Diagnosis 16. Mr D says his wife went to the Trust many times with nosebleeds during 2019. He is concerned because the Trust’s information leaflets say this can be a sign of cancer, but the Trust did not investigate this. He also says when his wife was diagnosed with a tumour in June 2020, the Trust did not follow this up until his wife had more symptoms in May 2021 and then it diagnosed a malignant tumour (cancerous).
17. Mrs D attended the ED in July 2019 with ongoing nosebleeds. On 1 August at a follow up clinic appointment it was noted that Mrs D’s bleeding had settled with the use of antiseptic and steroid creams. Mrs D had a small procedure to cauterise her nostrils on the same day and was discharged with the advice to return to the ED should she experience any more symptoms.
18. NICE guidance on how to manage ongoing nosebleeds says treatment for this should be prescribing antiseptic creams and nasal cautery (a procedure for nosebleeds).
19. The management of Mrs D’s nosebleeds was in line with the NICE guidance. Our adviser has explained there is no recommendation in these guidelines to look for cancers in other parts of the body when a patient presents with ongoing nosebleeds. This means the Trust would not have been expected to look for signs of this at this time based on the symptoms Mrs D had.
20. After being admitted to the Trust in June 2020 with abdominal pain, Mrs D had a CT scan and a mass was found and diagnosed as a haematoma. It noted this was due to the vessels in the abdominal wall bleeding because Mrs D was taking warfarin, an anticoagulant (blood thinning) medication. A follow up scan in July 2020 showed the mass had decreased slightly in size consistent with a haematoma, so Mrs D was discharged. The Trust said this was standard practice.
21. As part of our consideration, we asked our radiology adviser to review both CT scans from June and July 2020 to see if the Trust had correctly diagnosed Mrs D. We asked if it had followed the correct guidelines in discharging her from the service after this diagnosis.
22. Our radiology adviser explained that the Trust’s diagnosis of a haematoma after the first scan was correct. But they did not agree that the haematoma was due to the vessels in the abdominal wall bleeding because Mrs D was taking warfarin. They explained the haematoma was more centred in the fold of membrane that attaches the intestine to the abdominal wall. So it was not linked to Mrs D taking warfarin.
23. Our radiology adviser explained that after the second scan, the haematoma had slightly reduced in size. But, compared to the CT scan in June, the haematoma now showed an abnormality which was irregular in shape and size and was inseparable from the small bowels with a few loops of the surrounding small bowel displaying a thickened wall. They explained that while a haematoma could become more organised and contain content of mixed density, a soft tissue lesion could not be excluded. These findings show the possibility of an underlying small bowel lesion.
24. The UK clinical practice guidelines say in cases like Mrs D’s, the Trust should have referred her to a multidisciplinary team (a team made up of health professionals from different specialisms) to review the scans. In particular, this should have happened because of her recent episode of bleeding. It says a repeat CT abdomen and pelvis scan with contrast should also have been planned for in three months’ time.
25. We have found that the Trust got it wrong when it did not report on Mrs D’s follow-up CT scan correctly. Because of this it did not give Mrs D the follow up care she needed. We have gone on to look at the impact of this failing.
26. We asked our oncology adviser whether it is likely the diagnosis of the tumour would have been made sooner if Mrs D had been given a CT scan three months after the diagnosis of a haematoma. We asked if this would have given her more treatment options and prevented clinical deterioration.
27. The cancer.org study shows that an earlier diagnosis and treatment, where surgery is an option, gives a 95% five-year survival rate. If only medical treatment is an option, there is a 55% survival rate. Our oncology adviser explained that had Mrs D been diagnosed ten months before, her tumour might not have spread and she might have been able to have surgery. When it was diagnosed, surgery was no longer an option.
28. We have considered what the impact of this was on Mr D, who says his wife sadly died because of the Trust’s late diagnosis. He says watching her die in pain had a negative impact on the quality of his life and he worries constantly for his own health, should he become ill.
29. Although we might not be able to say Mrs D would not have died, her chances of survival had this ten-month delay not happened were potentially much higher. This is an injustice to Mr D because he has the uncertainty of not knowing if things could have been different.
30. In its final response, the Trust apologised for any miscommunication about the original scan. It has not acknowledged that it got anything wrong when reporting the original CT scans or with the follow-up care for Mrs D.
31. In line with our Principles for Remedy we would expect an organisation to acknowledge any failing we find and the impact of it. As the Trust has not done this, we uphold this part of Mr D’s complaint and make recommendations at the end of our report. We hope this action gives Mr D the reassurances he needs.
Treatment 32. Mr D says the Trust failed to treat his wife’s rheumatoid pain effectively in the last months of her life.
33. When Mrs D began cancer treatment in May 2021, she was taken off her longterm rheumatology medication, methotrexate, because of having chemotherapy.
34. During February and March 2022, Mrs D expressed concerns over the amount of pain she was in from her rheumatology symptoms. The options on how to manage this were discussed between the rheumatology team and oncology service. But Mrs D did not have a steroid injection to manage her pain until 5 May.
35. NICE guidance for the management of rheumatoid arthritis says monitoring should include rapid access to specialist care for flares and ongoing drug monitoring. Before her diagnosis and treatment, Mrs D’s rheumatology symptoms were being managed in line with this and she was taking methotrexate.
36. BSR safety guidelines say this medication should not be used in patients with a malignancy and they should be discontinued. The Trust acted in line with these guidelines when it stopped this medication and started Mrs D on chemotherapy.
37. There was still a responsibility to manage Mrs D’s rheumatology pain after this medication was stopped. Our rheumatology adviser explained the pain management would have been the responsibility of all teams including Mrs D’s GP.
38. Our rheumatology adviser explained that Mrs D had very little prescribed medication for pain relief when methotrexate was stopped. They explained this may not have been a major problem at first, but in the later stages of her illness this may have meant increased pain because of her active arthritis.
39. We have found that the Trust got it wrong when it did not manage Mrs D’s rheumatology pain in line with NICE guidelines. This is because when medication was stopped, no action was taken to manage her arthritis.
40. In its final response, the Trust apologised if the service Mr D experienced ‘fell below his expectations’ and caused frustration at the time. But it has not acknowledged the distress Mr D experienced at seeing his wife in pain, which could have been avoided.
41. The Trust has not acted in line with our Principles because it has not acknowledged this failing or the impact this had. We uphold this part of Mr D’s complaint and make recommendations at the end of our report. We hope this will give Mr D the reassurance and peace of mind he needs to address his concerns.