20. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the Trust got something wrong. We do this by comparing what should have happened with what did happen. We have done this for each aspect of Mrs O’s complaint and have set out below what we have seen.
CT Scan
21. Mrs O complains the Trust delayed her husband’s CT scan. The Trust agrees the scan was delayed but says this was due to Mr O’s possibly having COVID-19. The Trust says the delay in doing the scan was in line with infection control procedures for the medical imaging department during COVID. Mrs O does not doubt this was the reason but still thinks the delay was inappropriate.
22. The Trust says there was a separate scanner set up for COVID patients to minimise the risk of cross-infections. The Trust had to wait until the result of Mr O’s COVID swab came back before it could confirm where the scan should be done. Mr O had the scan the same day his negative COVID result came back.
23. We can see Mr O was admitted to hospital on 21 March 2020. The records show he came in with breathlessness and abdominal pain, and the management plan was to arrange a CT scan for further investigations. However, in line with the Public Health Guidelines, due to his symptoms, Mr O also had to have a COVID test on the same day. We have seen this guidance needed for individuals to be isolated if they had been in close contact with someone who had been tested positive for COVID.
24. The results of the COVID test came back as negative on 24 March 2020, and the records show Mr O had a CT scan on the same day. It is not clear why it took three days for the COVID test result to come back.
25. We do, however, understand that Mr O was admitted during the peak of COVID. The pandemic was a unique situation that brought unforeseen challenges across the NHS. We need to understand if it was not possible for an organisation to act in line with the relevant standards/guidance. It is helpful to look at the General Medical Council’s (GMC) statement by the chief executives of statutory regulators of health and social care professionals, which asked healthcare professionals to use their judgement to weigh up the risks and give safe care to their patients. The statement said COVID was a very difficult time, so professionals may need to do things differently from usual to care for their patients.
26. Mr O was admitted in the first few weeks when COVID suddenly became a widespread problem in the UK. At the time, hospitals had to very quickly make changes to keep patients and staff safe, and had to work with many more patients and fewer staff than usual. We understand organisations may have found it difficult due to the pandemic to keep up their usual standards of clinical care. We are not saying this to excuse the delay but to put it into context. There is no doubt there was a delay in the CT scan being done, and therefore we have found failings.
27. We then looked at the impact the delay of the CT scan had on Mr O’s cancer treatment. We think, even though the CT scan took longer than expected, the overall care was in line with the cancer pathway. Specifically, we would expect a decision to start treatment within 31 days of the diagnosis, and for treatment to start within 62 days of the first referral, which the records show was what happened. As such, we have seen no negative impact here.
Biopsy
28. Mrs O complains the Trust delayed taking a biopsy from her husband, even though his file was marked as a priority case. The Trust does not deny there was delay, however, it says this was because Mr O needed to isolate because of his contact with a patient with COVID. The Trust says Mr O had his biopsy as soon as possible after the end of his isolation. The Trust says Mr O was on the cancer pathway, and they did not breach the standards set out for cancer patients.
29. The records show on 24 March 2020, the consultant physician met with Mr O to talk about the findings of the CT scan Mr O had had earlier that day. The physician told Mr O the scans showed he might have cancer, and they would therefore need to get a tissue sample for a diagnosis and to decide on treatments and talk about the prognosis. The records also say the biopsy would take place once Mr O had finished his isolation period on 4 April 2020, in keeping with Public Health England guidelines.
30. We have seen this guidance said individuals had to isolate if they had been in close contact with someone who had been tested positive for COVID. The medical records state that even though Mr O’s COVID results came back as negative, another patient on his bay had been tested positive for COVID, and Mr O therefore had to self-isolate.
31. The records show staff did a biopsy of Mr O’s right upper neck node on 14 April 2020. Staff had an MDT meeting on 20 April 2020, where they talked about the results of the biopsy and found Mr O had small-cell lung cancer.
32. There was a ten-day period between the time Mr O ended his isolation and the day he had the biopsy. We looked at the expectations for timescales in relation to a biopsy. We have no specific guidelines for this, but we do have the wider NHS targets relating to cancer.
33. Our adviser explained that, besides the two-week cancer wait referral (that sets the standards for the first assessment), there are two other key NHS targets for cancer, which are set out in the Handbook. The guidelines state that:
‘Patients can expect to be treated at the right time and according to their clinical priority. Patients with urgent conditions, such as cancer, will be able to be seen and receive treatment more quickly. Organisations’ performance is monitored across all waiting time pledges.
There are a number of government pledges on waiting times, including:
• a maximum one-month (31-day) wait from diagnosis to first definitive treatment for all cancers; • a maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy; • a maximum two-month (62-day) wait from urgent referral for suspected cancer to first treatment for all cancers.’
34. Our adviser says patients on the cancer pathway need to be able to start treatment within 62 days of the first referral and within 31 days of a decision to start treatment.
35. The records show the cancer pathway started on 24 March 2020, when the CT scan showed probable cancer. Mr O had a biopsy done within three weeks because he had to isolate due to the COVID guidelines. Doctors made a diagnosis on 20 April 2020, and on 22 April 2020 they sent a referral to the specialist hospital for consideration of treatment. Mr O was to start chemotherapy on 4 May 2020. Taking the date of diagnosis as 20 April 2020 and a planned date to start chemotherapy on 4 May 2020, we can see a decision to start treatment from the date of diagnosis was made within 31 days, in line with the guidelines.
36. When Mr O had tests taken at the hospital, clinicians thought he should not go on to have chemotherapy due to the worsening of his health. The Trust contacted Macmillan on 5 May 2020 to talk about prognosis, and Mr O got a referral for radiotherapy on 6 May 2020. In mid-May 2020, the Trust got in touch with Mr O to talk about the treatment, but they were unable to speak to him as he was too unwell to talk on the phone. Mr O sadly died the following day. We think the Trust did follow the 31- and 62-days cancer pathway.
37. Once we were sure the Trust had followed the cancer pathway properly, we looked at what we could find out about the delay of the biopsy.
38. Our adviser says in day-to-day practice, delays do happen for many of reasons. During the COVID-19 pandemic, particularly in the early days of the first waves and lockdown, there was a lot of disruption to most clinical services. The reasons the Trust gave for postponing the biopsy were believable and reasonable and in keeping with the need to keep Mr O, other patients and staff safe.
Medication
39. Mrs O complains the Trust delayed in giving her husband his regular medication (Stiralto for breathing), as they were out of stock. The Trust accepts a delay in this, apologised and explained that the inhaler was out of stock when Mr O was transferred to the ward, but that this was ordered as soon as he was admitted to the ward.
40. The records show the Trust did important checks for Mr O, where staff recorded his breathing, blood pressure, temperature and pulse from 21 March 2020 to 24 March 2020. The records show Mr O’s breathing stayed between 18 and 20 breaths per minute, which gave a National Early Warning Score (NEWS) of 0. The NEWS is made up of physiological measurements like respiratory rate and pulse rate. A NEWS of 0 means that there are no areas of concern in a patient’s health status, so Mr O’s NEWS did not show he needed any medical input.
41. We asked our adviser whether this had a negative impact on Mr O’s health when he was an inpatient at the Trust. Our adviser said, after looking at Mr O clinical records, the lack of the inhaler did not have a big impact on his breathing. The adviser said the clinical records covering Mr O’s admission (clinical entries, observation charts, nursing charts) did not seem to show a worsening of his health caused by the difficulty in finding a suitable inhaler.
42. We looked at Mr O’s medical records for the time he was an inpatient to see whether the lack of his regular inhaler had an impact on his oxygen levels. According to current NICE parameters (NICE, ‘Treatment Summaries: Oxygen’), for most acutely ill patients with normal or low carbon dioxide levels in the blood, oxygen levels in the blood should be 94%–98%. The records show Mr O’s oxygen levels stayed between 94% and 96% during the time he was an inpatient. The records show when Mr O’s oxygen level dropped slightly below the accepted level to 94%, staff did another oxygen test on the same day, which showed the levels had gone back up to 95% and 96%. We are therefore happy that the lack of the inhaler did not cause any worsening of Mr O’s health.
43. While we have not seen any negative impact, we are pleased to see the Trust apologised for not having Mr O’s medication and understands it should have asked Mrs O to bring in the medication from home once they found out it was out of stock. The Trust says it has taken learning from this, which it would share with staff at their safety huddle.
Aftercare
44. Mrs O complains after the Trust discharged her husband, it gave him no medication or support, and no one saw Mr O until 7 May 2020, when a district nurse came to visit. The Trust says it referred Mr O to the Macmillan team after discharge and can see they were in regular contact with him.
45. The records show on 24 March 2020, Mr O got the results of his CT scan, which showed he might have cancer. However, doctors needed to do a biopsy to investigate further. Mr O was keen to be discharged and agreed he would share the results of the scan with Mrs O when he was at home. On discharge from the Trust, the plan was for a Macmillan nurse to contact him in 24 to 48 hours.
46. The records show on 26 March 2020, an internet consultation took place with a clinical nurse specialists (CNS), where she told Mr O he would have the biopsy after his isolation was finished. The nurse also gave him her contact details for any further questions and support.
47. Our adviser told us what support they expected the Trust to give after it had discharged Mr O. The adviser referred to the NICE guidelines, which outline support and palliative care (treatment for the symptoms of an incurable illness) for adults with cancer.
48. Section 8.16 says assessments should be made by health care professionals who have received further education and training in palliative care. Where this is not possible, assessments should be done either by the local specialist palliative care team or with their help.
49. Our adviser says the Trust appropriately referred Mr O to the Macmillan Palliative Care Team for an assessment by a CNS nurse. The evidence shows Mr O got the right aftercare once the Trust had discharged him. We do not doubt Mr and Mrs O felt a lack of support, but we have seen nothing to show the care Mr O got fell below the expected standard.
50. We accept this was a distressing time for Mrs O, as she was not able to have input in the care and treatment for her husband due to the pandemic. However, we are satisfied that the Trust appropriately referred Mr O to the Macmillan nurse, and that he got a contact number for when he needed help.
51. We fully understand this experience was deeply upsetting for Mrs O, and we do not wish to minimise how challenging it has been to raise her complaint with us. We would like to thank Mrs O for her effort in bringing this complaint to us.