On 29th October 2014 commenced an investigation into the death of Robert Watt; aged
75. The investigation concluded at the end of the inquest on 17th April 2015. The conclusion of the inquest was that Robert Watt died of Ia. Carcinomatosis 1b. Carcinoma bladder 2. Carcinoma Prostate at Wisdom Hospice on 25"h October 2014 from a bladder cancer which at the time of diagnosis was too advanced to treat The conclusion was that he died of natural causes_

Robert Watt had a PMH which included chronic kidney disease and prostate cancer. He was under the care of the renal unit at Kent and Canterbury Hospital and the urology unit at Medway Maritime Hospital. In November 2013 he was discharged back to primary care as his prostate cancer was stable. In 2014 Mr: Watt was referred by his GP through the rapid access protocol to a haematuria clinic run by Medway NHS Foundation He was to undergo a cystoscopy which did not go ahead. A letter the clinic to his GP indicates that the reason for this was that Mr Watt had been in contact requesting to be removed from the waiting list His wife has no recollection of this having happened nor did they receive a copy of the letter. An investigation revealed that these matters being dealt with by admin staff, the importance of attending the clinic would not have been discussed with Mr: Watt Although the fact of non-attendance was recorded electronically, a copy of the letter was not placed with Mr. Watt's medical notes, thus when he subsequently attended a urology review; the registrar was not aware of the non-attendance. Had he been aware, the haematuria would have been investigated and on the balance of probabilities he would not have died when he did. On September 2014 Mr: Watt was admitted to Medway Maritime Hospital with weight loss and rectal bleeding: He remained an inpatient for 8 days. During that time although malignancy was suspected the limited investigations that took place did not reveal the cause of his symptoms_ A CT with contrast was not carried out as a renal specialist had advised against it given poor kidney function, but a CT without contrast was not undertaken which the consultant accepted should have been: A urologist was consulted because of haematuria but this was left to a FY1 doctor: An on-call urologist was not asked to review Mr: Watt who was discharged on September 2014 without a diagnosis for further investigations to be carried out as an outpatient It was accepted by the consultant urologist that matters should not have progressed in this way The fact that Mr Watt had ahigh grade advanced bladder cancer was diagnosed by CT following an admission on 26" September 2014 to Kent and Canterbury Hospital when Mr Watts wife sought an alternative opinion. Although Mr: Watt underwent a TURB the cancer was incurable and he died on October 2014 May Trust from 14"h 22nd 25"

In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action: