Frimley Health NHS Foundation Trust

5. Mrs L complains about the care and treatment her husband, Mr L, received from the Trust between 29 August 2019 and 3 December 2019. She specifically complains about a locum (temporary substitute) vascular consultant (a specialist in conditions affecting the circulation, including disease of the arteries and veins), Dr A. She says the Trust:

• suspected her husband had bowel cancer while he was in hospital for an unrelated condition between 6 August 2019 and 3 September 2019 but did not contact him about it until 23 September 2019, when a nurse consultant (a qualified nurse specialising in a particular area) phoned to say he did not have cancer • did not provide her and her husband with any help and advice between his appointments in October and November 2019 even though he was in a lot of pain • did not keep them updated on what was happening between October and November 2019 even though the locum vascular consultant was concerned Mr L may have had cancer • diagnosed her husband with a sarcoma (a rare type of cancer that grows in connective tissues and blood vessels in the arms and legs) on 28 November 2019 but should have diagnosed this sooner • did not treat her husband’s fluid retention before discharging him from hospital on 29 November 2019 • did not give her husband a Do Not Attempt Resuscitation (DNAR) form before discharging him on 29 November 2019, and • delayed arranging palliative care when it discharged her husband on 29 November 2019, resulting in a nurse not visiting him until 2 December 2019.

6. Mrs L also complains about how the Trust handled her complaint, saying it gave her inaccurate information in its responses to her complaint.

7. Mr L sadly died at home in December 2019 and Mrs L believes his death was avoidable. She believes the suspected and diagnosed cancers were linked and the Trust should have diagnosed cancer sooner.

8. Mrs L says her husband spent the last few months of his life, particularly his last few days, in pain and the Trust neglected him. She says her husband’s death has been devastating for her, her son and their family. She also says she cannot come to terms with the way he died and the Trust has compounded her distress through the way it handled her complaint.

9. Mrs L wants the Trust to give explanations, accept any failings, make improvements to its service and pay her compensation.

10. Mr L saw Dr A on 26 June 2019. Dr A registered him for surgery for critical limb-threatening ischaemia (a severe stage of peripheral arterial disease in which the blood flow to arms, legs or feet is blocked). The Trust admitted Mr L for a bilateral iliac angiography (a procedure to open narrow or blocked blood vessels supplying blood to the legs) on 6 August 2019.

11. During the admission, Mr L told staff he had been experiencing some rectal bleeding. The Trust did a sigmoidoscopy (in which a camera is used to look at the colon and rectum) to investigate this and found a suspicious lesion (an area of tissue damaged by injury or disease). The Trust took biopsies (procedures to take small tissue samples) of the lesion and discharged Mr L on 3 September 2019.

12. A nurse consultant phoned Mr L on 23 September 2019 with the biopsy results. They told him the tests showed the lesion was a rectal ulcer (an open sore) and not cancer. They wrote to him the following day confirming this.

13. Mr L then had a follow-up appointment with Dr A on 2 October 2019 to see how he was doing following his surgery. Mr L told Dr A that he had noticed a lump on his left thigh while in hospital. Dr A thought it was a haematoma (an abnormal pooling of blood) but requested an urgent magnetic resonance imaging (MRI) scan (a non-invasive imaging technology) to investigate.

14. Mr L had an MRI scan on 17 October 2019 and saw Dr A again on 13 November 2019. Dr A told Mr L they did not have the results of the scan and would chase them up. Dr A says Mr L told them he was in pain and they offered to admit him to hospital, but Mr L declined because of his recent lengthy hospital stay.

15. Dr A chased up the MRI report and received it later that day. It did not raise any suspicions of cancer. Dr A discussed Mr L’s case in a vascular multidisciplinary (MDT) meeting on 18 November 2019. The team advised Dr A to request an urgent contrast MRI scan (in which a contrast agent (dye) is given before the scan to improve visibility) to rule out cancer.

16. Mr L had a second MRI scan on 23 November 2019. Again, the report did not raise any suspicions of cancer but Dr A sent the images to the on-call vascular radiologist for discussion. The radiologist suspected Mr L had a sarcoma.

17. On 27 November 2019, Dr A wrote to a consultant surgical oncologist (cancer specialist) asking for their urgent opinion. The same day, an ambulance took Mr L to hospital as he was unable to pass water. Dr A went to see Mr L while he was in hospital and told him they thought he had cancer. A CT scan (computerised tomography scan – a form of X-ray examination) later that day sadly confirmed this.

18. The Trust discharged Mr L on 29 November 2019 with a referral for palliative care at home. Macmillan Cancer Support nurses visited him on 2 December 2019. He sadly died that month. We cannot imagine what a difficult time this must have been for Mr L and Mrs L. We were sorry to hear of her loss.

Suspected colorectal cancer

22. Mrs L is understandably concerned the suspected cancer in August 2019 and the diagnosed cancer in November 2019 were linked.

23. NICE CG131 says doctors should offer patients with symptoms like rectal bleeding a colonoscopy or sigmoidoscopy (procedures to look inside the rectum or colon) to confirm colorectal (bowel) cancer and perform a biopsy on any suspicious lesion. We see the Trust investigated and ruled out colorectal cancer in line with this guidance.

24. Our oncology adviser says we do not really know what the sarcoma seen in November 2019 was as Mr L did not have any further tests. However, they do not think there was any link between the suspected and diagnosed cancers as they have different symptoms and natures.

25. Overall, the Trust acted in line with NICE CG131 by carrying out a sigmoidoscopy to investigate Mr L’s symptoms and taking biopsies of the suspicious lesion. The test results show Mr L did not have colorectal cancer. We hope this reassures Mrs L about this part of her husband’s care.

26. Mrs L says the Trust did not contact her husband between 3 September 2019 and 23 September 2019. She says that, when it did contact him, a consultant nurse only phoned to say he did not have cancer.

27. The records show the Trust discussed Mr Collins’s case at an MDT meeting on 16 September 2019. The meeting notes say they were waiting for the biopsy results. The Trust discussed his case at another MDT meeting on 23 September 2019. The notes of that meeting say the biopsy results show he had a solitary rectal ulcer.

28. The Trust phoned Mr L the same day as the second MDT meeting and sent him a letter the following day. This letter clearly sets out the results, provides advice and includes contact details in case Mr L had any questions. We do not think the Trust needed to contact him until it had the test results.

29. Overall, the Trust’s communication was appropriate and in line with section 32 of the GMC’s Good Medical Practice. This says doctors must give patients the information they want or need to know in a way they can understand. We hope this addresses Mrs L’s concerns.

Investigations into the lump on Mr L’s leg

30. Mrs L believes the Trust should have diagnosed her husband’s cancer sooner than it did.

31. Mr L first reported concerns about a lump on his left thigh during his appointment with Dr A on 2 October 2019. Dr A thought it was a haematoma but requested an urgent MRI scan to investigate. Our vascular adviser says a haematoma was likely as Mr L was on blood thinning medication which increases the risk of one developing.

32. Section 1.11.4 of NICE NG12 says clinicians should consider an urgent direct access ultrasound when someone has an unexplained lump that is increasing in size as it can indicate a possible soft tissue sarcoma. Dr A acted in line with this guidance and opted for an MRI scan, which provides detailed imaging.

33. Our radiology adviser says the MRI images from 17 October 2019 show a mass lesion in the posterior compartment of Mr L’s left thigh (that is, in one of the three groups of muscles and nerves in the thigh). They said there were multiple nodules (growths of abnormal tissue) surrounded by a capsule (a membrane that encloses a structure in the body).

34. Our radiology adviser says there were multiple satellite (secondary) lesions in the posterior and anterior compartments of the left thigh. They say there were mass lesions in the soft tissues on the right-hand side. They also say there were multiple bony metastases (cancer that starts in one area and spreads to a bone).

35. Our radiology adviser says the lesion in Mr L’s left thigh may have represented a primary sarcoma (the original tumour). They say a haematoma can sometimes be difficult to differentiate from a sarcoma, but the multiple satellite lesions and bony metastases should have alerted the radiologist to the possibility of a tumour with metastases.

36. Reporting standard 1 in the RCR guidance says a radiology report should bring about appropriate care and include a tentative or differential (potential) diagnosis when an abnormality is seen. Reporting standard 2 says reports should suggest further investigations or specialist referral if they affect patient management.

37. The Trust did not report the MRI scan in line with the RCR guidance. The radiology advice we have received indicates the report should have raised a suspicion of metastatic disease. This means the Trust did not take appropriate action to diagnose or investigate as the RCR guidance sets out. This is a failing.

38. Mr L saw Dr A on 13 November 2019, but Dr A did not have the scan results. Section 15b of the GMC’s Good Medical Practice says doctors must quickly provide or arrange suitable investigations, if necessary. Dr A acted in line with this guidance by chasing the results later that day.

39. The records show the MRI scan took place on 17 October 2019 and the Trust reported it on 13 November 2019. The Trust has told us it should report urgent scans within two weeks. It took 27 days to report this scan, which is well outside this timescale. The Trust only reported the scan when Dr A chased the results. This is a failing.

40. The MRI report said Mr L had a probable soft tissue haematoma. Dr A took the case to the next vascular MDT meeting on 18 November 2019. The MDT meeting recommended an urgent contrast MRI scan to rule out cancer. Our vascular adviser feels Dr A’s decision to take the case to the MDT shows excellent care.

41. Dr A’s actions here were in line with sections 15c and 16d of the GMC’s Good Medical Practice. Section 15c says doctors must refer a patient to another practitioner when this serves their needs. Section 16d says doctors must consult colleagues when appropriate.

42. Mr L had the second urgent MRI scan on 23 November 2019. The Trust reported the results on 26 November 2019, but the report says the radiologist did not use contrast. It also says the lesions were much more visible and seemed to have developed. The report recommended a contrast MRI scan.

43. The radiologist did not carry out a contrast MRI scan as requested. This is not in line with reporting standard 1 from the RCR guidance or section 15b of the GMC’s Good Medical Practice. The radiology advice we have received indicates the Trust should have suspected cancer based on the results of this MRI scan. These are failings.

44. Dr A sent Mr L’s scans to the on-call vascular radiologist who suspected a sarcoma. Dr A wrote to a consultant surgical oncologist asking for their urgent opinion. This action was in line with sections 15c and 16d of the GMC’s Good Medical Practice. Our vascular adviser feels this was another example of good practice by Dr A.

45. Overall, we see several failings with Mr L’s care here. The Trust should have suspected cancer following the MRI scan on 17 October 2019. It is very likely to have diagnosed cancer earlier had it reported the first MRI scan results sooner or done a contrast MRI scan when asked. We consider the impact of these failings in this statement.

Communication

46. Mrs L says she and Mr L phoned the Trust for help several times between appointments with Dr A as her husband was in a lot of pain. She says they spoke with some of Dr A’s colleagues. One told them Mr L’s pain was normal, and another directed him to his GP.

47. We have carefully checked Mr L’s records and cannot see any notes of these phone calls. Our vascular adviser says whoever Mr and Mrs L spoke to should have informed Dr A’s secretary. They could then have arranged a clinical review either at the Trust or with Mr L’s GP.

48. The Trust’s handling of these phone calls was not in line with our Principles of Good Administration. These say public bodies should provide effective services with appropriately trained and competent staff. This is a failing. We consider the impact in this statement.

49. Mrs L also complains Dr A did not keep her and her husband updated on what was happening with the results of his scans, although she now knows Dr A was concerned her husband may have had cancer.

50. Dr A had reason to suspect Mr L had cancer only after asking for a second opinion on 26 November 2019. Dr A wrote to a specialist asking for their urgent opinion on 27 November and spoke to Mr L the following day. So, Dr A spoke to Mr L within two days of suspecting he had cancer.

51. This communication is in line with section 49 of the GMC’s Good Medical Practice. This says doctors must work in partnership with patients, sharing with them the information they need to make decisions about their care. We hope this reassures Mrs L.

Ascitic drain

52. Mrs L says the Trust did not treat her husband’s fluid retention before sending him home on 29 November 2019.

53. The Trust admitted Mr L with abdominal distention (swelling) on 28 November 2019. It planned to clear this fluid using an ascitic drain (where excess fluid is removed from the stomach using a needle and tube) to make him more comfortable.

54. The Trust later decided to first stop Mr L’s blood-thinning medication and wait until his international normalised ratio (a measure of how long it takes your blood to clot) had fallen to a safe level. Blood-thinning medication can increase international normalised ratio and the higher the level, the longer it takes blood to clot.

55. Our oncology adviser has explained that poor clotting makes an ascitic drain riskier. So, the Trust’s decision to delay the drain to give Mr L’s international normalised ratio time to fall is in line with section 15b of the GMC’s Good Medical Practice.

56. The records also show the Trust booked an outpatient appointment and discharged Mr L as he was very keen to go home and did not want to stay in hospital. This decision was in line with section 31 of the GMC’s Good Medical Practice, which says doctors must listen to patients and take account of their views.

DNAR order

57. Mrs L says the Trust did not provide her husband with a DNAR order before discharging him on 29 November 2019. A DNAR order is a document that tells clinicians not to attempt cardiopulmonary resuscitation.

58. We have seen a DNAR order dated 28 November 2019 in the Trust’s records. The Trust should have given this to Mr L when discharging him, so other clinicians knew he did not want to be resuscitated. The notes written by the Macmillan nurses show they asked Mr L’s GP for a DNAR order, indicating the Trust did not give him one.

59. This is not in line with section 44a of the GMC’s Good Medical Practice. This says doctors must share all relevant information with colleagues involved in a patient’s care, including when they refer patients to other providers. This is a failing. We consider the impact of this later in our report.

Referral for palliative care

60. Mrs L says the Trust delayed arranging community palliative care for her husband when it discharged him on 29 November 2019.

61. Mr L’s records show the Trust’s palliative care team assessed him in hospital. The assessment says he was adamant he wanted to go home, so the Trust discharged him on 29 November 2019 (Friday) with a referral for community palliative care in line with his wishes. Macmillan nurses visited him on 2 December 2019 (Monday).

62. Our oncology adviser tells us the NHS does not generally provide emergency palliative care at home, which explains the gap between Friday and Monday. The records show the Trust offered to keep Mr L in hospital or move him to a hospice, where he would have received care over the weekend. We recognise this was Mr L’s decision and many people choose to go home in this situation.

63. We see the Trust discharged Mr L in line with his wishes. It also referred him for community palliative care and provided appropriate end-of-life medications for pain and restlessness. Overall, the Trust managed Mr L’s discharge in line with NICE CG142 and section 31 of the GMC’s Good Medical Practice.

64. We recognise the Trust may not have clearly communicated how choosing to go home would leave Mr L and Mrs L without support over the weekend. It is also possible it did communicate this but, understandably, Mr L and Mrs L did not take it in at the time. We know from speaking to Mrs L what a horrible time this was for her and her husband. We hope our report address her concerns.

Complaint handling

65. Mrs L says the Trust has not been open and honest with her about what went wrong with her husband’s care. We hope our report addresses the concerns she still has about what happened.

66. Mrs L sent the Trust a brief email on 8 May 2020. The Trust did not speak to her about her concerns at any point, which is not in line with our Principles of Good Complaint Handling. These say public bodies should listen to and consider the complainant’s views, asking them to clarify where necessary to make sure they understand clearly what the complaint is about.

67. The Trust’s investigation found reporting of the MRI scan results on 17 October 2019 was delayed and happened only when Dr A chased the results. It found staff misinterpreted the scans, meaning the Trust could have diagnosed Mr L’s cancer sooner. Dr A also told the investigation they felt the patient safety team needed to look at Mr L’s care.

68. The Trust’s first complaint response was brief and provided only an overview of what happened. Both its responses failed to inform Mrs L of the issues it had found. This is not in line with our Principles of Good Complaint Handling, which say public bodies should be open and honest. They also say when things have gone wrong, public bodies should explain fully and say what they will do to put things right.

69. Overall, the Trust took no action to understand Mrs L’s concerns and provided poor responses that were not open and honest about what happened. We recognise the Trust’s second response was better than its first, but the second response may not have been necessary had the Trust spoken to Mrs L about her concerns and been open and accountable from the start. This is a failing. We consider the impact of this later in our report.

Impact

Delayed cancer diagnosis

70. Mrs L believes her husband’s death was avoidable. She also says he spent the last few months of his life, particularly his last few days, in pain and the Trust neglected him. She says his death has been devastating for her and her family. She says she cannot come to terms with the way he died. We are sorry to hear how much she has struggled.

71. Our radiology adviser says the lesion and metastases increased in size and number between the MRI scans on 17 October and 23 November 2019. They say the CT scan on 28 November indicates significant disease progression over a short period of time. They say this suggests Mr L had an aggressive tumour. Our oncology adviser agrees.

72. Our oncology adviser says if the MRI scan on 17 October 2019 had flagged possible cancer, the Trust would have done a diagnostic biopsy and staging. (This helps determine where a cancer is located, if/where it has spread and if it is affecting other parts of the body.) They say the Trust would have then referred Mr L for palliative chemotherapy. It seems likely Mr L would have declined this as he did so on 28 November 2019.

73. Overall, both our radiology and oncology advisers feel Mr L would still have died when he did even if the Trust had diagnosed cancer sooner. This is because Mr L appears to have had a very aggressive cancer and it seems likely he would have declined any further treatment. We understand this is difficult for Mrs L to accept.

74. It is clear Mr L was distressed and in a lot of pain during the last few weeks of his life. The notes of an appointment on 22 November 2019 say his mood was very low and he was tearful. Dr A says they offered to admit him on 13 November 2019, indicating Mr L must have been in a lot of pain and the records from his final admission show how bad this pain was. Mrs L has also told us how much her husband suffered and how difficult it was for her to watch.

75. We think an earlier diagnosis would have meant the Trust could have provided or arranged better palliative care for Mr L. We do not underestimate what a difference this would have made to Mr L and Mrs L. It could have meant Mr L’s final weeks were much more peaceful and comfortable. He would also have had time to put his affairs in order and say goodbye to loved ones. So, we partly uphold this part of the complaint.

Communication

76. Mrs L says the Trust left her husband in pain between appointments as it did not provide him with any help when she and Mr L phoned for advice.

77. Our vascular adviser says responsibility for pain management at home lies with Mr L’s GP rather than the Trust. They say the Trust appropriately discharged Mr L to his GP with a prescription for strong analgesia (pain-relief medication) and he already had a long term, pain-relief patch for severe pain.

78. With this in mind, we do not think this failing had any clinical impact on Mr L, but we accept these phone calls would have caused additional distress and worry to Mr L and Mrs L at an already difficult time. So, we partly uphold this part of the complaint.

DNAR order

79. Mrs L says having to get another DNAR order caused her and her husband additional distress. We recognise this will have caused some further upset at an already incredibly difficult time. So, we uphold this part of the complaint.

Complaint handling

80. Mrs L says the Trust’s complaint handling has compounded her distress. We know from our conversations with her just how upsetting she found the complaints process. We think the Trust’s poor complaint handling unnecessarily lengthened the process and made it more distressing than it needed to be. So, we uphold this part of the complaint.

1. Mrs L complains about the care and treatment Frimley Health NHS Foundation Trust (the Trust) provided to her late husband. Mr L sadly died shortly after the Trust diagnosed his cancer in 2019. Mrs L thinks the Trust should have made this diagnosis sooner and could have saved his life. We are very sorry for Mrs L’s loss.

2. We find the Trust should have diagnosed Mr L’s cancer earlier than it did. We do not think this would have prevented his death, but it would have allowed the Trust to provide him with better palliative care and support. We do not underestimate what a difference this would have made to Mr L and Mrs L.

3. Mrs L also complains about the way the Trust handled her complaint. We find the Trust did not take sufficient action to understand her complaint. It also gave poor responses and was not open and honest with her about failings in her husband’s care.

4. We partly uphold Mrs L’s complaint. We recommend the Trust write to her to accept the failings we have found and to apologise. We recommend it produce an action plan setting out what it will do to prevent these failings in future. We also recommend the Trust pay £1,500 to Mrs L.

81. In considering our recommendations, we have referred to our Principles for Remedy.

82. Our Principles for Remedy say where poor service or maladministration (fault) has led to injustice or hardship, the organisation should take steps to put things right. We recommend the Trust write to Mrs L to accept the failings we have found and to apologise.

83. Our Principles for Remedy say public organisations should look for continuous improvement and use the lessons learned from complaints to make sure they do not repeat maladministration or poor service. We recommend the Trust produce an action plan setting out what it will do to prevent the failings we have seen from happening again.

84. Our Principles for Remedy also say public organisations should put things right and, if possible, return the person affected to the position they would have been in if the poor service had not happened. If that is not possible, the organisation should compensate them appropriately. We think financial compensation is appropriate in this case.

85. To decide on a level of financial compensation, we review similar cases in which a person has experienced a similar injustice, along with our severity of injustice scale. Having done this, we recommend the Trust pay £1,500 to Mrs L in recognition of the impact of the failings we have found.