the family wished the GP to answer. She wrote:

'the GP told my father that he had cancer, and that most probably this was renal .... Mr B had undergone a blood test, urine test, ECG and an X ray. How could the GP possibly reach a diagnosis from just these tests? ....

' .... We would like to know why further tests were rejected by the GP ....

'the GP appeared to think that 'the cancer' would take its course very quickly .... Why then did he not put any support services in place? ....

'We regret very much the way the GP broke the news to my Mother and Father. It was very direct and shocked them very much. Has .... the GP reconsider[ed] his attitude and manner when breaking bad news?'

15. On 9 February 1998, the GP replied to Mrs A as follows:

'1. The blood test and urine test both showed abnormalities which allowed me to derive information. The blood test demonstrated that there was a severe process occurring most probably infection or tumour (cancer). The urine test showed some abnormal cells.

'2. Many tests are invasive and painful. I thought that the test most likely to be helpful was an ultrasound of the abdomen which I had already arranged. Further tests were not rejected but delayed until it could be seen whether they would benefit or harm Mr B.

'I spoke .... to Mr and Mrs B at their home and it was clear that Mr B was very ill but at the time they did not appear to need support services. I arranged a follow up visit from the District Nurse to further assess [his] needs the following week.

'I was asked directly what I felt to be the cause of Mr B's problems and I answered that question. Mr B was aware that he was dying. I gave Mr and Mrs B time to discuss between themselves while I waited downstairs .... I offered a choice of Mr B being admitted to hospital or waiting for the results of further tests but explained that he was seriously unwell and that he would become more so as time went on. There is a belief among many doctors that doctors should withhold the truth from their patients to protect them, but most doctors will agree that if a patient asks a direct question they should answer that question.'

16. On 18 February, Mrs A wrote to the Authority and requested an independent review of her complaint about the GP's clinical management of her father's care. She said that her remaining grievances were that:

'1. How could the GP reach such a conclusive diagnosis from just a blood test, urine test, ECG and an X ray? The family understand that a GP could suspect a certain condition, but surely he should have referred to a hospital consultant for specialist investigations and diagnosis?

'2. The family very much regrets the GP's attitude in breaking such devastating news to Mr and Mrs B in their home ....

'3. Why did the GP prescribe tablets for ulcers, rather than for Mr B's chest?'

17. On 9 March, the Authority's convener wrote to Mrs A and referred her complaint back to local resolution for conciliation between Mrs A and the GP in the presence of a lay conciliator (see also paragraph 23).

18. Following that conciliation meeting, Mrs A wrote to the convener and again asked for an independent review. She said that she had identified three main concerns in her letter of 18 February and added:

' .... I do not feel that the process was helped by the GP's refusal to allow a representative from the Community Health Council (CHC) to accompany me to the meeting .... '

19. The convener sought medical advice and the advice of a lay chairman in the light of which she decided not to establish an independent review as she felt that all reasonable steps had been taken to answer Mrs A's complaints.

Mrs A's evidence

Mrs A's formal complaint to the Ombudsman

20. On 24 June 1998, Mrs A wrote to the Ombudsman as follows:

'My Father's health had been deteriorating since January 1997, when he caught a 'flu bug. He went to the doctor about his chest infection and the GP gave him some tablets, telling him that they were for his ulcer. Mr B had not been troubled by ulcers since the 1950s, and told the GP that he was concerned with his chest. Nevertheless, the GP advised him to take the tablets, which he did. Mr B continued to get worse. In summer, Mr B had a blood test, a urine test, ECG, and an x-ray. From these tests, the GP visited my Mother and Father and told Father that he had cancer, most probably renal. He was told that there was no point in having further tests, as these would be painful and would not show anything different. The cancer would take its course very quickly, and Mr B might only have weeks to live. From this information Father appeared to go into shock. Subsequent to being told about the cancer, Mr B appeared to lose the will to live, but wanted further tests ...

'When the hospital tests showed no sign of cancer, Mr B visibly 'perked up' and looked a lot better .... He later died of bronchopneumonia in hospital. We were told by the hospital that he did not have cancer .... I list below our remaining grievances:

'1. How could the GP reach such a conclusive diagnosis from just a blood test, urine test, ECG and an X ray? The family understand that a GP could suspect a certain condition, but surely he should have referred to a hospital consultant for specialist investigations and diagnosis? The GP just told us that the tests showed abnormal results. He said this could either be an infection or cancer. Why did he choose cancer?

'2. The family very much regrets the GP's attitude in breaking such devastating news to Mr and Mrs B in their home. When the GP called, he was taken to the bedroom by Mrs B and he told them it was cancer, 'probably renal'. He said he would wait downstairs while they had 'a little talk'. After a while the GP came back upstairs and asked if they had any questions, and if they had talked. They had not been able to discuss the diagnosis, but had just cried together. The GP told Mr B he could go to hospital for further tests, but appeared certain of the cancer and its rapid progress ....

'Why did the GP prescribe tablets for ulcers .... rather than for Mr B's chest?'

21. Mrs A, when interviewed by the Ombudsman's investigating officer, said that in January 1997 her father contracted influenza which made his chest worse than usual. He saw the GP, but later told his son that the GP had not listened to what he had said about his chest but was more interested in his stomach. He had been given a prescription for his ulcer and did not seem to understand why. Mrs A saw her father on 19 July. He 'sat as if in a world of his own' and appeared shocked. He said, 'I'm not worried. If my time's up, it's up, there's nothing I can do about it'. Mrs A and her sister went to see the GP and asked him why he thought it was cancer, without tests. He said that Mr B was 'very poorly' and he only had to look at Mr B's hands to see it was cancer - they were very pale. He told them their father's blood 'was haywire' and mentioned his liver and kidneys. The GP said he did not think Mr B should be subjected to medical intervention. Mrs A said that, during the later conciliation meeting, the GP used medical terminology which they could not understand, although the conciliator asked him not to. They asked him why he had prescribed tablets for ulcers but did not get a clear explanation. The GP mentioned bacteria and said it caused some ulcers. The GP apologised for the distress his telling Mr B he had cancer had caused.

Mrs B's evidence

22. Mrs B told the Ombudsman's investigating officer that when the GP came to the house on 18 July, she took him upstairs. The first thing the GP said was, 'Well Mr B, you have cancer'. He said it would be quick and would take three months. He asked whether Mr B would like to go to hospital. Mrs B said if it was going to be quick she would look after him at home. The GP went downstairs to allow them to talk. When he came upstairs he asked them if they had talked but they said they had not; they had been too shocked and upset. There was a telephone call for the GP. He then said he would send a nurse down to see them the next day; but she did not come.

The GP's evidence

23. The GP, in response to the Statement of Complaint, provided the Ombudsman's office with a detailed report of the medical facts related to Mr B's care and treatment, the consultations he had with him (see Appendix B) and the meetings he had with Mrs A and her sister and, later, Mrs A and Mrs B. The accounts the GP provided of these meetings are as follows:

The GP's meeting with Mrs A and Mrs A's sister - 28 July 1997

' .... The mood of the consultation was of a complaint and Mrs A was particularly upset. I decided to continue the discussion as I felt it likely that they were experiencing some feelings of grief .... and that expressing these feelings directly might benefit them.

'They asked a series of questions - how could I have diagnosed kidney cancer from only one blood test? Why did I not admit Mr B on Friday? Why did the nurse arrive on Wednesday? Why did I suggest that he should ask his family to visit him? Why did I tell him the diagnosis? Why did I treat his stomach bug? Why did I not visit over the weekend or at least Monday? Why did I not arrange further tests? Why did I not give him warning of the bad news?

' .... I explained that there were a number of blood and other tests performed on Mr B. Mrs A stated that this was not true so I took the results out of the notes and showed that there were several pieces of paper. I further stated that there was .... a further test (the abdomen ultrasound) arranged. She stated that no ultrasound had been arranged and I showed her the notes where I had written 'abdo U/S'. She stated that I had written this into the notes at a later date. I suggested she contacted the ultrasound department directly to determine the date .... and I gave her the date on which it had been sent.

' .... I explained that I had two blood tests (full blood count) which showed that all classes of blood cells had fallen - red cells, white cells, platelets. The significance of the fall was a syndrome called pancytopaenia and that the most likely cause on the evidence I had at the present time was the bone marrow being replaced by a tumour, probably kidney, but that I could not exclude infection, .... The treatment I had given was antibiotics which would treat any infection, not just the stomach bug.

' .... Mrs A said that they had been told by a junior doctor at the hospital on the basis of initial examination that there was no evidence of kidney cancer. I stated that I had not detected any mass on my examination [on 18 July] but there was tenderness .... and that there was a report showing severely dysplastic (abnormal) cells and that the ultrasound would be able to show if there was any tumour. I explained that Mr B had asked me about his condition and I answered his questions .... he had a right to know .... I had explained to Mr B that the tests were looking for serious illness prior to the visit.

'I explained that there always remained a possibility that some treatment would be effective but his pancytopaenia whatever its cause was usually serious and if it continued that he would die, as white cells and platelets cannot be replaced by a transfusion. I explained that if I had felt the hospital would be able to help Mr B I would have arranged admission but I had discussed Mr B's condition with him and he had chosen not to be admitted. I explained that I had arranged follow-up appropriate to his condition and the nurse was contacted on Monday.

'I had explained the complaint procedure.'

The GP's conciliated meeting with Mrs A and Mrs B - 27 April 1998

'The Conciliator .... encouraged Mrs B to give her version of events. To summarise she stated that Mr B had not had treatment for his pneumonia, only for his stomach and that after being told that he had cancer he gave up and died quickly. Mrs A then stated that although Mr B had seemed resigned to his illness she felt that not enough had been done to help [him], specifically that there had been a delay in arranging follow up by the nurse and myself and that further tests had not been arranged and referral to hospital had not been done. They denied ever being told the diagnosis by [the consultant], especially they denied being told that he was uffering from pancytopaenia/bone marrow failure. therefore, explained the probable cause of death, that he was previously fit and that he had deteriorated over the month prior to admission and his lung disease noted in the post-mortem was not sufficient alone to result in his death. There were other abnormalities which had not been explained, the urine cytology and the falling blood counts with abnormal bone marrow. I agreed that the initial possibility of kidney cancer had now been discounted but that pancytopaenia is still serious on its own .... I explained that other diagnoses (excluding TB) could be discounted from his clinical state and progression leaving, overwhelming sepsis, aplastic anaemia or infiltration by cancer. As he had not responded to antibiotics then the latter two and the specific infection of tuberculosis were possibilities. Aplastic anaemia and infiltration by cancer are usually rapidly fatal and treatments and investigations are unpleasant. I accepted that I had not excluded tuberculosis but this was unlikely although can occur with reactivation of TB and this would show on the chest X-ray report. His chest X-ray was reported as clear. He had had treatment and tests for TB [which proved negative] whilst in hospital and this had upset the family. I explained that this was necessary to exclude this illness.

'Next I explained that when I saw Mr B on the 'visit' [the consultation of 18 July 1997] I had the results of two blood counts, separated in time, showing a deterioration which, when combined with his clinical deterioration, meant that the diagnosis was pancytopaenia (bone marrow failure). Mrs A stated that I was not able to make that diagnosis and I replied that she could get a second opinion and ask whether that diagnosis was reasonable at that time. I explained that I had not admitted him as he had said that he did not wish for admission and the discomfort that would entail. He said he would prefer to die at home.

' .... I explained that [I had prescribed three drugs] Omeprazole, Amoxycillin and Metronidazole. I agreed that these had been given for a stomach bug, H.pylori, but that they are antibiotics with a wide spectrum covering most of the two types of bacteria - Gram positive and Gram negative .... They would be expected to treat overwhelming sepsis [infection which very quickly overcomes the body's defence mechanisms to produce serious life-threatening illness] and other infections. Mrs B again insisted that the treatment was for the stomach and, therefore, would not work for chest infection. Further discussions of the properties of antibiotics continued. Mrs B then reiterated that her husband had died due to being told that he had cancer. Mrs A stated that he had seemed to accept the diagnosis and had 'picked up' after admission to hospital after which he had deteriorated. I explained that pancytopaenia leaves patients vulnerable to infection, anaemia and bleeding and that if an infection was treated he might improve before his final decline. Mrs B again insisted that it was 'being told' that killed him and that I was, therefore, responsible for his death. I expressed sympathy .... '

24. At interview, the GP told the Ombudsman's investigating officer that his first contact with Mrs A had been on 28 July, shortly after her father had been admitted to hospital. The GP pointed out that, at the time, Mr B was alive and he had a duty of confidentiality to his patient; nevertheless he addressed Mrs A's concerns as fully as he could. Mrs A was very upset, both angry and grieving; but she was in control of herself and asked questions which appeared to show an understanding of the problems. The GP told the investigating officer that he spoke to Mrs A in lay terms and had to state some points a number of times before she could grasp them; for example, she did not immediately understand that antibiotics could work in more than one area of the body at the same time. It was difficult to convince Mrs A that there had been no chest infection at the time of the chest x-ray. The GP and Mrs A had had an in-depth thirty-five minute discussion and Mrs A had someone with her who would also be able to recall the information given. He referred them to the consultant for a second opinion.

25. The GP said that, at the later conciliation meeting, he had tried to address every facet of Mrs A's concerns and to help her and her mother understand the apparent inconsistencies between the consultant pathologist's (autopsy report at paragraph 10) and the consultant gastroenterologist's clinical opinion (paragraph 11). The meeting had lasted over an hour and was very emotional. The GP said that he had apologised for any upset and distress he had caused. He explained to the investigator that he had not wanted a CHC representative present at the meeting because he felt that might make it more confrontational. He thought Mrs A quite capable of putting her complaint and he wanted to resolve, rather than escalate it. That was why he had attended on his own.

26. The GP believed that his written response to Mrs A had answered her questions. He felt that Mrs A's complaint arose from her belief that the explanations from the various doctors involved were inconsistent and also because lay people have little knowledge of aplastic anaemia and, therefore, find it difficult to accept as a diagnosis. He had explained to the family that bronchopneumonia was a terminal event; but he did not think they understood what he was saying because they were unable to accept the principle diagnosis of pancytopaenia. Mrs A was not the GP's patient and, therefore, there was no relationship of trust between them. That, coupled with the unfamiliarity of the diagnosis, impeded the family's belief in what he had told them. The GP was distressed by the complaint and commented that at all stages he had been as open and honest as possible.

The practice manager's evidence

27. The practice manager said, in a written statement, that he met the family twice and that they did not seem to have a common agenda. It was difficult to ascertain the exact nature of their complaint and he suggested that they contact a CHC to assist them. He found the complaint very difficult to deal with because of its confusing nature and the family's evident hostility. Mrs B had refused initially to meet with the GP and the rest of the family agreed.

Findings

28. As I have made clear in paragraphs 4 and 5 of this report, the focus of this investigation has not been the quality of the GP's clinical actions and judgment in the care of the complainant's father but whether he answered Mrs A's concerns adequately when he dealt with her complaint. However, the circumstances of Mr B's illness and the diagnostic complexities with which the GP was faced are relevant to Mrs A's perception of what he did and said. I have appended to this report a note, in layman's language, setting out the opinion of one of the Ombudsman's professional general practice advisers on the clinical issues in this case which I hope Mrs A and the family will find helpful (Appendix A). I have also appended the GP's account of his consultations with Mr B which provide helpful background (Appendix B). I am advised that the autopsy report (paragraph 10) was not a full clinical report—it did not for example mention pancytopaenia which was clearly present. That may well be because the report was produced for a particular purpose—an industrial injury claim.

29. The Ombudsman's adviser concluded that the GP commissioned appropriate diagnostic tests and demonstrated good practice in recognising the significance of the bacterial infection H.pylori and tried to eradicate it—so giving rise to Mrs A's concern that he was ignoring Mr A's chest complaint. These difficulties were compounded by the fact that the cause of death recorded at post mortem was bronchopneumonia and Mrs A and the family's failure to understand that this resulted from Mr B's vulnerability to infection. Mr B did not have pneumonia when the GP saw him. He developed the infection while in hospital and his body was unable to combat it because of his underlying condition. The GP diagnosed this as pancytopaenia (a reduction in all the main types of blood cells) which pointed in his opinion to cancer as the most likely cause. The adviser also confirmed that the GP had acted appropriately in first preparing Mr B for, and then breaking bad news.

30. I consider it likely, and in the circumstances understandable, that Mr and Mrs B might have been unable to absorb the full import of what the GP said to them on 18 July. I do not criticise Mrs A and her family for failing to comprehend the complex inter-relationship of clinical conditions, in the distressing circumstances of Mr B's illness. Neither, however, do I criticise the GP's attempts to explain matters. He has pointed out that he met willingly with Mrs A while her father was alive to try to address her concerns. Later, he provided written answers to her questions (his letter of 9 February 1998) and, still later, he attended a conciliated meeting. While I understand the GP's reasons for not wishing a CHC representative to attend that meeting, I think that, given the complex medical situation and the strength of the family's emotions, this may have provided helpful support for the family. This aside, in my opinion the GP made open and transparent attempts to answer Mrs A's questions. Unfortunately, however, it is clear that Mrs A lost confidence in the GP and was unable to accept what he told her. I am satisfied however, that the GP has been, as he has stated, 'open and honest' throughout. I do not uphold this complaint.

31. I fully appreciate how confusing the circumstances of Mr B's death have been for his family. I hope, however, that this report will help them to understand what happened and that the GP's explanations of his diagnosis, care and treatment were reasonable, honest and correct. Back to top

Annex A to E.678/98-99

Internal professional advice on Mrs A's complaint against the GP

1. In the latter half of 1998, Mrs A's complaint, the GP's formal response to the Ombudsman and documentary evidence including clinical records were examined by one of the Ombudsman's professional advisers, a general practitioner of considerable experience and standing within the profession.

2. The adviser noted the following results of diagnostic investigations from the records maintained by the GP:

1. ESR 101mm (a simple test for screening for certain conditions including cancer)
2. urine sample showed dysplastic (abnormal) cells
3. previous history of DU (duodenal ulcer), serology to H.pylori recently checked and result positive (positive evidence of bacteria resent in duodenal ulceration—susceptible to antibiotics)
4. Chest x-ray checked by GP clear

3. The adviser also noted that the GP examined Mr B and found that his liver was enlarged. The adviser observed that, clearly, the GP thought that Mr B was very unwell and that he arranged an ultrasound of Mr B's abdomen which was reported as normal.

4. The Ombudsman's professional adviser was of the view that the GP had commissioned appropriate investigations to identify the cause of Mr B's illness and commented that it is only in the last few years that the continuing presence of the bacterial infection H.pyloria in the stomach of people with ulcers has been appreciated and that only very recently has an easy test for it been available to GPs. The adviser commented that the GP's identification of this factor was evidence of good practice. He tried to eradicate the 'bug' as its continuing presence can be a sign of the development of a number of conditions including cancer and ulcers.

5. The ESR of 101, the abnormal cells in Mr B's urine and an enlarged, hard liver pointed to a likely diagnosis of cancer with something going wrong in the kidney or urinary tract.

6. Mr B's chest x-ray was clear. 'Creps' or sounds in the base of the chest are a common finding in men with Mr B's history of pneumoconiosis (lung disease caused by inhaled dust) and do not confirm the presence of lung infection.

7. The Ombudsman's adviser also noted that when Mr B was admitted to hospital he was investigated extensively for pyrexia (fever) of unknown origin and bone marrow dysfunction. He died from bronchopneumonia (inflammation of the lung caused by bacteria) though this was not initially present. The post-mortem carried out on Mr B did not identify his underlying condition, but malignancy (cancer) or tuberculosis were the main suspects. (Note: tuberculosis was excluded by hospital tests.)

8. The Ombudsman's adviser said that on the basis of the GP's clinical examination and investigation cancer was the likely diagnosis. There were questions about Mr B's management which needed to be put to him and this influenced the GP's decision to tell his patient his diagnosis. There is a range of views as to how much information should be given; but most GPs would attempt to answer direct questions from patients and families. It is not always realistic, as in this case, to spare a patient distressing news. In the circumstances the GP appeared in the adviser's view to have dealt with the breaking of bad news in a reasonably sensitive manner and that he had prepared Mr B for bad news in the course of earlier consultations. He made appropriate follow up arrangements and asked a district nurse to call. He also arranged to see Mr B himself one week later.

9. The adviser concluded, with regard to the autopsy, that it did not include findings which would help explain Mr B's clinical condition before death and certainly did not suggest that the GP had been wrong in his diagnosis.

Annex B to E678./98-99

Clinical Events

1. In his formal response to the statement of complaint, the GP described his consultations with Mr B as follows:

'3.6.97 Seen .... with a cough and right sided chest pain. He said he was sweating and tired all the time. I also asked him about his ulcer which was still troubling him at times .... I examined his chest .... I gave him a card to take to hospital for a chest X-ray and a blood test for H.pylori, which is a bacteria found in the stomach and duodenum of patients with duodenal ulcer. I explained that the chest X-ray was to see if there was an infection on his chest and the blood test was to see if he had H.pylori .... He had had a duodenal ulcer in the past. He stated that he had had pleurisy (chest infection) at the age of 18 and a history of .... blood in the urine.

'10.6.97 He consulted again for his cough and the results of the investigations were explained to the patient, specifically that the chest X-ray was clear showing no infection and that his blood test confirmed the H.pylori infection in his stomach. He also said his chest/epigastric pain was worse. He complained of discharge from his ears and a rash on his chest .... I prescribed amoxycillin (an antibiotic), metronidazole and omeprazole.

' .... I explained that his condition should improve .... that I felt it was a duodenal ulcer causing the chest and abdominal pain. If a chest infection was present then it would be treated by the antibiotics as would any infection in the ears.

'8.7.97 He attended surgery again complaining of dizziness, stomach ache, flashing in front of his eyes and had had pain in his back and chest at times. He was at this time unable to continue gardening because when he bent down he became dizzy. He also said that the taste of food had changed .... I .... arranged an ECG .... , thyroid function tests, liver function tests, full blood count and erythrocyte sedimentation rate [ESR] (to measure stickiness in the blood). I explained that at this time an infective cause was less likely as he had had recent antibiotics but in view of the progressive symptoms, more serious causes needed to be considered. This was to give him the chance to prepare himself for bad news.

'11.7.97 Mr B attended the surgery at our request .... He continued to have chest pain and was chesty. He said that he had been short of breath for 2 weeks and was tired all the time. He had a 1cm liver edge and tenderness in the epigastrium. He was tender in the right loin .... I tested his urine and found he had some blood in his urine. His liver was slightly enlarged. I arranged a repeat full blood count and ESR, U&E's (kidney test), urine cytology to look for abnormal cells in the urine and requested an ultrasound of the abdomen which was marked 'urgent'. I explained that the blood test had shown that he was not making blood well and that his blood was very sticky. I stated that I was not sure what was causing his symptoms at this time but a further blood test would help me to understand why he was not making his blood and a scan of his abdomen would find if there was any problem with his liver or kidney and that a urine test might help me discover if there was "something nasty" in his kidney. Again giving him further time to prepare for bad news.

'18.7.97 A visit was requested. The symptoms given to the Receptionist were that he was coughing, chesty with a pain in his throat and dizzy. I attended after surgery .... he still had a cough and was chesty and his appetite had reduced and he was dizzy .... On examination his abdomen showed no masses or tenderness, he had some inspiratory noises in the left chest and there were late crepitations in the right base. The results from the blood count showed that both his red cells and white cells had reduced over one week. I explained it could be caused by an infiltrating cancer, a severe infection and other rare causes. I felt that the most probable cause was bone marrow infiltration but that Mr B should continue to take his antibiotics .... in case there was an infection. His wife said that he was getting worse and falling over and I explained that this was the result of the illness. At that point the telephone rang and (a GP Colleague) passed me a verbal report of the urine cytology which showed severely dysplastic (abnormal) cells in the urine and I explained this to the patient and his wife and that it may mean cancer of the kidney. I went downstairs to allow this information to sink in and then returned to discuss the options available. I explained that his condition and his blood tests were declining quickly and gave him the option of in-patient investigation or remaining at home. The patient then asked me why he was getting worse and why he could not walk so well. I explained that although I could not be sure which of the possibilities was causing his problem, the pancytopaenia meant the disease was likely to be quite advanced and it was likely that he was going to die in the next few weeks whatever was done.

'Both Mr B and his wife were upset by this news but Mr B continued and asked if there was anything that could be done. I explained that we could arrange further investigations from home if he wished to pursue investigations. I explained that he might live slightly longer in hospital and that there always remained a small possibility that they would find a treatable cause of his pancytopaenia. He stated that he would prefer to stay at home in the presence of his wife, I explained that he could change his mind at any point and decide to be admitted to hospital. I then addressed the direct questions from the patient. He asked specifically whether I could arrange an ultrasound of his neck with his abdomen. I explained that this would not be helpful as ultrasound does not image the neck very well. He wished to travel to Australia which I suggested was not possible in his condition. I advised them to apply for Attendance Allowance and I arranged a nurse for the following Tuesday and a follow up visit by myself in one week.

Ombudsman's note: This account is consistent with Mr B's clinical records. Back to top

Annex C

Schedule of abbreviations used in this report

aplastic anaemia - 'reduction in haemoglobin in the blood which carries oxygen due to impaired production of red blood cells causing excessive tiredness and fatigue, breathlessness, pallor and poor resistence to infection.

chronic obstructive airways disease - '(commonly abbreviated to COAD) also known as chronic obstructive pulmonary disease (commonly abbreviated to COPD) - obstruction to the airways which is not reversible and which is due to a combination of widespread disease of the airways within the lungs (chronic bronchitis) and emphysema.

cytology - 'the study of cells under a microscope to assist in the diagnosis of disease.

ECG (electrocardiogram) - 'a measurement of the heart's performance.

emphysema - 'increase in the size of the airspaces in the lungs with destruction of the walls of the airspaces and loss of the functioning tissue of the lung.

overwhelming sepsis - 'infection which very quickly overcomes the body's defence mechanisms to produce serious, life-threatening illness.

malignancy - 'cancer.

neoplasm - 'cancer.

pancytopaenia - 'a reduction in all of the main types of blood cells—red, white (for fighting infection) and platelets (to prevent bleeding).

purpuric rash - 'purple in colour, does not blanch with pressure - usually indicating a low platelet count.

thrombocytopenia - 'a reduction of the number of platelets in the blood.

tumour - 'cancer.

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Short text of this investigation

Last updated: 9 January 2006