Pre-operative management
24. 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 the Trust aims to provide Mrs I with an apology and a detailed explanation of the concerns we found below.
25. Mrs I is unhappy about the handling of her situation up to her diagnosis of cancer. Mrs I says there were several red flags with the conversations before her operation.
26. Mrs I complains she should have been treated as if there could be cancer. She says the consultants should have focused on her history of gynaecology issues, such as being perimenopausal (a natural period of transition, which begins several years before menopause) and having endometriosis.
27. The Trust responded to Mrs I concerns during a meeting and in its complaint response letter. The Trust refers to Mrs I’s care journey since 2001 which resulted in her being treated by the Trust’s endometriosis team.
28. The Trust explained an ovarian cyst was seen on her MRI scan and the radiology team were unhappy with the result.
29. The Trust explained her blood test for ovarian cancer markers could have been raised because of her endometriosis or a malignancy. The Trust held an MDT meeting to decide on the best way to manage Mrs I’s symptoms.
30. Given that Mrs I was perimenopausal and there were low suspicions of any cancer, the Trust explained Mrs I was referred for staging surgery and why a cyst would not be drained before surgery.
31. We have considered whether the planning before Mrs I’s operation was appropriate and if the Trust gave her the correct care.
The Trust took this action:
• 7 June - the MDT’s plan was to do a CT scan and blood tests • 28 June - the results from the CT scan showed possible ovarian cancer.
• 5 July - an MDT was held for staging laparotomy (incision made in the abdomen for a biopsy) • 23 July - an MRI showed possible ovarian cancer • 13 August - an MDT decided there was a low risk of cancer and referred Mrs I for staging surgery.
32. Our adviser informed us this work was completed in line with the NICE guidelines on suspected cancer which say:
‘measure serum CA125 (blood tests) in secondary care in all women with suspected ovarian cancer’.
‘if the ultrasound, serum CA125 and clinical status suggest ovarian cancer, perform a CT scan of the pelvis and abdomen to establish the extent of disease’.
33. The Trust followed the NICE guidance on suspected cancer which states ‘optimal surgical staging constitutes midline laparotomy to allow thorough assessment of the abdomen and pelvis’.
34. Based on the diagnostic work, the Trust followed the NICE guidance on suspected cancer before Mrs I’s operation and her laparotomy. We do not find anything went wrong with this part of Mrs I’s care.
35. We next looked at whether the Trust considered Mrs I’s history and delivered the appropriate care and treatment before her operation.
36. The records show Mrs I was seen by a gynaecologist on 25 January 2021, where it was observed she had an abdominal mass and pain. As she had a medical history of endometriosis and fibroids, the gynaecologist planned for further investigations.
37. On 28 March, Mrs I had an ultrasound scan (procedure that uses high-frequency sound waves to create an image of part of the inside of the body). The results of this showed a large left sided unusual ovarian cyst. She was referred to MDT on 24 May.
38. Our adviser told us there was an unusual delay from the time Mrs I had an ultrasound scan to the time she was referred to MDT.
39. NICE guidance on suspected cancer says, ‘if the ultrasound suggests ovarian cancer, make an urgent referral to a gynaecological cancer service’.
40. In terms of cancer waiting times, NHS providers guidance says there are currently eight main operational standards for cancer waiting times and three key timeframes for when patients should be seen or treated as part of their cancer pathway. These are, ‘two weeks, one month (31 days) and two months (62 days)’.
41. In Mrs I’s case, according to NICE guidance on suspected cancer her referral was urgent. This means she should have been seen within two weeks. NHS providers note ‘a maximum two-week wait to see a specialist for all patients referred with suspected cancer symptoms’. We consider the delay falls short of what we would expect from an organisation.
42. Our adviser told us while the care appears to be delayed, this, does not seem to have changed the outcome.
43. Our adviser says the cancer was confined to the ovary only until it was upgraded when the cyst ruptured during surgery. It was also confirmed by our adviser that Mrs I’s cyst was not changed due to the delays.
44. We understand this was a challenging time for Mrs I and we do not underestimate the stress she went through. Although we recognise the outcome of Mrs I’s ruptured cyst would have been the same, we understand it was worrying for her as she had to wait to be seen by a specialist.
45. Our ‘Principles for Remedy’ say ‘where maladministration [fault] or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise.’
46. As Mrs I wants service improvements as an outcome of her complaint, we asked the Trust whether it would be willing to accept the shortcomings we have found.
47. The Trust confirmed it will send a response to Mrs I with an apology and to explain its service improvements.
48. We hope this gives Mrs I reassurance and closure.
Cyst drainage
49. Mrs I feels worried for the future because of the rupture and cancerous cells entering her abdomen.
50. The Trust responded to Mrs I’s concerns in a meeting, as well as by commenting on this issue in its complaint response. The Trust explained the surgery was very complicated.
Mrs I’s large bowel was stuck to her cyst. When a cyst is covered by the bowel and in her case, her bladder, it is even harder for the naked eye to see. The Trust explains during her surgery, Mrs I’s bowel was going into the cyst and when the cyst was being removed, surgeons had to make a quick decision on whether to continue.
51. We asked our adviser whether the explanation given by the Trust was appropriate and accurate.
52. Our adviser told us the Trust explains the removal of an intact cyst would have involved removing part of Mrs I’s bowel. The risk of a colostomy (an operation that creates an opening for the colon or large intestine through the abdomen) was not valid. Our adviser said the simple explanation is the cyst ruptured while cutting it off the bowel and this could not be avoided.
53. Our adviser says the Trust suggests there was a reasonable alternative which is not realistic. Mrs I says in her complaint to us and the Trust, she got different explanations for what happened.
54. We understand this made Mrs I confused and her trust and confidence in the Trust has been affected.
55. Our ‘Principles of Good Administration’ say, ‘Public bodies should provide services that are easily accessible to their customers. Policies and procedures should be clear and there must be accurate, complete, and understandable information about the service’. We find the service Mrs I received falls short of what we would expect.
56. We have looked at the Trust’s complaint response to see what action it has taken to put things right for Mrs I.
57. The complaint response says, ‘… it would appear there was some confusion as [the doctor] was clear that he did not blame another surgeon for what happened, but he had stated that the cyst ruptured when the bowel surgeon removed it and acknowledged that the terminology used added to this misunderstanding’.
58. The Trust also says, ‘I would like to add my own sincere and heartfelt apologies to those already offered by [staff] for the anxiety and distress you experienced as a result of the comments made to you about your surgery which left you questioning whether a mistake had been made’.
59. The Trust outlined several service improvements which include:
feedback shared with staff to reflect on their discussions with Mrs I to make sure communication is clear and supportive in the future, to not cause confusion or upset to women in their care • improvement in communication, particularly at anxious times, so patients feel supported and informed • issues raised in Mrs I’s complaint to be shared and discussed within the wider gynaecology team to make sure everyone can learn from her poor experience and improve their practice.
60. This is in line with our ‘Principles of Remedy’ that say where poor service has led to injustice or hardship, organisations should try to offer a remedy that returns the complainant to the position they would have been in otherwise. We can see the Trust has made significant efforts to put things right for Mrs I through accepting what went wrong, apologising and making service improvements.
61. For these reasons, we are confident the Trust has taken steps to make sure Mrs I’s concerns are addressed in an appropriate way.
Poor communication
62. Mrs I feels communication with the Trust has been unclear and she was told by a doctor she is at high risk of cancer returning.
63. The Trust’s complaint response says, ‘it is completely understandable when your cyst was found to be malignant, why you would be concerned about your cyst rupturing and potentially causing any cancer to spread. I hope you were therefore assured to learn that whilst there are many types of cysts, and there was nothing the surgical team could have done to avoid the rupture of your cyst, the staging and classification you referred to was for staging purposes and did not mean that your prognosis could be worse’.
64. To consider Mrs I’s concerns in detail, we considered whether the Trust communicated well and if it could have improved its communication to put her mind at rest.
65. The Trust explained it could not rule out cancer completely and as Mrs I’s surgery was complicated, it was expected for the cyst to burst. It explains this was unavoidable and this was explained to her during the meeting. We have already found this was an appropriate explanation to give Mrs I.
66. The Trust’s response says the main issue discussed in their meeting was who caused the cyst to rupture and who was to blame for this. The Trust provided a similar explanation and apologised for any misunderstanding caused.
67. As we have explained in the previous section, the Trust has taken several steps to correct its communication errors. The Trust has provided reassurance about the high risk of cancer returning and made improvements in its communication.
68. We next considered whether the Trust communicated appropriately with Mrs I about other areas of her care.
69. Our adviser informed us there was no formal communication in relation to Mrs I’s first MDT referral on 24 May. We cannot see records of whether the outcome of her CT and MRI scans was appropriately communicated to Mrs I. We also cannot see that the results of Mrs I's ultrasound scan was communicated to her in good time, because the referral to an MDT was around two months later.
70. GMC ‘Good medical practice’ says, ‘you must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.’
71. We can see this did not take place and the communication falls short of what we would expect. We contacted the Trust to tell them this. The Trust said it will provide an explanation and apology to Mrs I.
72. Understandably, the events were distressing for Mrs I. We hope the outcome she wanted of service improvements brings closure to her concerns.