Summary: Ms A complains about a Council, Care Home and an Integrated Care Board regarding a referral for her sister, Dr B’s suspected cancer. Ms A says a delayed referral led to delayed treatment for her sister and she subsequently died. We found fault in communication and complaint handling leading to uncertainty for Ms A. The Care Home has agreed to our recommendations to carry out actions to address this uncertainty.

The complaint

1. Ms A complained about the delay in Bridge Side Lodge Care Home (the Home) referring her sister, Dr B, to her GP for a possible cancer diagnosis in 2022. Dr B’s stay at the Home was funded by London Borough of Hackney Council (the Council) and North East London Integrated Care Board (the ICB).
2. Ms A said her sister first showed signs of bleeding in January 2022, then March 2022 but the Care Home did not make a referral to her GP until May 2022, despite it being in the records that the GP should be consulted if it happened more than once.
3. Ms A also said as Lasting Power of Attorney for Health for her sister, she should have been informed by the Home of these health concerns.
4. Ms A felt this led to a crucial delay in her sister’s treatment and she was only suitable for palliative care by the time she was diagnosed.
5. Ms A would like an explanation and for acknowledgement of mistakes, apologies and service improvements.

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The Ombudsmen’s role and powers

6. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
7. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
8. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
9. When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened.
10. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(1), as amended)

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How I considered this complaint

11. I considered evidence provided by the Home and Ms A as well as relevant law, policy and guidance.
12. Ms A and the organisations had an opportunity to comment on my draft decision before I made this final decision.

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What I found

Background

13. Dr B was resident in the Home with dementia and its related health issues in 2022. She was diagnosed with cancer in June 2022 and died in 2023.
14. Ms A said Home staff found blood in her sister’s incontinence pad in January 2022 and consulted with the GP who told them to let them know if there was a recurrence.
15. Ms A said staff found more blood in March 2022 but did not inform the GP until it happened again in May 2022. The GP then placed Dr B on the two-week cancer pathway and her cancer was diagnosed in June.
16. Ms A felt she should have been informed about these bleeding episodes and that there was a crucial delay in diagnosis caused by staff not informing the GP, which led to her sister’s death.
17. The Home outlined the events saying in January 2022 staff noticed blood in the pad and consulted the GP who told them to monitor the situation and contact them again if there was a recurrence.
18. Then it said in March 2022 the staff noticed watery blood in the pad but did not consult the GP, deciding instead to monitor the situation.
19. The Home said in April staff noticed more blood and notified the GP the next day but the Home had no record of what the GP’s instructions were.
20. Then in May the Home said that Ms A had noticed blood in her sister’s pad on two occasions and a nurse at the Home spoke to the GP who said to save the pads for review the following week.
21. The Home said the GP reviewed Dr B the following week who made a two-week referral for suspected cancer.
22. The Home said it recognised there was a missed opportunity after the March episode, when team members did not consult the GP after a second occurrence of bleeding. The Home said it was watery blood and staff might not have thought it was the same as the January episode.
23. However, the Home said it should have informed the GP in March.
24. The Home went on to say the clinical pathway for post menopausal bleeding requires:

• primary monitoring,
• swab; and
• review before the cancer pathway can be activated.

25. The Home went on to say staff members relied on the GP and other professionals to initiate each step and could not influence what speed a GP makes referrals or orders tests.
26. The Home said in future it would monitor the standard of its documentation and its daily flash meetings discuss any medical referrals and follow-ups. Also, the Home said it was in the process of implementation of weekly clinical meetings. During these meetings it will review all outstanding actions and ensure any emerging clinical concerns are escalated without delay.

Analysis

27. The Home’s daily care records, which it supplied to us, make mention of the January, March and April episodes of bleeding.
28. Both the January and March episodes are in the GP’s records. In the January note the GP states that staff found blood in the incontinence pad and the GP told staff to monitor and inform them if it happened again.
29. The GP’s records state that in March the Home informed them of bleeding. This contradicts the Home’s response. It would be an unlikely coincidence that the GP records would have this episode documented on this date without any input from the Home, especially when the Home had recorded a bleeding episode on this date. We can say on the balance of probabilities that the Home did inform the GP, and so the Home’s response is inaccurate on this March episode of bleeding.
30. In the March GP record, it states ‘not seen this before’. It is not clear if this is the GP retelling what care staff have told them or if the GP is saying they themselves have not seen it before in this patient.
31. Either way, the GP gave the same advice they did last time, to monitor and tell them if it happened again.
32. There is a record in the Home’s daily care notes of bleeding in April. It says that staff took a picture of the pad and would send it to the GP.
33. The GP record for this says that the Home informed them of vaginal discharge but it says, ‘no blood’. The GP organised a clinical swab to rule out a urinary tract infection and the swab came back as normal. So, there is confusion about whether the GP was informed about this instance of bleeding.
34. However, the GP notes show three occasions when the Home did inform the GP of bleeding - January, March and May.
35. The May episode in the GP notes states Ms A had seen blood in the pad twice.
36. The GP stated staff have not seen any bleeding themselves. This is not the case, and the GP had been informed twice of this.
37. The GP instructions were for family or carer to save the pad and take a picture and contact again if worried about new symptoms.
38. It seems the GP kept being under the impression that these were new symptoms. But the earlier instances are recorded in the GP notes. However do not know what action the GP would have taken if they had realised that the March occasion was the second episode of bleeding.
39. Regarding communication, there is a record in March of the Home informing Ms A of her sister’s bleeding. However, there is no record of the Home informing her about the April bleeding episode. Again, there is an entry in May which indicates that Ms A knew about that month’s bleeding episode.
40. The Home has told us while the notes indicate Ms A was informed of bleeding on at least some occasions, there is no consistent, auditable documentation showing that the outcomes of GP and MDT discussions (advice/decisions/next steps) were then shared back to her in a reliable and standardised way (for example: method, time, who spoke, summary provided, and agreed next steps). The Home accept this is not best practice and contributed to Ms A’s uncertainty.
41. We do not find fault with the Home regarding a lack of reporting of the bleeding to the GP. We do find that the Home’s communication with Ms A was at fault and that the Home’s complaint response was inaccurate. These have all led to uncertainty for Ms A on whether the outcome for her sister could have been different.

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Action

42. Due to the faults I have outlined and the uncertainty they have caused to Ms A, I make the following recommendations:
43. By 28 April 2026, the Home should:

• write to Ms A apologising for the uncertainty caused by its faults in communication and complaint response; and
• should provide evidence to Ms A of the improvements made with recording of communication and medical referrals since its complaint response.

44. The Home should provide us with evidence it has complied with the above actions.

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Decision

45. I found fault causing injustice to Ms A and made recommendations to address this injustice.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman