New Public Interest report issued today finds that a cancer patient would have likely survived longer, had an earlier urgent referral been made by the patient’s GP practice.

The Complaint

We launched an investigation after Ms D complained about the care and treatment provided to her grandmother, Mrs F.

Ms D said that the symptoms of her grandmother’s bladder cancer were repeatedly misdiagnosed and mistreated as UTIs by Mrs F’s GP Practice in the area of Aneurin Bevan University Health Board. She also said that the time taken to refer her grandmother, and the missed opportunities to make a correct diagnosis, led to her grandmother’s death.

 

Our Investigation

Our investigation considered whether the Practice failed to take appropriate action which would have resulted in an earlier diagnosis of Mrs F’s bladder cancer.

Our investigation found that Mrs F’s symptoms should have resulted in an urgent suspected cancer referral in July 2021.

However, despite ongoing symptoms and multiple opportunities, Mrs F was only referred by the Practice for further investigation in May 2022.

We decided that 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.

Whilst I accept that it can be difficult for GPs to consider multiple issues within the constraints of a single appointment slot, if issues cannot be sufficiently addressed then a follow-up appointment should be arranged.”

Public Services Ombudsman for Wales, Michelle Morris.

Our Recommendations

We recommended that the Practice should apologise to Ms D, identify any learning points from the case, and provide relevant training to clinicians.

As a result of the complaint, the Practice said that it would make changes to the way it follows up patients with UTIs. It would set up an alert system for the follow-up of patients with persistent blood in their urine, especially as a single finding. We recommended that the Practice provides confirmation to our office that the new alert system is in use.

The Practice has accepted our findings and conclusions and has agreed to implement these recommendations.

Read the full report: