Failure to communicate cancer diagnosis was terminal
15. When deciding if we should carry out a detailed investigation of a complaint, we look at whether there are signs something has gone wrong, and whether this has had a damaging effect. We look to see if the organisation has taken steps to put this right, in line with our Principles. We have done this and consider the Trust has already done enough to put right the impact of this event.
16. Mrs Y complained the Trust did not tell her about her husband’s terminal diagnosis. She said instead the doctors told her they were ‘cautiously optimistic’ when asked if Mr Y was going to die. Mrs Y has said this led to her and her husband having false hope, and did not give her time to fully prepare for Mr Y’s death.
17. Mrs Y attended a bereavement meeting at the Trust on 23 September 2021, and the Trust gave Mrs Y a written summary of this meeting on 16 November 2021. This summary states, in the meeting the Trust apologised its communication was not up to the expected standard and staff were not clearer or more sympathetic when communicating Mr Y’s diagnosis. The letter states, ‘I told you I was also very sorry the information provided about his prognosis was less than satisfactory’, before specifically addressing why the staff used the words ‘cautiously optimistic’.
18. Our Principles say organisations should be open and accountable. This means they should be ‘open and honest when accounting for their decisions and actions. They should give clear, evidence-based explanations, and reasons for their decisions.’
19. The Trust has accepted its communication regarding Mr Y’s diagnosis did not meet the expected standard. The Trust has apologised for this failing and provided an explanation for why it believes this failure happened. The summary of the bereavement meeting makes it clear the Trust was very sorry for this failing.
20. We have carefully considered this issue, and we are satisfied the Trust has appropriately accepted and apologised for its failure to clearly communicate Mr Y’s prognosis. This is in line with our Principles, which include providing apologies, explanations and accepting responsibility as ways to put right failings.
21. We recognise the failure to make it clear Mr Y would die led to Mrs Y having false hope, and added to the distress of her husband’s death. As Mrs Y has stated she wanted a full, complete apology from the Trust, the actions the Trust took to put this right were appropriate, in our view.
22. For this reason, we have decided not to consider the complaint further. We can see the Trust has taken Mrs Y’s complaint seriously and hope she will be reassured by our independent consideration.
Not being told about Mr Y’s cancer
23. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this, and we have not found any signs something has gone wrong.
24. Mrs Y has complained the Trust did not tell her or her husband Mr Y had cancer after the CT scan identified this on 13 June 2021.
25. On 24 May 2021, Mr Y consulted his GP, who sent him for a chest X-ray. The X-ray showed shadowing on the lungs, which led the GP to refer Mr Y to a specialist. He had a CT scan on 1 June 2021. This scan showed enlarged nodules, so doctors informed Mr Y he needed a biopsy. Prior to the biopsy taking place, on 13 June 2021 Mr Y was admitted to A&E with breathing difficulties, and he had a further CT scan. The Trust first became aware of Mr Y’s cancer after seeing the results of this scan on 13 June 2021.
26. The Trust’s summary of the bereavement meeting explains the consultant told Mr and Mrs Y that Mr Y had cancer after seeing the results of the CT scan on 13 June 2021. This is in line with a complaint Mrs Y initially included on her complaint form to us, reporting she was upset at how the consultant broke the news of Mr Y’s cancer. In our discussion with Mrs Y, however, she stated she appreciated the consultant’s bluntness when informing them Mr Y had cancer.
27. Mrs Y initially expressed dissatisfaction with how the consultant told them Mr Y had cancer after the second CT scan. The Trust has apologised for how the consultant initially gave this information to Mrs Y. Mrs Y has confirmed the consultant did tell them Mr Y had cancer. So, we have been unable to identify any sign of a failing in relation to this concern. For this reason, we have decided not to consider the complaint further.
The Trust’s decision to discharge Mr Y from hospital
28. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this, and we have not found any signs something has gone wrong.
29. The Trust admitted Mr Y to the Trust hospital through A&E on 13 June 2021, after NHS 111 advised him to attend. Mrs Y has described Mr Y as being ‘very breathless’ and stated his cough was ‘very bad’. When in A&E, Mrs Y has stated staff told him he would need to stay on the ward to receive strong IV antibiotics. The Trust then discharged him the following day. Mrs Y complained the Trust did not give Mr Y the strong IV antibiotics and believes this was a failing of the Trust, as the discharge papers showed Mr Y had pneumonia.
30. The Trust stated it discharged Mr Y on 14 June 2021 after a meeting between the consultant and the respiratory team. It said it decided the cancer, and not an infection, was causing Mr Y’s symptoms. It said it prescribed antibiotics in case there was an underlying infection. The Trust explained doctors changed Mr Y’s treatment to oral antibiotics, because the clinical diagnosis was cancer and further IV antibiotics were not clinically needed.
31. Our adviser explained there are three things which could indicate a need for Mr Y to stay in hospital: IV therapy, oxygen therapy or suction (where a device is used to remove secretions from the airways). Our adviser stated Mr Y did not need suction, based on information in the medical records.
32. NICE guideline 138 ‘Pneumonia (community-acquired): antimicrobial prescribing’ provides guidance on the types of antibiotics which doctors should use to treat pneumonia. It recommends giving oral antibiotics as the first line of treatment, if the person is able to take them, and the severity of their condition does not need IV antibiotics.
33. It also recommends doctors should use a patient’s CURB-65 score to help decide what antibiotics to prescribe. CURB-65 is a tool used in hospitals to assess the severity of pneumonia. It is based on the patient’s level of confusion, the level of urea (the main waste component of urine) in the blood, their breathing and heart rates, and age.
34. Our adviser said Mr Y’s medical records showed he would have had a score of 2 on the CURB-65 metric. The NICE pneumonia guidance states for a CURB-65 score of 1 or 2, the first choice of treatment should be oral antibiotics. This indicates the Trust acted in line with the guidance by providing oral antibiotics.
35. When in hospital, the Trust gave Mr Y the antibiotics benzylpenicillin intravenously initially, and then co-amoxiclav and doxycycline orally. Benzylpenicillin is a narrow spectrum antibiotic (it will treat only one type of bacteria), whereas co-amoxiclav and doxycycline are broad spectrum antibiotics (they will target a wider range of bacteria), and so would have been more likely to help Mr Y.
36. On 13 June 2021, when Mr Y was admitted to hospital, his initial oxygen levels were low and he needed oxygen therapy. On 14 June 2021, Mr Y’s recorded oxygen level was 93%, which our adviser said was slightly low, as ideally it should be 95% or above. The records show the respiratory team reviewed Mr Y before the decision to discharge him and found his oxygen level was 95% on room air. This is considered a normal oxygen level, which means ongoing oxygen therapy was not needed.
37. A review of the medical records has shown Mr Y did not require IV therapy, oxygen therapy or suction. The evidence indicates the Trust followed the relevant guidelines when making the decision to discharge Mr Y.
38. Based on this, there is no sign of failings relating to the decision to discharge Mr Y on 14 June 2021. So, we will not consider the issue further for this reason.
39. We recognise Mrs Y may be disappointed with this decision and we are sorry for any distress it causes. It is our role to be objective and transparent in explaining our decision. We hope Mrs Y understands the reasons for our decision.