10. On 26 May 2015 Mr V contacted the Trust’s IBD (Irritable Bowel Disease) helpline. He complained of pain around the anal area with increased discharge. He said he found it difficult to sit for a long period of time. The Trust made an appointment for Mr A to see the consultant colorectal surgeon (the surgeon).
11. On 1 June 2015 Mr V saw the surgeon. The surgeon noted Mr V was getting increasing symptoms from his rectal stump. He noted Mr A had a throbbing discomfort and some mucus discharge. The surgeon was unable to perform a rectal examination due to rectal stricture (narrowing) which was uncomfortable for Mr V. The surgeon noted it might be worth performing an examination under anaesthetic, with dilation, to see if he could examine his rectum properly, or open the stricture up a little. He said beyond this they may have to think about a completion proctectomy.
12. On 17 June 2015 Mr V contacted the IBD helpline. He asked for pain relief while he was waiting for his examination under anaesthetic. The Trust prescribed pain relief gel. On 29 June he contacted the helpline again. He complained of a very sore rectal/anal area, and that the area was inflamed and felt like a hard boulder. The Trust arranged for him to see a colorectal registrar on 1 July. At that appointment, the registrar was unable to complete a rectal examination, and noted he had taken steps to try to expedite the examination under anaesthetic.
13. On 9 July 2015 Mr V attended the Trust’s emergency department complaining of pain and inflammation of his rectal stump. He said he had felt feverish and unwell for the previous two days. The Trust gave Mr V steroids and antibiotics and admitted him. On 13 July the Trust gastroenterologist (the gastroenterologist) saw Mr V. He noted it was too early to do the examination under anaesthetic because they would have to wait for the inflammation to settle. The Trust discharged Mr V the next day.
14. On 7 August 2015 the surgeon performed an examination under anaesthetic. The surgeon could not dilate Mr V’s rectum very much because there was a dense fibrous stricture. He noted Mr V’s rectum was too narrow to pass a proctoscope, rigid sigmoidoscope (instruments to visualise the rectum) or take a biopsy.
15. Paragraph 15 of the GMC guidance says doctors must:
‘provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
a) adequately assess the patient’s condition, taking account of their history […], their views and values; where necessary, examine the patient
b) promptly provide or arrange suitable advice, investigations or treatment where necessary
c) refer a patient to another practitioner when this serves the patient’s needs.’
16. Our surgery adviser said that up to this point the Trust acted in line with the GMC guidance. Following Mr V’s initial contact with the IBD helpline, the Trust arranged to see him within one week. When a rectal examination was not possible, the Trust acted in line with the GMC guidance by arranging a different suitable investigation - the examination under anaesthetic. At that point there was no suspicion of anything related to the rectal stump that would have required an urgent appointment. On that basis, our surgeon adviser said the ten-week period between the first appointment and the examination under anaesthetic was ‘prompt’ treatment, in that context. We also note the Trust tried to expedite the further examination, but it needed Mr V’s inflammation to settle.
17. Mrs V told us her husband had previously had unsuccessful attempts at rectal examinations because of his strictures. She therefore queried whether the Trust should have attempted the examination under anaesthetic at all this time. Our second surgery adviser said the difficulties with previous attempts did not necessarily mean an examination under anaesthetic would also be unsuccessful this time. The main purposes of the examination were to investigate Mr V’s symptoms and to provide him some relief from those symptoms. While we know now the attempt was unsuccessful, it was still appropriate for the Trust to try. The Trust acted in line with the GMC guidance. Up to this point our we find no failings in the Trust’s actions.
18. On 14 August 2015 Mr V saw the gastroenterologist. Mr V said he had reached a position where he wanted to consider a completion proctectomy. The gastroenterologist noted Mr V had gained little benefit from the dilation. There had been some reduction in his perianal pain, but Mr V still needed pain relief at night. In his clinic letter from that appointment, the gastroenterologist said Mr V ‘may well need an MRI pelvis beforehand and I will discuss this at the IBD [multi-disciplinary team meeting] next week’.
19. On 1 September 2015 the Trust discussed Mr A in its IBD multi-disciplinary team meeting. The gastroenterologist and the surgeon agreed with Mr V’s request for a completion proctectomy. The meeting said it would arrange for the surgeon to see Mr V in his clinic to make the necessary arrangements. There is no documented discussion of the potential MRI scan previously mentioned by the gastroenterologist.
20. The surgeon saw Mr V in clinic on 23 September 2015. He noted Mr and Mrs V were keen to get on with things because Mr V was suffering. The surgeon added Mr V to his surgery waiting list to have an operation at the first available opportunity.
21. On 6 January 2016 the surgeon performed Mr V’s completion proctectomy operation. While the operation was difficult, it appeared to be successful. The Trust discharged Mr V on 13 January. On 27 January, the Trust completed a biopsy of the tissue it had removed. The biopsy identified a cancerous tumour.
22. The GMC guidance is again relevant when looking at this period of care and treatment. In particular, that doctors should adequately assess a patient’s condition and provide suitable investigations. Our surgery adviser said Mr V was a high-risk patient because of his longstanding history of disease, his new and unexplained symptoms, and the inadequate results of the investigation under anaesthetic. Our surgery adviser said in those circumstances adequately assessing the patient’s condition should have included performing an MRI scan. Indeed, this is what the gastroenterologist noted in his 14 August 2015 clinic letter. But despite his comment that the IBD multi-disciplinary team would discuss the need for an MRI scan, there is no evidence that happened. There is no documented reason for not performing the MRI scan the gastroenterologist suggested. That being so, we find the Trust failed to act in line with GMC guidance when it did not perform an MRI scan in the autumn of 2015.
23. We have gone on to consider whether the failure to perform an MRI scan had any impact on the outcome for Mr V. Our consideration of that is to some extent hampered by the failing itself. The Trust did not perform an MRI scan and, as such, the evidence is limited as to what a scan would have shown had the Trust performed it.
24. Our radiology adviser explained the key relevant points in the RadioGraphics journal article. He explained MRI scans are the investigation of choice for staging rectal cancers. He said MRI scans are usually performed following endoscopic identification of a tumour, and a biopsy. Treatment can then be based on the MRI scan findings. He said in cases where endoscopy is inconclusive, as in Mr V’s case, an MRI scan can be used to identify a tumour if it has spread beyond the wall of the rectum.
25. Cancer staging is used to give more detail about a cancer. T1, T2, T3 and T4 refer to the size and/or extent of the tumour. The higher the number after the T, the larger the tumour or the more it has grown into nearby tissues. Our radiology adviser said T1 tumours can be difficult to identify with an MRI scan. He said in Mr V’s case an MRI scan may have been able to identify the tumour if it involved the wall of the rectum (T2), had spread into adjacent fat (T3), or had invaded a local structure. The histology report following Mr V’s surgery staged his tumour as T3.
26. That said, our radiology adviser commented it is impossible in hindsight to say whether an MRI scan would definitely have seen the tumour. But in view of the histology report he said an MRI scan would likely have seen a suspicious legion.
27. We asked our oncology adviser about whether Mr V’s treatment would have been different had an MRI scan identified Mr V’s tumour. Our oncology adviser said that if an MRI scan had identified what appeared to be a tumour, confirmation of the diagnosis by biopsy may not have been possible, given the previous failed attempt at an examination under anaesthetic.
28. Our oncology adviser said the multi-disciplinary team would therefore have had to assume a cancer diagnosis based on the radiology report. Our oncology adviser said that in this situation suitable treatment would be either radical surgery followed by radiotherapy, or pre-operative chemoradiotherapy followed by radical surgery. He said that in view of Mr V’s chronic Crohn’s disease, it is more likely a multi-disciplinary team would opt for surgery in the first instance.
29. Even though the Trust did not carry out an MRI scan, it did perform radical surgery followed by radiotherapy shortly after Mr V’s tumour was identified. We find, therefore, that the Trust’s failure to perform an MRI scan did not adversely affect the treatment provided to Mr V. The Trust did still provide treatment suitable for his cancer, even though it had not yet identified the tumour.
30. We finally considered whether the failure to perform an MRI scan caused any significant delay to Mr V’s treatment. The NHS Constitution set out a Government pledge of a maximum 31-day wait from cancer diagnosis to first definitive treatment. If the Trust’s 1 September 2015 multi-disciplinary team meeting had requested an MRI scan, that might reasonably have happened by early October. Had the multi-disciplinary team reviewed the scan by mid-October, and had that scan indeed identified Mr V’s tumour, that would have meant surgery by around mid-November.
31. The Trust performed Mr V’s surgery on 6 January 2016, approximately seven weeks later than the timescale set out above. We must also bear in mind that the above timeline is an estimate, and surgery in that scenario may have been slightly earlier or later. Our oncology adviser said an earlier diagnosis of Mr V’s cancer would not have made a difference to the treatment options available. Nor would it have made a difference to the outcome from his surgery, the later spread of his cancer, or his sad death.
32. We find the Trust’s failure to perform an MRI scan did not have an adverse impact on the outcomes for Mr V. We therefore partly uphold Mrs V’s complaint. We know Mrs V’s main purpose in bringing this complaint was to find out whether Mr V was given every chance at a better outcome. We hope that our report helps her and her daughter to achieve the closure she seeks and that it reassures her that her husband did receive the appropriate treatment. We are grateful to her for bringing her complaint to our attention.