Milton Keynes University Hospital NHS Foundation Trust

3. Mrs A is complaining about her husband’s, Mr A, care at the Trust between April and September 2019. She complains the Trust failed to: • diagnose Mr A’s advanced bladder cancer between April and August 2019 • inform Mr A about the possibility of prostate cancer • inform him the scan on 8 May showed a blockage, not a possible cancer mass • inform Mr and Mrs A about the cancer diagnosis on 12 July, instead waiting until 6 August • confirm his bladder cancer was inoperable (they only found this out from another Trust on 20 August) • offer Mr A a hospital transfer and instead he had to attend a different hospital in Oxford as an outpatient. This included travelling to Oxford and staying at the hospital for 12 hours • inform Mrs A on 28 September blood clots are a common complication of abdominal cancer. She feels she should have been warned about the signs.

4. Mrs A also complains the Trust caused internal bleeding by inserting a nephrostomy (stent) going straight through Mr A’s kidney on 10 May and 24 May.

5. Mrs A believes if the Trust had diagnosed her husband sooner, this would have improved Mr A’s treatment and outcome. She believes they would have spent more quality time together and been more prepared. Mr and Mrs A had to travel to Oxford from their home, which she explained was exhausting. She also told us Mr A suffered significant internal bleeding from the Trust’s stent. She explained she suffered further distress as she did not know Mr A had a risk of blood clots forming, which resulted in his death.

6. By bringing her complaint to us Mrs A wants an apology, an explanation, and service improvements so the same thing does not happen to someone else.

7. Mr A was admitted as an emergency with renal (kidney) failure and urosepsis (type of sepsis that is caused by an infection in the urinary tract) on 10 April.

8. He had a CT scan of his kidneys on 15 April. A CT scan is several X-ray images and computer processing to create cross sectional images. The scan showed a possible small bleed in the right-hand side of his pelvis. The results were not conclusive of bladder cancer. At this point cancer had not been detected. Staff considered Mr A’s renal failure needed to be treated first.

9. On 8 May Mr A had an MRI to rule out advanced prostate cancer. An MRI provides precise details of soft tissues. The MRI indicated a suspicion of bladder cancer involving the prostate with the possible involvement of the lymph node in his groin. However, Mr A was unwell and not fit for any intervention under general anaesthetic to confirm the cancer diagnosis.

10. On 10 May Mr A had a nephrostomy (these are also known as stents) fitted to drain the urine straight from his kidneys. A nephrostomy is an opening that is made between the kidney and the skin. A thin, flexible tube (catheter) goes through the opening and into the kidney and drains into a bag outside of the body. Mr A’s right nephrostomy was successful but the left failed. Mrs A considers one of the drains being inserted incorrectly caused internal bleeding, which resulted in Mr A having a blood transfusion. Mr A’s kidneys remained unstable which delayed urgent investigations into the blockage to both kidneys. The Trust discharged Mr A to return for an MRI scan.

11. On 20 May Mr A was admitted with a dislodged left nephrostomy tube and fever. The Trust started him on antibiotics for suspected urosepsis.

12. The next day the Trust performed a flexible cystoscopy (procedure that uses a tube to examine the bladder and the urethra) on Mr A. The cystoscopy was not conclusive due to bleeding and cloudy urine. The cystoscopy showed he had an obstructed and enlarged prostate and his bladder was full of debris. It also noted a formation of lesions (this is any damage or abnormal change in the tissue) around the bladder neck.

13. On 23 May a CT scan showed Mr A had hydroureteronephrosis. This is a condition of excess urine accumulation in the kidneys that causes swelling. The following day the Trust fitted another nephrostomy. Unfortunately, he still had a high temperature and was not well enough for further investigation.

14. The Trust discharged Mr A on 29 May with plans for an outpatient cystoscopy.

15. On 12 July Mr A attended an outpatient appointment for a transurethral resection of bladder tumour (TURBT), this is an operation to get a biopsy from inside the bladder. The pathologist confirmed Mr A had cancer in a report dated 26 July.

16. The Trust had a multi-disciplinary team (MDT) meeting on 5 August to discuss the results of the report. The following day the Trust told Mr and Mrs A, he had advanced bladder cancer.

17. Mr A was admitted back into hospital with a large bowel obstruction. This occurs when a tumour, scar tissue, or something else blocks the large intestine. Gas and stool build up, and the intestine may rupture.

18. During this admission the Trust carried out CT scan staging. Staging tells the doctor how big a cancer is and whether it has spread. Knowing the stage helps the doctor decide which treatment the patient needs. The Trust sought input from the urology team, and it decided to investigate Mr A’s bladder tumour as an outpatient.

19. On 16 August Mr A had a colostomy procedure (this is opening to remove waste from the body).

20. On 28 September Mr A sadly died suddenly from a pulmonary embolism (blood clot in the lung).

Failed to diagnose Mr A’s advanced bladder cancer between April to August 2019.

24. We first looked at Mrs A’s complaint the Trust failed to diagnose Mr A’s advanced bladder cancer between April and August 2019. She believes the Trust could have diagnosed it sooner. The Trust disagrees and explains Mr A was not well enough to have earlier investigations.

25. Mr A was extremely unwell with renal failure when he first presented at the Trust in April. Our adviser explained it is standard practice to deal with a patient’s presenting problems first. This allows this condition to resolve before putting a patient through a general anaesthetic. The NHS constitution supports this which explains people have the right to receive care and treatment that is appropriate to them and based on their needs. On this basis, it was reasonable the Trust initially focussed on Mr A’s presenting problems.

26. As his care continued, the Trust planned to investigate what was causing Mr A’s health issues. On 28 April the plan was to carry out an MRI scan and tissue biopsies as an outpatient. At this time the Trust could not rule cancer out, as the test results were not conclusive. The MRI on 10 May showed the possibility of bladder cancer, but the Trust considered Mr A was not well enough to have investigations to confirm this.

27. Delivering Cancer Waiting Times, A Good Practice Guide’s cancer targets recommend patients should not wait longer than 62 days from the time of referral with suspected cancer to definitive treatment. In this case this would have been surgery, radiotherapy or chemotherapy.

28. From the above guidance it states the referral date is the start date. However, our adviser explained we would consider Mr A’s start date as being later, as he was not well enough to start a cancer pathway until 29 May. As Mr A had treatment, by way of the TURBT on 12 July, the Trust met this target.

29. We cannot see any indications of service failure by the Trust by not confirming the cancer sooner. This is because Mr A was not stable for investigations, and it was right for it to wait for his condition to improve before undertaking investigations. We do not underestimate how distressing this was for Mr and Mrs A.

Failed to inform them about the possibility of prostate cancer and the findings of the scan on 8 May

30. Mrs A is concerned the Trust failed to inform Mr A about the possibility of prostate cancer after his scan on 8 May. Mrs A explains the Trust told them it was a blockage, not a mass.

31. The Trust disagreed and explained Mr A was never diagnosed with prostate cancer. It went on to explain the MRI scan showed Mr A’s bladder wall had thickened and infiltrated into his prostate.

32. Cancer Research UK explains bladder cancer usually begins in the cells of the bladder lining. In some cases, it may spread into surrounding bladder muscle. If the cancer penetrates this muscle, it can spread to other parts of the body. This is through the lymphatic system. These vessels run throughout the body and collect extra fluid from the body’s tissues. This fluid is called lymph. Lymph carries wastes and certain nutrients.

33. Bladder cancers can invade the bladder wall, involving the muscular layers of the wall. As bladder cancer grows it can invade the entire way through the wall and into the fat surrounding the bladder or even into other organs such as the prostate. This is the most common way bladder cancer spreads. When the cancer has spread outside of the original point it is called advanced bladder cancer.

34. The relevant guidance is the NHS England Implementing the Cancer Taskforce Recommendation, Commissioning Person Centre for people affected by Cancer. The guidance states it is deemed good medical practice to involve the patient in their care, provide support and establish their needs. The NHS Constitution for England states ‘Patients come first in everything we do. We fully involve patients, staff, families, carers, communities, and professionals inside and outside the NHS’.

35. The Trust did suspect there was a possibility Mr A had cancer at this time. This could have been prostate cancer or bladder cancer which had spread into surrounding organs. In line with these two pieces of guidance, we would have expected the Trust to have discussed their suspicions earlier with Mr and Mrs A. We have seen no evidence it did this. On this basis, we have seen indications of failings.

36. This knowledge would not have improved Mr A’s clinical outcome or changed his treatment. However, it is reasonable to say Mr and Mrs A experienced distress and uncertainty between June and August when they did not understand what was happening.

37. We therefore considered what the Trust has done to address this. Its final response acknowledged the MRI images indicated Mr A had possible cancer. It also accepted there is no documentation to suggest staff had any discussions about this with Mr A or his family.

38. The Trust apologised and acknowledged the communication between the team, Mr A and his family was poor. It also explained it had shared her complaint with the wider urology team and reiterated the importance of effective, open communication to its staff.

39. We consider the action the Trust has taken is in line with our principles for remedy. This explains for some complaints appropriate remedies include an apology, explanation, and acknowledgement of responsibility.

40. We appreciate this was significantly distressing for Mr and Mrs A. We are satisfied the Trust has already done enough to put this right and therefore we are not going to take further action.

Failed to inform Mr and Mrs A about the cancer diagnosis on the 12 July

41. Mrs A’s next complaint also relates to communication. She is concerned the Trust failed to inform her and her husband about the cancer diagnosis on 12 July, instead waiting until 6 August.

42. As above, Mr A had his TURBT on 12 July and the pathology report confirming he had cancer was available on 26 July, a Friday. The results on Friday were too late to go into the MDT meeting on 29 July. The Trust discussed the results at the local urology MDT on Monday 5 August. The following day, the Trust told Mr A about his cancer.

43. The Trust’s own website has a section about bladder tumours and TURBT. It explains results should be available two to three weeks after the operation. It goes on to say the expectation is that the case would be discussed at the urology MDT meeting, which is held on a Monday, and further to that, the patient will receive an appointment.

44. We understand Mrs A considers the Trust should have told her husband sooner about the cancer. We can see the Trust told Mr A three weeks after the operation. As this is in line with the Trust’s own policy, we cannot say this wait amounts to a failing.

Failed to confirm his bladder cancer was inoperable

45. Mrs A says the Trust did not inform them Mr A’s bladder cancer was inoperable. Instead, she said it was only the hospital in Oxford that told them. The Trust explained it was not aware the cancer was inoperable before this and had referred him to the specialist team in Oxford for treatment.

46. On 20 August Mr A went to Oxford to see a urologist. The record from this appointment confirmed his cancer was too advanced for the removal of his bladder but he was to receive radiotherapy and chemotherapy.

47. Our clinical adviser explained bladder cancer is deemed operable unless it involves surrounding organs. The records support the fact the Trust was not aware the cancer was inoperable at the time it referred him to Oxford.

48. The GMC Good Medical Practice, Section 34, guidance is clear that a clinician must communicate effectively with the patient. It states the clinician must give patients the information they want or need to know in a way they can understand. As the Trust was not aware of this information, we cannot say it acted outside of this guidance.

49. We have seen no indication of service failing by the Trust because this information was only established when Mr A attended the Oxford hospital.

Failed to offer Mr A a hospital transfer to Oxford

50. Mrs A complains the Trust should have offered her husband a hospital transfer, instead of him travelling to the Oxford Hospital for 12-hour days. The Trust was unable to find Mr A a bed in Oxford. It explained if Mr A waited for a bed to become available this would have delayed his treatment, and it noted his condition was stable.

51. The relevant guidance is Delayed transfers of care: a quick guide. Due to limited beds available in hospitals, patients who need a transfer experience a delay.

52. The Trust’s head of clinical services confirmed it would be normal to discharge a patient home if their condition was stable, pending an outpatient appointment. They explained an outpatient appointment would not be reason enough to keep them in hospital. Mr A was discharged on 19 August and attended his appointment the next day.

53. We fully appreciate Mrs A and her husband struggled significantly with the travel between their home and Oxford and the long days affected them significantly.

54. We have seen no indication of service failings by the Trust because it acted in line with the guidance mentioned above. Mr A was stable to be discharged, and the Trust could not find a bed in the Oxford hospital for him.

The Trust caused internal bleeding with the nephrostomies on 10 May and 24 May

55. Moving to Mrs A’s complaint her husband suffered internal bleeding because the Trust put a nephrostomy straight through his kidney. The Trust does not dispute this but explained it is a known complication and was unavoidable.

56. On 10 May Mr A had the first nephrostomy fitted. Mrs A is concerned one of the drains being inserted incorrectly caused internal bleeding, which resulted in Mr A having a blood transfusion. He had a new nephrostomy fitted on 24 May, and there was also some bleeding after this.

57. A nephrostomy is generally considered to be quite a safe procedure but there is a small risk of bleeding from the kidney or surrounding area. Diagnosis and Management of Haemorrhagic Complications of Interventional Radiology Procedures states there is a 1-4% risk of bleeding requiring blood transfusion after nephrostomy insertion. Our clinical adviser explained this is a recognised complication and would normally be indicated at the time of consent for the procedure.

58. Mr A’s consent form states the risks of the procedure were pain, bleeding, infection, and an unsuccessful procedure. He signed this consent form on 8 May. On this basis we can see the clinician appropriately explained and warned Mr A of the risks of the procedure. Therefore, Mr A was aware of the risks and consented to undergo the procedure.

59. We did not see any evidence either procedure was carried out incorrectly, and unfortunately bleeding is a recognised complication Mr A was aware of. We recognise the complications caused a lot of pain and distress. We did not find any evidence of failings in the procedures.

Failed to inform Mrs A on 28 September that blood clots are a common complication of abdominal cancer

60. Mrs A complains the Trust should have warned her about the possibility of her husband developing a blood clot. Mr A did have a blood clot in the lung which is called a Pulmonary Embolism (PE) on 28 September. The Trust said Mr A was not at a higher risk of a clot due to him having had his bowel surgery many weeks before he developed the clot.

61. Mr A had his bowel surgery on 16 August and unfortunately passed away suddenly due to the PE on 30 September.

62. The Trust explained there is a higher risk of clots and PE in cancer patients. The Trust decided not to keep Mr A on blood thinning medication. Mr A was still bleeding due to the nephrostomies. Mr A had blood in his urine, was bleeding heavily and required blood transfusions. The Trust explained for these reasons it was unsuitable to put Mr A on blood thinning medication to stop blood clots.

63. The GMC’s Good Medical Practice says staff must communicate effectively. This means giving patients the information they want or need to know in a way they can understand. It says staff must be responsive in giving patients information and support.

64. We consider there is an indication here the Trust’s communication fell below standard as we cannot see staff explained the risk of the blood clot.

65. The Trust did suspect blood clots were a possibility due to Mr A’s abdominal cancer. We would have expected the Trust to have discussed the risk with Mr and Mrs A. We have seen no evidence in the medical records this was discussed with Mr and Mrs A. We have seen indications of failings.

66. In its complaint response the Trust expressed its apologies if staff did not clearly explain Mr A’s risk of blood clots at the time.

67. Mrs A told us of her distress to find out Mr A was at risk of a blood clot from the consultant when she arrived at the Trust after her husband had suffered a PE.

68. We recognise Mrs A finding out Mr A was at risk of a blood clot would have caused her distress. We cannot link a lack of communication at the time to Mr A suffering from a PE. The Trust has now further explained Mr A would not have been on preventive blood clotting medication so long after his operation.

69. As such, consulting our severity of injustice scale, we consider this impact fits in at level one. We understand only finding out about the blood clot later would cause Mrs A some level of distress. We are satisfied the Trust has done enough to put this right by apologising. Therefore, we would not expect the Trust to do more here.

Summary

70. We have decided to take no further action on Mrs A’s complaint. We do not underestimate the impact Mrs A told us about as a result of her experience. We understand our decision cannot change Mrs A’s experience, but we hope our explanations provide Mrs A with answers to her concerns.

1. We have carefully considered Mrs A’s complaint about Milton Keynes University Hospital (the Trust). We are sorry to hear about her experience and do not underestimate how difficult this has been.

2. We have decided not to consider the complaint further. This is because we have not seen any evidence that anything went seriously wrong with the diagnosis of Mr A’s cancer. Although we saw indications of failings in respect of some of the other concerns Mrs A has raised, we consider the Trust has already done enough to address the impact of this. We will explain our decision below.