GP practice missed opportunities to refer patient for cancer investigations

What happened

Mr C saw his GP in summer 2012, reporting weight loss and pain when urinating. The GP conducted some blood tests, examined his chest and discovered a heart murmur. The GP then referred Mr C to a cardiologist. There was nothing at that stage to indicate suspected kidney cancer. Over the following 11 months Mr C attended multiple appointments at the GP Practice and his local hospital, reporting similar symptoms.

In spring 2013 the GP examined Mr C's abdomen and urgently referred him for further investigations for suspected gastrointestinal (stomach) cancer. The investigations were carried out at the trust and no cancer was found in the bowel or stomach. Mr C had further appointments at the GP Practice throughout summer 2013 but the GP did not take further action to investigate his ongoing weight loss and abnormal blood test results. In autumn 2013, the GP examined Mr C's abdomen and identified a large hard swelling. The GP requested a CT scan but did not indicate that it was urgent. The CT scan confirmed a diagnosis of terminal kidney cancer. Mr C passed away in spring 2014.

Mrs C said that witnessing her husband's illness and eventual death had caused her considerable distress and worry. She said his death would have been avoided had appropriate investigations been carried out sooner. Mrs C complained to the Practice but was dissatisfied with its response. She wanted an apology, service improvements and a payment.

What we found

It was not possible to determine when Mr C's kidney cancer was present and detectable. However, he should have been referred under the two-week pathway for gastrointestinal cancer when he first saw his GP in summer 2012. By the time his kidney cancer was diagnosed in 2013, there had been several missed opportunities to refer him for the appropriate investigations. This resulted in an injustice to Mrs C, which can never be put right. This missed opportunity meant that she will never know for sure whether earlier diagnosis and treatment of her husband's cancer was possible and what difference this would have made.

Putting it right

The Practice acknowledged and apologised for the failings we found. It paid Mrs C £1,500 for the impact of these failings. It also produced an action plan to show what it had learned from the complaint.