The scene

A 47-year-old man went to see his GP after noticing bright red blood on the toilet paper when wiping his bottom. The GP asked about his symptoms, particularly whether he had experienced any recent change in bowel habit, pain or unexplained weight loss. None of these symptoms were reported although the patient was unsure of his weight. The GP examined him and found haemorrhoids. She also arranged a routine blood test and for the patient to be weighed.

The patient’s blood count was normal and his weight was 75 kilos, which was around the same as when he registered with the practice two years before. Satisfied the patient’s symptoms were consistent with a diagnosis of haemorrhoids, the GP reassured him there was no reason to suspect cancer and gave advice on how to alleviate the problem.

Aside from a telephone consultation nine months later about an unrelated matter, there was no contact from the patient for 18 months. When he returned, he complained that his stools had been loose and dark in colour for several weeks and his weight had fallen to 70kg. The GP arranged an urgent referral and the patient was later diagnosed with bowel cancer, which required rectal surgery and a colostomy.

The GP called the MDU after receiving an angry letter of complaint from the patient, through NHS England, criticising her for not referring him to a specialist at the first consultation and not asking about his bowel health during the telephone consultation. He accused the GP of allowing his cancer to develop and blamed her for him having to use a colostomy bag at only 48, which could have been avoided "if she had done her job".

MDU advice

The adviser explained the complaints procedure and the open response expected by NHS England. They suggested that it would be helpful to discuss the complaint as a significant event at the practice and to review and reflect on the relevant NICE guidelines on suspected colorectal cancer recognition and referral.

The guidelines recommend that GPs consider an urgent cancer pathway referral for adults aged under 50 who have rectal bleeding and any unexplained abdominal pain, change in bowel habits, weight loss or iron deficiency anaemia.

The practice concluded their colleague’s diagnosis was reasonable, as she had specifically asked the patient whether he had these other symptoms during the consultation and arranged a weight check and blood count. While the patient’s letter was upsetting, they understood that it was not unusual for a patient to respond with anger to a diagnosis of cancer.

With help from the MDU, the GP drafted a response that explained her actions while also highlighting that she had taken the concerns seriously. She acknowledged that while the telephone consultation was about a different matter, on reflection it offered a missed opportunity to follow up. However, with regards the referral she was able to reference the NICE guidelines.

The outcome

In line with the NHS complaints procedure, the response was sent to NHS England who were managing the complaint. They sought an opinion from one of their clinical advisers who was supportive of the GP’s actions. He noted that she had kept clear records of what had taken place during each interaction with the patient, including the steps she had taken to exclude anything more concerning and her relevant negative findings. This showed that she had followed the appropriate NICE guidelines.

The patient did not take his complaint further.

Delayed diagnosis of bowel cancer

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