Milton Keynes University Hospital NHS Foundation Trust

9. Miss H complains the Trust delayed providing radiotherapy for prostate cancer to her father, Mr H.

10. Specifically, she says he should have received radiotherapy treatment during 2019, as originally planned. She also believes her father’s age should not have been a factor in refusing him radiotherapy.

11. She believes if the delays had not happened then her father would not have received news on October 2019, that radiotherapy treatment was no longer an option for him.

12. She believes the shock of this news caused her father’s blood pressure to rise which she says led to the aortic dissection (where the inner layer of the aorta tears and blood passes through this tear causing the layers of the aorta to separate) from which he died.

13. Miss H says her father’s unexpected death has caused her distress.

14. In bringing the complaint to us, Miss H seeks an acknowledgement of the delays and an apology. She also wants to see service changes, including a change in procedures, so age is not a factor doctors use to decide if treatment is appropriate if a patient is otherwise fit and well.

15. The following is a brief background. It does not include all the events, only events relevant to the scope of our investigation and essential to understanding our decision.

16. Mr H was known to have an abdominal aortic aneurysm (AAA), which is a bulge or swelling in the main blood vessel that runs from the heart down through the chest and stomach. Vascular (blood vessel) specialists were monitoring this condition.

17. In April 2018 doctors diagnosed Mr H with prostate cancer and referred him to oncology (cancer specialists).

18. He began androgen deprivation therapy (ADT), a type of hormone therapy, in May 2018 and was due to have radiotherapy in August. In May 2018, consultant clinical oncologist, Dr A said treatment should be with the intention of curing his condition. The plan was ADT for two years, as well as radical radiotherapy (high dose radiotherapy which aims to destroy cancer cells).

19. Unfortunately, Mr H’s aneurysm progressed, which meant doctors delayed his radiotherapy treatment. Surgeons repaired the aneurysm in December 2018 and discharged Mr H from the vascular clinic in January 2019. It is the events after this point which are the subject of this complaint.

20. In January 2019, Dr A told Mr H he was safe to continue with the previously planned radiotherapy. He hoped to start this in February.

21. In March 2019 Dr A consented Mr H for radical radiotherapy. He noted Mr H remained well and had good prostate-specific antigen (PSA) response. PSA is a protein produced by cells of the prostate gland. They discussed the side effects of radiotherapy as well as the benefits.

22. Following this, Mr H could not travel to Oxford for treatment and the council would not fund transportation for him. Dr A asked for a consultation for Mr H with Dr B, a consultant clinical oncologist, with a view to him having radiotherapy at a private unit (funded by the Trust). Treatment at this unit is on a case by case basis for patients who cannot travel to Oxford.

23. The Trust explained to us that at that time Dr B had to review, consent, and treat the patients at that unit. This meant a further appointment was necessary.

24. In June 2019 Mr H had an appointment with Dr B who explained that at his age, with his other comorbidities (other conditions or diseases), radical radiotherapy was not a treatment option. The letter to the GP following that appointment says Dr B discussed the plan with Mr H. They planned to keep an eye on his PSA and review him in six months. They said that as and when his PSA started to rise, they would think about palliative radiotherapy, which is treatment to relieve symptoms.

25. In October 2017 Mr H attended an appointment with his daughter in the oncology clinic. Dr A discussed Dr B’s changed plan and why radiotherapy was not appropriate. Mr H was unhappy he would not receive radiotherapy. Dr A explained that Mr H’s PSA level had increased, which showed progression of his disease, but Dr A reassured him the hormone treatment would hold off his cancer.

26. At the appointment Mr H experienced chest pains and lost consciousness. Staff transferred him to the emergency department (ED). Sadly, Mr H died the same day.

27. The cause of death was a dissecting aortic aneurysm, which is where the inner layer of the aorta tears and blood passes through this tear causing the layers of the aorta to separate.

28. Miss H complained to the Trust about her father not receiving radiotherapy. She said she believed receiving that news led to her father’s sudden death.

29. The Trust responded to the complaint saying it offered Mr H radical treatment as it was felt he may live to the see the survival benefit. It said the surgery to repair the aneurysm delayed him starting radiotherapy. His PSA levels had then started to rise showing he had developed hormone resistant cancer. It said this change in his condition made radical treatment unfavourable.

33. Miss H’s complaint is about delays in the Trust starting her father’s radiotherapy during 2019.

34. We began by looking at when the Trust made the decision to offer radiotherapy.

35. Dr B initially offered radiotherapy to Mr H in May 2018. We have not considered if that decision was reasonable as it is outside the scope of our investigation, which is about the events of 2019.

36. Dr A made a further decision about treatment in January 2019, following Mr H’s surgery. It is this decision which forms part of our investigation as it affects what happens in the months after.

37. The records show in January 2019, Dr A found Mr H was suitable for radiotherapy, following the AAA repair. We have considered what should have happened at that time.

38. The EAU guidelines are national guidelines. They say life expectancy of 10 years is mandatory for there to be any benefit from radiotherapy.

39. At that time Mr H was 87 years old. Although it is difficult for doctors to predict how long a patient will live, Mr H was already beyond average life expectancy. He had also recently had surgery to repair the AAA, which compromised his life expectancy. A medical journal article says average survival following AAA repair is four years.

40. We can see Miss H does not believe her father’s age should have been taken into account. However, the guideline refers to life expectancy and age is a part of that. We acknowledge many people do live into their 90s. Considering Mr H’s age and his recent surgery, in our view it was more likely than not that he did not have a life expectancy of 10 more years.

41. In line with the EAU guidelines, the Trust should not have offered Mr H radiotherapy in January 2019. Doing so was a failing.

42. As this is new information to Miss H, who believes the Trust delayed her father’s treatment, we have provided some further explanation about the reasons why life expectancy is such an important factor.

43. Our adviser told us hormone therapy on its own would normally keep prostate cancer under control for many years. Most men with prostate cancer do not die from this. He said they would usually die from some other condition.

44. The side effects of radiotherapy are significant and can be greater in elderly patients. Having radiotherapy would mean experiencing two or three months of very bad quality of life from the side effects. Sadly, this would be for no benefit as it was unlikely to extend Mr H’s life.

45. We acknowledge Miss H says her father would have accepted the side effects of treatment and believes it should have been his decision. Whilst a patient can decide whether to accept an offered treatment, they cannot insist upon this if medical staff decide it is not right for them.

Impact of this failing

46. As outlined in paragraph 39, we found the Trust did not act in line with EAU guidelines.

47. Due to the failure, Mr H and Miss H believed for several months that Mr H would receive radiotherapy treatment.

48. If the failing had not happened, the Trust would have told him in January 2019 that radiotherapy was not an appropriate treatment option. Miss H says if this had happened, her father would have looked for alternatives such as clinical trials. We do not doubt this. However, we cannot say what emotional impact the news would have had on Mr H if he had received it in January 2019.

49. Miss H is concerned the shock of receiving the news in October 2019 caused her father’s sudden death.

50. We know Mr H saw Dr B in June 2019. At that time Dr B did not identify a mistake in the January decision to offer radiotherapy treatment but he revisited the care plan. The records show Dr B explained to Mr H that at his age and with his comorbidities, it was unlikely radiotherapy would extend his life.

51. This decision by Dr B corrected the earlier mistake to offer Mr H radiotherapy.

52. The records show Dr B outlined a plan for Mr H’s ongoing care and treatment. In comments to us, Miss H disagrees her father was told at this appointment that he would not receive radiotherapy. She says the first he knew was when he received the letter from Dr B.

53. This means that when Mr H saw Dr A in October 2019, Mr H had already been aware for several months he would not receive radiotherapy treatment.

54. Miss H told us she had never seen her father so deflated as he was at that appointment. We do not doubt he found the conversation on this date very difficult as he received news about the progression of his disease. We acknowledge how terribly distressing it was for Miss H when her father collapsed.

55. It is more likely than not that Mr H was aware in June, when told by Dr B, that he would not receive radiotherapy. Even if Mr H did not take this information in until he got the clinic letter, he knew about it well before his appointment in October 2019. This means it was not this news which caused his collapse on that day. As such the Trust’s failure did not lead to Mr H’s death. In reaching this view, we in no way suggest Miss H’s father’s sudden death was not incredibly sad or serious.

56. We have also looked at what impact the Trust’s failing had on Miss H.

57. The failure meant Miss H did not have the correct understanding from the outset about what should have happened with the treatment of her father’s condition.

58. It left her believing he could not be treated due to progression of his disease when there had been delays in arranging treatment. This meant that when her father died so suddenly, she believed things might have been different. This added to her distress at such a difficult time, when she was already grieving for her father who had died so unexpectedly.

59. We partly uphold this complaint.

1. We have investigated Miss H’s complaint about Milton Keynes University Hospital NHS Trust (the Trust) delaying radiotherapy treatment to her father for prostate cancer. Sadly, Mr H died from an unrelated condition before receiving radiotherapy. His sudden death was shocking for Miss H and caused her significant distress.

2. We partly uphold this complaint. This is because we found a failure in the Trust’s decision in January 2019 to offer radiotherapy treatment (treatment with radiation to kill cancer cells) to Mr H. This meant Mr H incorrectly believed for several months he would receive this treatment.

3. We found the failing meant there were a few months where Miss H believed her father would receive radiotherapy treatment, when that should never have been the case.

4. This meant that when her father died unexpectedly, she believed things might have been different. This added to her distress when she was already grieving for her father.

5. We have not found that hearing he would not receive treatment led to Mr H’s death on October 2019.

6. We did not find any failings in the Trust considering Mr H’s age, when deciding whether to offer radiotherapy.

7. We have made recommendations for the Trust to write to Miss H to acknowledge the failing and apologise for the impact upon her.

8. We have also asked the Trust to produce an action plan, setting out what action it will take to prevent a repeat of these events.

60. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

61. By 19 September, the Trust should write to Miss H to acknowledge it should not have offered radiotherapy treatment to her father in January 2019. It should apologise for the distress this caused to her when she was already grieving for her father. The Trust should send a copy of this letter to us.

62. Our Principles say that public organisations should seek continuous improvement and should use the lessons learnt from complaints to ensure they do not repeat maladministration or poor service. In line with this, we recommend that by 19 November, the Trust produces an action plan to set out:

· what action it will take to prevent the failing happening again

· who is responsible for the action

· the timeframe for completion.

63. The Trust should send a copy of the action plan to us and Miss H. It should also send an anonymised copy of the final report and action plan to NHS Improvement and the Care Quality Commission.