Grandmother died after GP practice failed to refer her for cancer probe

Martin Shipton

A complaint has been upheld against a GP practice whose delay in referring a patient to hospital for an investigation of her symptoms probably resulted in her premature death from bladder cancer.

Michelle Morris, the Public Services Ombudsman for Wales, concluded that a presence of blood in Mrs F’s urine without infection should have resulted

in an urgent suspected cancer referral in July 2021.

There were a number of missed opportunities to make such a referral by the GP practice in the area of the Aneurin Bevan University Health Board, but it wasn’t made until May 2022.

‘Significant service failing’

In her report on the case, Ms Morris states:”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. While 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 [her granddaughter] Ms D and her family.”

The report sets out in detail Mrs F’s interaction with the GP practice. She presented at the practice on June 1 2021 with increased urinary frequency and some pain whilst urinating. A urine dipstick test (a test involving treated paper dipped in a sample of urine) showed white and red blood cells in her urine. A diagnosis of a urinary tract infection (UTI) was made, and Mrs F was prescribed nitrofurantoin (antibiotics used to treat UTIs).

On June 3 she contacted the practice as she still had blood in her urine. Mrs F was given a further prescription of nitrofurantoin.

On July 21 Mrs F presented at the practice with a cough and increased urination. There was no visible blood on the urine dipstick test conducted. However, a urine sample sent for laboratory testing showed traces of blood. There was no bacterial growth that would suggest an infection.

Mrs F presented at the practice on August 23 with urgency to pass urine and nocturia (frequent urination during the night) that she said had been ongoing for a year. She was prescribed mirabegron (medication used to treat the symptoms of an overactive bladder).

On January 4 2022 Mrs F provided a sample of urine for dipstick analysis that showed blood in her urine. The practice was not able to provide any information about why this test was conducted.

On March 7 she saw an advanced nurse practitioner (ANP) as she was experiencing irritation of the vulva. A urine dipstick test showed red blood cells and protein in Mrs F’s urine. She was prescribed cream for the inflammation.

On March 21 Mrs F was reviewed by a GP. It was noted that her vulva was less inflamed, and she was asked to be reviewed in four weeks. On April 26 she was reviewed by a GP. It was noted that her vulva appeared less inflamed. A urine sample was obtained and sent for laboratory testing. This showed no bacterial growth, but red blood cells were noted. Mrs F was prescribed antibiotics for a UTI.

On May 19 she contacted the surgery with urinary symptoms and was advised to send a urine sample. A dipstick test showed blood in her urine.On May 20 Mrs F attended an appointment with an ANP, who referred her urgently to the Urology Department for further investigation because of her ongoing urinary symptoms. The referral was sent on May 23 and an appointment was made for Mrs F on June 17.

On 10 June Mrs F contacted the practice with recurrence of her urinary symptoms. She informed the GP of the planned outpatient appointment with the Urology Department on June 17 and the GP offered her an admission to hospital or a course of antibiotics until she was seen by the specialist. Mrs F chose to be prescribed antibiotics.

Out of Hours GP Service

On June 12 she contacted the Out of Hours GP Service reporting that she had had problems passing urine and passing blood when urinating for weeks. She was examined and it was noted that her urethra (a tube connected to the bladder for passing urine) was swollen and reddened.

Mrs F was advised to see her GP about a gynaecology appointment and to keep taking the antibiotics she had been prescribed.

On June 13 she attended the Emergency Department at a local hospital with blood in her urine, backache, and vomiting. It was noted that she had been experiencing difficulty passing urine, haematuria and lower back pain for more than a month. The following day Mrs F underwent a computerised tomography scan (CT scan – a scan that takes detailed pictures inside the body) that showed an irregular bladder lesion. She was advised by the on-call urologist to attend the outpatient appointment on June 17 arranged as a result of the GP referral and was discharged from hospital on June 16.

On June 17 Mrs F attended the outpatient appointment. It was noted that she had visible haematuria and clots when she passed urine that she said had occurred for several months. Mrs F underwent a flexible cystoscopy (an examination of the bladder using a flexible telescope) that showed lesions at the base of her bladder, which were recognised as possible bladder cancer.

On July 5 she underwent a Trans Urethral Removal of Bladder Tumour (“TURBT” – an operation to remove early bladder cancer).

Grade 3 bladder cancer 

Later that month, on July 20, Mrs F was diagnosed with grade 3 bladder cancer (indicating the cancer had started to spread).

On September 5 Mrs F underwent a second TURBT procedure to remove more of the bladder tumour. A study of the tissue removed during the procedure confirmed a grade 3 tumour and suspected muscle invasive disease.

On October 18 Mrs F was admitted to hospital with a history of haematuria, dysuria and loin pain. A suspicion that the tumour was muscle invasive was noted. She was discharged on October 23.

On November 2 Mrs F was admitted to hospital with dysuria and clots in the urine. She was discharged from hospital on 7 November.

26. On 15 November Mrs F underwent a radical cystectomy with ileal conduit (a process to remove the entire bladder and create a urinary diversion) as she was still experiencing urinary frequency, urgency and dysuria. She was referred for adjuvant cancer treatment (additional cancer treatment given after the primary treatment to lower the risk that the cancer will return).

On January 15 2023 she underwent a CT scan that showed that the cancer had spread to her lung. An X-ray on February 1 showed the cancer had further spread to her bones. She began receiving palliative care in February and sadly died on April 29.

Misdiagnosed

Ms D said she believed that the symptoms of her grandmother’s bladder cancer were repeatedly misdiagnosed and mistreated as UTIs by the practice. Ms D believed that the time taken to refer her grandmother, and the misdiagnoses made, led to her grandmother’s death.

Ms D wanted the practice to acknowledge and take accountability of its failings.

The practice said that it had reflected on the care provided to Mrs F. It said it had written a significant event analysis and presented the case at its regular practice meeting. It said that recurrent UTIs are very common in the elderly. It said that during Mrs F’s presentation at the practice she had symptoms suggestive of UTI, hence it was concluded this was the most likely diagnosis and she was treated with antibiotics when required.

The practice highlighted that, in some instances, symptoms can be due to different causes and an early diagnosis of cancer can be difficult to establish.

As a result of the complaint, the practice said 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.

The GP adviser to the Ombudsman noted that there were multiple interactions between Mrs F and the practice between June 2021 and June 2022, with the majority of consultations focusing on her urinary symptoms and concerns. Overall, the adviser considered that there were multiple missed opportunities to investigate Mrs F’s symptoms and to refer her at an earlier stage, in line with NICE (National Institute for Health and Care Excellence) guidelines. The GP adviser’s opinion was that Mrs F’s symptoms were not reviewed from a bigger picture perspective and that the focus remained incorrectly on assumptions of recurrent UTIs, despite both urine dipstick tests and laboratory tested samples repeatedly demonstrating no infection was present.

The Ombudsman recommended that the GP practice should ensure that measures were in place to stop such failings happening again. She said she was pleased to note that the practice had already made changes to the way it follows up patients with recurrent urinary tract symptoms.