Royal Free London NHS Foundation Trust

4. Mr B was diagnosed with stage 4 kidney cancer in November 2018. Mrs B complains about aspects of the care and treatment the Trust provided to Mr B in 2018. She says:

• signs of kidney cancer were not detected during tests, including a kidney, ureter and bladder (KUB) scan, in March 2018 • this led to an eight-month delay in diagnosing kidney cancer from the earliest opportunity to do so.

5. Mrs B believes there were opportunities to diagnose her husband’s cancer eight months earlier. She says if the cancer had been diagnosed sooner, it may not have been as advanced and spread to his lungs, and his prognosis may have been better. By the time the cancer was diagnosed, it was too advanced for any treatment except palliative care, and Mr B died within six months of his diagnosis. Mrs B believes if the diagnosis had not been delayed, her husband would have had a better prognosis and more treatment options and may not have died from the cancer. Mrs B has also lost confidence in the Trust.

6. Mrs B wants to know whether there was a delay in the diagnosis of her husband’s cancer and, if so, whether this could have changed the prognosis and outcome.

7. In March 2018, Mr B’s GP found non-visible haematuria (microscopic blood in urine) during a routine appointment. The GP referred Mr B to the urology service at the Trust to have this investigated. Mr B had investigations, including an ultrasound scan of his KUB, in March 2018.

8. On 28 November 2018, Mr B attended the Trust with a four-week history of shortness of breath and 2kg weight loss in the previous four months. Tests showed suspected cancerous lesions in his lungs. Further investigations revealed primary cancerous lesions in the left kidney that had spread to Mr B’s lungs and bones. Mr B was diagnosed with stage 4 metastatic urothelial cancer of the left kidney. Cancer is graded accorded to how severe it is. Stage 4 cancer means the cancer has spread from the place where it started to other areas of the body (metastasis).

9. Mr B sadly died from cancer in June 2019.

13. We first looked at what should have happened when the Trust received a referral from Mr B’s GP to investigate non-visible haematuria. The NICE standards say non-visible, unexplained haematuria in a person aged 60 and over may be a possible sign of bladder cancer. An urgent referral should be made for this to be investigated using a suspected cancer pathway. An appointment should be provided within two weeks.

14. Mr B visited his GP, who referred him to the Trust in March 2018. The Trust first saw him on 18 March 2018, when he had a flexible bladder cystoscopy (a test involving a camera being inserted into the bladder through the urinary tract). The cystoscopy report said he had a thickened bladder wall and enlarged prostate, but no other abnormalities were found.

15. On 22 March 2018 Mr B had an ultrasound scan of his KUB four days after the cystoscopy. The ultrasound scan report said both kidneys were normal in size, shape and texture, with no dilation of the ducts. No kidney stones or masses were seen during the scan. The bladder wall was thickened and the prostate was enlarged, but no other abnormalities were seen.

16. Mr B saw a consultant at the urology clinic on 10 April 2018. The consultant then wrote to Mr B’s GP with the results of the tests. The consultant said other than a thickened bladder wall and enlarged prostate the test results were normal. Mr B was discharged from urology.

17. The Trust saw Mr B quickly on referral from his GP and did initial investigations to screen him for cancer. This is in line with NICE standards.

18. Our surgical adviser explains Mr B had urothelial cell cancer, which is a rare type of kidney cancer. In the kidneys, the urothelial cells line the renal pelvis, an area in the middle of the kidneys where urine is collected and stored before it travels down the ureter to the bladder. The surgical adviser explains the risk of having this type of cancer with symptoms of non-visible haematuria is extremely low.

19. No specific standards set out the type of imaging methods to use to screen patients with non-visible haematuria for cancer. Our adviser explained studies have shown ultrasound scans to be safe alternatives to computed tomography for identifying cancers of the urinary tract. Mr B’s investigations included a flexible cystoscopy of the bladder and an ultrasound scan of the KUB. These tests are in line with standard practice for investigations into non-visible haematuria.

20. The RCR standards say, ‘a radiology report should…answer the clinical question and include a tentative or differential diagnosis when an abnormality is seen and relevant negative observations’.

21. The ultrasound scan report says both kidneys were normal in size, shape and texture, with no dilation (enlargement of tubes), obvious calculi (kidney stones) or masses identified. It reports the bladder wall as trabeculated (thickened) and an enlarged prostate. Aside from these two findings, the scan results were reported as normal.

22. Our radiology adviser looked at the cystoscopy and ultrasound scan reports and the images of the ultrasound scan. There were no signs of tumours or masses in the kidneys, and the ultrasound scan report reflects the ultrasound scan images.

23. Therefore, the cystoscopy and ultrasound scan imaging and reports are in line with the RCR standards.

24. Overall, we consider the care and treatment the Trust provided in March and April 2018 was in line with the relevant standards and established good clinical practice. There is nothing to suggest the Trust missed signs of a tumour in the left kidney at that time.

25. We have not seen evidence of failings in the Trust’s actions, so we will not be investigating this complaint further.

26. We hope this reassures Mrs B the Trust did not miss signs of cancer when it initially investigated her husband’s symptoms in March 2018. We know this cannot change the distressing and difficult experiences Mrs B had during her husband’s diagnosis and illness or the sad outcome. We hope the knowledge the Trust did not miss Mr B’s cancer when he had tests in March 2018 gives some comfort to Mrs B.

1. We have carefully considered Mrs B’s complaint about the Royal Free London NHS Foundation Trust (the Trust).

2. We have seen no evidence the Trust missed signs of cancer or did anything seriously wrong when Mrs B’s husband, Mr B, had an ultrasound scan in March 2018.

3. We recognise Mrs B may be disappointed with our decision. Understandably, Mrs B experienced a very distressing and difficult time when her husband was diagnosed with cancer later in 2018 and died a few months afterwards. We hope the explanations in this report reassure Mrs B there is nothing to suggest the Trust missed signs of cancer when Mr B went to the Trust for tests in March 2018.