Radiotherapy treatment
24. Mrs O complains the Trust provided radiotherapy treatment to Mr O in February 2020 which caused him to become paralysed from the waist down. Mrs O complains the Trust did not advise that paralysis was a risk of radiotherapy.
25. We understand why Mrs O is so concerned about her husband’s paralysis so soon after the radiotherapy treatment.
26. The NICE guideline CG75 provides advice to clinicians for the treatment of painful spinal metastases (cancer that has travelled to the spine from another area in the body). It also provides advice for the prevention of metastatic spinal cord compression (MSCC). MSCC is a well-known complication of cancer which happens when a cancerous tumour damages or presses on the nerves in the spine.
27. The guidance explains that doctors should offer palliative radiotherapy to patients with spinal metastases that cause non-mechanical spinal pain. It also says to urgently consider patients for surgery to stabilise the spine and prevent MSCC if they have spinal metastases and evidence of spinal failure and instability.
28. An ambulance took Mr O to hospital on 11 February following a fall at home. A doctor reviewed him and suspected he may be suffering from MSCC. They arranged for him to have an MRI scan on 12 February to check for this.
29. The MRI scan showed Mr O had a compression fracture to his T10 vertebra and that the cancer had spread to multiple other areas of the spine. While the scan does not appear to have shown MSCC at that point, the radiotherapist noted ‘impending cord compression’. They recommended the treating team urgently refer Mr O to Hospital B for consideration for surgery.
30. In line with the NICE guideline CG75, the Trust transferred Mr O to Hospital B on 18 February. An orthopaedic surgeon reviewed him and gave him two options. The first was to have surgery to stabilise his spine but they explained such surgery would be risky. The second was to have radiotherapy treatment to improve his symptoms. Mr O chose to proceed with radiotherapy.
31. Hospital B transferred Mr O back to the Trust where he had radiotherapy treatment between 25 and 29 February.
32. We have found the decision to provide radiotherapy treatment was in line with the NICE guideline, CG75. This is because the guidance is clear that the treating team should offer radiotherapy to patients where cancer has spread to the spine, and who are in pain. This is with the intention of improving symptoms and preventing MSCC. We have not identified any failings in the decision to provide radiotherapy.
33. Mrs O is also concerned the Trust did not advise her, or Mr O, that paralysis was a risk of the radiotherapy. Again, we understand why this is of such concern to Mrs O.
34. The NICE guideline CG75 says patients should have the opportunity to make informed decisions about their care and treatment. It also says the intended benefits and risks should be discussed with the patient before agreeing a treatment plan.
35. We can see that before the procedure Mr O signed a consent form. This explained the Trust were providing the radiotherapy to help reduce Mr O’s pain and to prevent ‘neurological deterioration’. We understand that by this, the Trust were referring to the prevention of MSCC. The consent form went on to explain that the risks of the radiotherapy were ‘fatigue, pain, and skin redness’.
36. Our adviser explained the radiotherapist who completed the consent form noted the common side effects of this treatment. Our adviser explained paralysis is not a known risk of radiotherapy and so it is not a side effect which the radiotherapist needed to mention.
37. Taking this advice into account, we have no concerns about the level of information provided to Mr O prior to the treatment. The radiotherapist gave appropriate information to Mr O about the benefits, and side effects, to allow him to provide informed consent.
38. Our adviser explained that Mr O’s disease caused his paralysis and not the radiotherapy. We hope this information provides some reassurance to Mrs O.
Visit from radiotherapist
39. Mrs O also complains no one from the radiotherapy department went to see Mr O following the treatment to explain what happened, or to offer support.
40. The GMC guidance says doctors must communicate effectively. It says doctors should: · listen to patients, take account of their views, and respond honestly to their questions · give patients the information they want or need to know in a way they can understand · be considerate to those close to the patient and be sensitive and responsive in giving them information and support · be readily accessible to patients and colleagues seeking information, advice, or support.
41. We can see Mr O had multiple visits from members of the multidisciplinary team following his radiotherapy treatment. This included oncology doctors, clinical nurse specialists, dietitians, surgical doctors, palliative care doctors, physiotherapists, and occupational therapists. Our adviser said Mr O had significant support to answer any questions or concerns he had about his paralysis.
42. Our adviser said the radiotherapist did not need to visit Mr O following the treatment as the radiotherapy did not cause the paralysis. They explained the disease was causing these symptoms and so Mr O could discuss this with the attending oncologists.
43. Mrs O disputes that oncology doctors visited her husband following the radiotherapy. However, the medical records show that oncology visited Mr O on 2 and 9 March. The notes from these reviews contain a sufficient level of detail to persuade us these visits occurred.
44. We can see from the records that on 8 March, Mrs O raised a concern with a junior doctor. The doctor noted she was upset as no one at the Trust had informed her or Mr O that paralysis may be a risk of radiotherapy. She also said she was upset no one from oncology had been to see Mr O.
45. We can see the doctor advised Mrs O she could raise any concerns about care with the Patient Advice and Liaison Service. They also arranged for oncology to review Mr O the following day. It is not clear if Mrs O was present during this review. However, we cannot see that Mr O raised any concerns with the oncologist about his paralysis, or about it being potentially caused by the radiotherapy.
46. Considering all the evidence, we do not consider it was a failing that the radiotherapist did not visit Mr O following the treatment. This is because it appears Mr O had access to support regarding his paralysis, in line with GMC guidance.
Emotional support
47. Mrs O complains there was a total lack of emotional support during Mr O’s admission in March and April 2020, and the Trust showed no recognition of how Mr and Mrs O were feeling.
48. The NICE supportive palliative care guidance says, ‘supportive and palliative care services should be delivered as much as possible, where patients and carers want them – in the community, in hospital or in a hospice’.
49. We can see that following readmission to hospital on 21 February, the clinical team made a referral to the Supportive Palliative Care Team on 5 March. A specialist nurse reviewed Mr O the following day and completed an assessment.
50. The specialist nurse did not feel Mr O required ongoing specialist review and so they discharged him from the service. However, they noted Mr O consented to ongoing support in the community after discharge.
51. It appears it then took longer than initially anticipated for the Trust to discharge Mr O. As such, he remained in hospital, meaning Mr and Mrs O were not receiving support from the Supportive Palliative Care Team.
52. The Trust has acknowledged that discharging Mr O from the Supportive Palliative Care Team at that point likely contributed to his and Mrs O’s feelings of abandonment. It said that, regrettably, the clinical team did not make a further referral for supportive palliative care until 5 April.
53. The Trust said the Supportive Palliative Care Team would have been happy to continue to support Mr and Mrs O if needed during that difficult time. It said that on reflection this information could have been communicated better.
54. Taking this into account, we consider there was a failing in the support offered to Mr and Mrs O between 5 March and 5 April as this was not in line with the NICE supportive palliative care guidance.
55. We can see that this left Mr O without full support for an entire month while he was an inpatient. We can see that the lack of support at this time would have added to Mrs O’s distress.
56. The Trust has already acknowledged its error and apologised for the distress this caused. However, we have made some additional recommendations to the Trust to put this right for Mrs O and to help prevent this same mistake happening again.
Investigation of symptoms
57. Mrs O complains there was a lack of support or investigation into Mr O’s symptoms. This includes his complaints of excessive mucus and difficulty eating in October 2019, and his complaints of back pain between November 2019 and January 2020. Mrs O also says the Trust did not take any action after his CT scan in January 2020 showed an issue with his T10 vertebra.
Excessive mucus and difficulty eating
58. The NICE guideline for oesophageal cancer says to offer stents to people who need immediate relief from dysphagia (difficulty swallowing). It says this should be dependent on the degree of dysphagia and its impact on nutrition and quality of life, performance status, and prognosis. The guidance says a stent can help assist with swallowing in patients that are unsuitable for curative treatment.
59. The Trust explained that prior to organising the stent, it weighed the potential risks of going ahead with this treatment, which included bleeding and perforation of the oesophagus and stent migration (where the stent slips down below the tumour).
60. The Trust was concerned Mr O was particularly at risk of stent migration, which can occur when the tumour shrinks. The Trust said it had hoped the chemotherapy would shrink the tumour to allow Mr O to swallow more comfortably, and therefore avoid the risk of stenting.
61. It appears the Trust considered the risks and benefits of the stent and decided to go ahead with this once it was clear chemotherapy had not been successful in improving Mr O’s swallowing. The Trust organised a stent for Mr O in November 2019, in line with the NICE guidelines for oesophageal cancer. We can see at the follow up appointment in the oncology clinic, on 22 November 2019, the consultant oncologist noted Mr O’s eating had improved following the stent.
62. We have also reviewed the October 2019 clinical letters from Mr O’s appointments with his oncologist. We cannot see any documented evidence that Mr O raised a complaint about excessive mucus with his oncologist. This conflicts with what Mrs O tells us, as she is certain Mr O raised this during his oncology appointments. She is concerned this meant Mr O was eating less and less.
63. Given the conflicting accounts, it is difficult for us to comment on exactly what was said, and whether Mr O specifically raised concerns about excessive mucus. We accept this may have been raised but not documented.
64. Either way, we consider the evidence suggests the Trust took appropriate action, in line with the NICE guidance, to address Mr O’s eating problems. The documentation shows the stent improved Mr O’s oral intake. He was also under the care of the nutrition and dietic service to help prevent further weight loss and improve his overall intake. We have therefore identified no failings in this area of the complaint.
Back pain
65. Mrs O complains the Trust took no action regarding Mr O’s complaints of back pain between November 2019 and January 2020. We were very sorry to hear that Mr O was suffering from back pain during this period.
66. The GMC guidance says doctor should:
· adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social, and cultural factors), their views and values and examine the patient where necessary · promptly provide or arrange suitable advice, investigations, or treatment where necessary.
67. The medical records show Mr O first mentioned back pain to a specialist registrar in oncology on 17 December 2019. Mr O said he had recently pulled a muscle in his side, which he believed was causing the pain. The registrar documented the pain sounded muscular and clearly did not think it required investigation at that point.
68. Mr O advised the consultant he was managing the pain with paracetamol and ibuprofen. The consultant discussed the possibility of starting codeine with Mr O, but he declined it stating he would prefer to carry on with his ibuprofen and paracetamol for the time being.
69. Mrs O told us she does not recall the registrar suggesting codeine to Mr O. She only remembers the registrar advising to take paracetamol and ibuprofen. However, we note that over two years has passed since this appointment occurred, whereas the registrar’s note is from the time of these events. We have seen no strong evidence to cause us to doubt that the registrar suggested codeine.
70. Mr O then saw a different registrar on 6 January 2020. There is no documented evidence he mentioned back pain to the registrar at this appointment. We acknowledge Mr O may still have been experiencing back pain at this point, but there is no documented evidence he raised this.
71. We have found the registrars acted in line with GMC guidance. At the first appointment, the registrar assessed the condition as being muscular, suggested appropriate pain-relieving treatment, and took account of Mr O’s views when he declined this treatment. At the following appointment, there is no evidence Mr O raised the issue again and so the GMC guidance would not require the registrar to take any further action.
CT scan January 2020
72. Mrs O also says the Trust did not take any action in relation to a CT scan in January 2020, which showed an issue with his T10 vertebra.
73. At the appointment on 6 January, the specialist registrar who saw Mr O requested a repeat CT scan to check if his condition was stable.
74. A radiologist performed the scan on 26 January and reported issues with two of Mr O’s vertebrae, which indicated the cancer had spread. Following the CT scan, Mr O had a follow up appointment with his consultant oncologist. The oncologist noted his disease was stable. However, they did not comment on the issue raised by the radiologist regarding the vertebrae.
75. Our adviser said the consultant should have requested an MRI scan of the spine when reviewing the result of the CT scan. This would have been to investigate the new findings and would have been in line with GMC guidance which says to arrange ‘suitable investigations where necessary’. We consider not acting on this new finding, when reviewing the scan, was a failing.
76. Mr O’s GP also wrote to the consultant on 4 February asking if any further action was needed regarding the findings of the MRI scan and explaining that Mr O had ongoing back pain.
77. However, it seems that before the consultant had time to respond to the GP, Mr O sustained a fall at home and went to Hospital A on 11 February. He then had an emergency MRI scan in hospital on 12 February which confirmed the cancer had spread to the spine. This subsequently led to Mr O receiving radiotherapy treatment.
78. We considered the impact of the consultant not arranging the MRI scan on 27 January. Our adviser explained that even if the consultant had ordered the MRI scan at the appointment, it would have been as a routine request rather than an emergency scan like the one which took place on 12 February.
79. As such, it is unlikely the MRI scan would have occurred any sooner than the emergency scan on 12 February. We therefore cannot see that this failing led to any delay in Mr O receiving further investigations or treatment.
Discharge from Hospital A in April 2020
80. Mrs O complains that on 9 April, Mr O was inappropriately discharged home in a bad state without any oxygen, only to be readmitted the following day. She tells us her husband was coughing badly, breathless, and confused. Mrs O has told us how distressing this was to both her and Mr O.
81. The DoH guidance says, ‘estimated date of discharge is based on the expected time required for tests and interventions to be completed, the integrated care pathway, and the time it is likely to take for the patient to be clinically stable and fit for discharge’. This means that patients should first be clinically stable enough for discharge to go ahead.
82. The medical records show that on the day of discharge a doctor reviewed Mr O. They noted his observations were normal and his respiratory rate was 20 which our adviser said does not indicate breathlessness. They also noted his oxygen saturation levels were 99%.
83. Mrs O tells us she does not recall her husband’s saturation levels ever being as high as 99 percent. However, both the notes from the medical doctor who reviewed Mr O and the nursing records from around the same time also say his saturation levels were 99%. As such, we are satisfied there is sufficient evidence to support this.
84. Based on the information in the medical records, our adviser said Mr O appears to have been clinically stable enough for the Trust to discharge him and he would not have required oxygen. Our adviser said Mr O’s heart rate was a little bit high, but for a patient who is very sick, this is normal and everything else was stable.
85. Taking into account this advice, and the evidence we have seen in the medical records, we have found the discharge was in line with the DoH guidance.
86. We were very sorry to hear that Mr O was readmitted a short time after and we understand how distressing this must have been. Our adviser explained that discharges are complex, and that the clinical situation often changes following a change of environment. We hope this information provides reassurance to Mrs O that the discharge was appropriate at the time.