Radiotherapy treatment
19. Miss A says her mother’s treatment plan was risky and dangerous, given the severity of her condition and the size and scale of the tumour. She says the plan did not adequately account for her mother’s excessive swelling, and the possible risk of advancing her condition.
20. The NICE guidance covers management of glioblastoma. It recommends that for a patient such as Ms A, a short course of hypofractionated radiotherapy treatment should be considered. Hypofractionated radiotherapy provides a higher dose per fraction, but the total dose is lower.
21. Radiotherapy is measured in units called Gray (Gy). Each radiotherapy treatment is called a fraction.
22. The Trust prescribed a total dose of 30 Gy. The Trust planned to deliver six treatments (fractions), at a dose of 5 Gy per fraction. It planned two to three fractions per week, over an approximate two to three week period.
23. Our oncology adviser confirmed this hypofractionated radiotherapy treatment was in line with the NICE guidance.
24. We recognise Miss A’s concerns about the Trust’s treatment plan for her mother. However, we have seen no evidence of a failing in the Trust’s treatment plan for Ms A.
Consent
25. Miss A says her mother was not able to make an informed decision about treatment. She says information provided during the consultation did not fully explain the high likelihood of either excessive swelling, or advancing Ms A’s condition, given the high dosage of radiation therapy recommended.
26. The GMC guidance says doctors must work in partnership with patients and communicate effectively. This means doctors must give patients the information they want or need to know in a way they can understand.
27. The clinic letter following the appointment on 8 March says Ms A had discussed what the planned radiotherapy and treatment would involve, and the possible side effects. The consent form, signed by Ms A on the same day, explains the intended benefits, as well as the serious or frequently occurring risks.
28. The Trust listed these risks as: fatigue, reversible hair loss, skin redness/darkening/itching, ears blocked, headaches, nausea, vomiting, worsening of symptoms and the need to increase steroids. The Trust also supplied a leaflet ‘Radiotherapy to the brain’.
29. Ms A signed the consent form to confirm that she agreed to the procedure.
30. Our oncology adviser said the Trust appears to have explained the rationale for the treatment. The Trust also explained the common side effects, and the important but less common side effects.
31. We note Miss A’s views on the information shared with Ms A. We have not seen any failings in the information provided to Ms A. Our adviser particularly highlighted how the Trust had explained the important but uncommon side effects, in addition to the common side effects.
Deterioration
32. Miss A says staff did not act promptly when notified by family about her mother’s deteriorating condition following radiotherapy. She says this led to life-threatening treatment continuing without subsequent consultation or medical re-assessment.
33. There are no specific guidelines which set out how deterioration should be responded to. The GMC guidance says doctors must provide a good standard of practice and care. If they assess, diagnose, or treat patients, doctors must adequately assess the patient’s condition, and promptly provide or arrange suitable advice, investigations, or treatment where necessary.
34. We understand from the Trust that on 26 March, a Clinical Nurse Specialist (CNS) contacted the Consultant Oncologist by email. This was after Miss A had raised concerns about Ms A’s left leg weakness, and new incontinence. The Consultant Oncologist asked another CNS to contact Miss A the following morning.
35. We understand the CNS spoke to Miss A on 27 March about her concerns. The CNS suggested Ms A increase her steroids and contact her GP for local support. The CNS planned to follow-up with Miss A and confirmed this plan with the Consultant Oncologist.
36. We also understand the CNS spoke with Miss A on 29 March, when Ms A attended the Trust for a blood test. The CNS planned to refer Ms A to the community palliative care team, to review the effects of the steroids, and to provide another source of support.
37. Our oncology adviser said the only option for intervention here was to increase the dose of steroids. There were no other interventions which would have affected the outcome for Ms A.
38. We can understand how distressing Ms A’s deteriorating condition may have been for Miss A. However, we have seen no evidence of a failing here. The CNS and the Consultant Oncologist were in contact about Ms A’s deterioration. They gave advice about support and amended Ms A’s treatment by increasing the steroid dose.
Steroids
39. Miss A complained the Trust gave insufficient steroids from the time radiotherapy treatment started on 23 March, and during her mother’s admission from 29 March 2018, to counter the effects of the swelling.
40. The GMC guidance says doctors must provide a good standard of practice and care. Doctors must prescribe drugs or treatment only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs. Doctors must provide effective treatments based on the best available evidence.
41. The Frontiers in Oncology article explains there are no standardised guidelines for the timing, dose, or duration of steroids. More than half of patients require an increase in steroid dose during radiotherapy to reduce intracranial pressure (ICP – the pressure exerted inside the skull on the brain tissue). Generally, steroids should be used at the smallest effective dose and for the shortest period. The use of steroids should be limited to symptomatic patients.
42. Our oncology adviser said that while Ms A was an outpatient, she was on the lowest dose which managed her symptoms. While Ms A was an outpatient, The Trust increased the dose. This was because the earlier dose had not been managing the symptoms.
43. Once Ms A was admitted to the Trust as an inpatient, the steroid dose was increased again. Our oncology adviser said this was because Ms A had worsening and new symptoms.
44. We have seen no evidence of a failing here. The Trust prescribed the lowest dose of steroid medication that managed Ms A’s symptoms. We can see that when it was clear that the steroids were not managing Ms A’s symptoms, the Trust increased the dose.
Emergency Department
45. Miss A says ED staff were slow and dismissive when Ms A presented in March 2018. She says this meant Ms A was not attended to fully until she had seizures and had to be sedated.
46. In the Trust’s response to the complaint, it referred to two standards relating to the timings of when Ms A should have been seen:
‘…the time intervals within which Ms A should have been seen.
1. Patients brought to the ED by ambulance essentially should have an initial assessment within 15 minutes.
2. Patients should be seen by a doctor (or other clinician) able to make a plan for the patient's care within 60 minutes of arrival, sooner if clinically indicated…’
47. Ms A was not initially seen as an ED patient. This was because she was brought to the ED with a suspected stroke, so was to be seen by the stroke team. Our A&E adviser said that because of this, the national targets of being triaged within 15 minutes and seen by a doctor within 60 minutes (which are measurements of an ED’s performance), would not strictly apply.
48. The GMC guidance says doctors must provide a good standard of practice and care. If they assess, diagnose, or treat patients, doctors must adequately assess the patient’s condition, and promptly provide or arrange suitable advice, investigations, or treatment where necessary.
49. The stroke guidance in place at the time said a CT scan should be undertaken ‘as soon as possible’. This has since been updated and under the current guidance, published in May 2019, the CT scan should now be done within an hour. We have included reference to this here as an indication of what ‘as soon as possible’ might mean.
50. An ED nurse triaged Ms A at 8.40pm, and the stroke team assessed her by around 9pm. The stroke team decided Ms A would not be a candidate for the administration of a clot-busting drug in patients with stroke (stroke thrombolysis). This was due to her known brain tumour.
51. The stroke team referred Ms A to the on-call medical team. Our A&E adviser said this would have avoided an unnecessary and potentially time-wasting assessment by an ED doctor, when it was clear Ms A would require admission under the care of the medical team. The stroke team also ordered a CT scan for Ms A following their assessment.
52. Ms A had presented with a known brain tumour, slurred speech, and not being able to walk. Our A&E adviser said a CT scan was needed before any treatment could be provided. This was because the Trust needed the scan to show whether the symptoms were due to bleeding, swelling, or potentially another cause.
53. Ms A had the CT scan by about 9.48pm, but it would have needed a radiologist to have reported on it before the Trust could take any action. Given Ms A was triaged at 8.40pm and the CT scan was completed at 9.48pm, it appears this would have been in line with the stroke guidance that was in place at the time.
54. The Trust said there was a delay before Ms A was seen by the medical team, and that this was due to a handover meeting taking place. It appears from the records that the seizure happened some time shortly after 10pm.
55. Our A&E adviser said that given these timings, there was realistically no opportunity to start any treatment in the short timeframe between the CT scan being completed and the seizure occurring.
56. We have seen no evidence of failings in the care and treatment provided while Ms A was in the ED. While we can understand Miss A’s concerns about Ms A’s condition at that time, we cannot see that the Trust could have treated Ms A any sooner or prevented the seizure.
57. It appears the Trust acted in line with the GMC guidance. The stroke team was not able to treat Ms A, because of her brain tumour. They did however promptly arrange a necessary CT scan, which the Trust needed before it could provide any treatment.
58. We acknowledge the Trust has said there was a delay in the medical team seeing Ms A. However, as set out above, the Trust had arranged and undertaken a necessary CT scan during this time. We therefore cannot see there was any impact of this on Ms A.