South Tyneside and Sunderland NHS Foundation Trust

3. Ms D complains about the care and treatment given to her father, Mr O, by South Tyneside and Sunderland NHS Foundation Trust (the Trust) from December 2015 to 26 May 2021. Ms D says Trust staff failed to diagnose her father’s asbestosis and missed opportunities to diagnose his lung cancer earlier, in particular:

• The Trust did not adequately take into account to Mr O’s prior asbestos exposure in his treatment and diagnosis during investigations December 2015 - January 2017, while Mr O was under observation with the chest clinic.

• The Trust did not follow up on Mr O’s abnormal X-ray in April 2020 and did not adequately take into account to Mr O’s prior asbestos exposure at this time.

• The Trust did not follow up on Mr O’s abnormal X-ray in December 2020, and did not adequately take into account to Mr O’s prior asbestos exposure and history of smoking at this time.

• The Trust cancelled Mr O’s scheduled biopsy in January 2021 and did not adequately take into account to Mr O’s prior asbestos exposure and history of smoking at this time.

4. Ms D says Trust staff did not communicate with the family well. They failed to tell Mr O and his family the purpose of some of the tests they were doing, and the abnormal X-ray results and were insensitive in the way they informed the family of the lung cancer diagnosis. She says the Trust did not confirm Mr O’s diagnosis in writing.

5. Ms D also complains Trust staff inserted an unnecessary and painful chest drain on 9 March 2021.

6. Ms D says her father’s lung cancer was not diagnosed until April 2021, by which time Mr O was too ill to undergo treatment. She says if Mr O’s lung cancer and asbestosis had been identified earlier, treatment to cure him or extend his life may have been available. She says this contributed to Mr O’s stroke and meant he died sooner than he would have with earlier diagnosis and care.

7. Ms D says there was a financial impact, Mr O did not receive benefits or lump sum payments linked to his industrial injuries, which he may have been entitled to if he had been diagnosed. She says this means his life was not as comfortable as it could have been.

8. Ms D says she has also been left with the debts of the estate. She says it has cost time and money in trying to get answers about Mr O’s death, through the Trust and the inquest.

9. Ms D says the chest drain added to Mr O’s pain and discomfort, and it compounded his family’s distress and worry.

10. Ms D says there was an emotional impact on Mr O and the whole family beyond what would be expected with a terminal diagnosis. This was caused by the failure of the Trust to tell the family they were doing certain tests to check for cancer and not informing them of the abnormal X-rays. Ms D says her father was ‘devastated’ and his family were ‘shocked’ when they were given the terminal diagnosis, as they thought this had already been ruled out. Ms D believes this emotional impact accelerated her father’s death.

11. Ms D would like an apology and explanations from the Trust. She seeks proof the issues she has raised have been addressed and will not happen to anybody else.

12. Ms D is seeking compensation for the distress caused by the failings in her father’s care and treatment and for the time, money and effort she has had to spend in pursuing her complaint. Ms D also seeks compensation for the payments her father missed out on.

13. On 28 November 2015, Mr O’s GP referred him to the Trust’s Chest Clinic for suspected lung cancer. Mr O was seen a number of times. He was discharged from the clinic on 28 November 2017 as he was stable and had no symptoms of immediate concern.

14. In April 2020, Mr O was admitted to Sunderland Royal Hospital, with a suspected COVID-19 infection. He tested negative for COVID-19 but a chest X-ray was abnormal. Doctors prescribed antibiotics for a chest infection and discharged him.

15. On 11 December 2020, Mr O went to Sunderland Royal Hospital Accident and Emergency (A&E) Department with shortness of breath and four to five days of back pain. He was diagnosed with atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). He was given blood thinning medication and discharged.

16. On 30 December 2020 Mr O’s GP referred him to the Trust’s Chest Clinic for possible cancer due to recent weight loss, and he was seen on 4 January 2021. Mr O was scheduled for a camera and biopsy procedure for 11 January, but this was cancelled because the CT scan and blood test results indicated Mr O had a lung abscess, which was treated with antibiotics.

17. There was a period to see whether the antibiotics had resolved the issue, and further investigations were carried out. On 9 March 2021 Mr O had a lung biopsy, which confirmed Mr O’s lung cancer diagnosis (squamous cell carcinoma). On 15 April, a multidisciplinary team (MDT) meeting discussed Mr O’s case. A holistic needs assessment was done the following day.

18. On 29 April 2021, Mr O was reviewed in the Oncology Department at another Trust. Staff told Mr O he had advanced stage three lung cancer and due to his comorbidities and the size of the tumour, a cure was unlikely. He was suitable for palliative treatment only. A second opinion confirmed palliative radiotherapy was appropriate.

19. Mr O collapsed on 20 May 2021 and was admitted to Sunderland Royal Hospital. Staff thought he may have had a stroke and a heart attack. He was put on an end-of-life care plan. Sadly, Mr O died on 26 May 2021.

20. The coroner recorded his cause of death as 1a Bronchopneumonia 1b Cerebral Infarction (stroke), Chronic Obstructive Pulmonary Disease and Asbestosis. His conclusion was that Mr O died due to ‘a combination of natural causes and industrial disease’.

25. Ms D was concerned that there were missed opportunities to diagnose her father sooner. He was eventually diagnosed with lung cancer in early 2021 and died in the May of that year. He had been seen and had tests in 2015 - 2017, April and December 2020 before that.

26. She was concerned about whether doctors took into account her father’s history or exposure to asbestos and of smoking and whether scan images had been interpreted correctly.

27. Asbestos is a building material used from the 1950s to the 1990s. People who worked in industries such as building or construction during that period may have been exposed to it and are at risk of asbestosis. The Asthma + Lung UK website explains ‘Asbestosis is a long-term lung condition caused by breathing in asbestos fibres. Asbestosis causes scarring of the lungs. It is a type of interstitial lung disease (ILD). Asbestosis usually develops around 20-30 years after breathing in asbestos fibres.’ Exposure to asbestosis also increases the risk of lung cancer.

28. Lung cancer and asbestosis are both conditions for which imaging plays an important role in diagnosis. The NHS website explains:

‘A chest X-ray is usually the 1st test used to diagnose lung cancer. Most lung tumours appear on X-rays as a white-grey mass… However, chest X-rays cannot give a definitive diagnosis because they often cannot distinguish between cancer and other conditions, such as a lung abscess… If a chest X-ray suggests you may have lung cancer, you should be referred to a specialist in chest conditions. A CT scan is usually the next test you'll have after a chest X-ray.’

and

‘Tests [for asbestosis] may include: a chest X-ray; a CT scan of the lungs; lung function tests to see how well your lungs are working.’

29. We considered whether there were unreasonable delays in diagnosing Mr O.

Treatment and diagnosis December 2015 to January 2017

30. During this period, Mr O was seen at the Trust’s chest clinic, having been referred by his GP for suspected lung cancer. We considered whether the doctors sufficiently took into account Mr O’s prior exposure to asbestos and history of smoking, in line with clinical standards as described in Good Medical Practice, which tells doctors:

‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: • adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.’

31. After a patient is seen in a clinic, the clinician usually writes to the GP to explain such things as why they were seen, their relevant history, findings, investigations carried out or planned, diagnosis and management plan. These letters serve as a record of the consultation.

32. We saw that the clinic letters between 2015 and 2017 recorded Mr O’s history of smoking and exposure to asbestos. Our respiratory adviser says that appropriate investigations were carried out to assess for diseases associated with smoking and asbestos exposure; lung function test, a CT scan and a bronchoscopy, which is a test to look at the inside of the breathing tubes (airways) in the lungs. This was in line with Good Medical Practice.

33. The CT scan in 2015 reported emphysema, which is a type of lung damage that can happen with chronic obstructive pulmonary disease (COPD), and pleural plaques (thickening of the lung lining). There was no asbestosis (scarring fibrosis damage within the lungs) apparent. A chest X-ray in 2017 also reported Mr O’s lungs were clear. The breathing tests demonstrated COPD, not asbestosis.

34. Our radiology adviser reviewed the chest X-ray of 7 November 2017. It shows emphysema and bilateral calcified pleural plaques, which indicates previous asbestos exposure. There is no evidence of asbestosis or lung cancer on this image.

35. The evidence from this period shows there was no indication that Mr O should have been diagnosed with asbestosis or lung cancer.

April 2020

36. Mr O was admitted to hospital on 4 April 2020 for suspected COVID-19 and had a chest X-ray. Our radiology adviser has reviewed the image and says it shows emphysema and pleural plaques, which were the same as the X-ray in 2017.

37. There was new consolidation in the lower part of the left lung. In this context ‘consolidation’ means air in the lungs is replaced by fluid or something else. This suggested Mr O had an infection. The X-ray report at the time noted this but it did not clearly state Mr O probably had an infection. It should have been followed up in line with the British Thoracic Society Guidelines, which say ‘A chest radiograph should be arranged after about 6 weeks for all those patients who have persistence of symptoms or physical signs, or who are at higher risk of malignancy (especially smokers and those aged >50 years)’. So a follow-up chest X-ray should have been offered to Mr O due to his age and smoking history to exclude underlying lung cancer. This is in line with evidence the coroner received from an independent expert witness.

38. We understand why Ms D was concerned that this was not followed up as it should have been. We considered what effect this had. We can reassure her that having reviewed later evidence, we saw no indication this delayed her father’s diagnosis. Our radiology adviser explained the consolidation later resolved and was not due to lung cancer. The lung cancer which eventually developed was in Mr O’s right lung and was not diagnosable on this X-ray image.

39. In the records from April 2020, Mr O’s history of smoking and exposure to asbestosis were noted, along with the previously diagnosed of COPD and pleural plaques. Our respiratory adviser says that no additional action was required regarding this. The chest X-ray did not show any sign of asbestosis or cancer, and as such, there is no indication either should have been diagnosed at this time.

A&E Investigations December 2020

40. Mr O went to A&E on 11 December 2020 complaining of shortness of breath and back pain for the last few days. He had an X-ray, which our radiology adviser has viewed. She explains it shows a cavity in the right mid-lung, which was missed by the reporting radiologist. A cavity in this regard is a collection of fluid. The Trust’s complaint response explains that as part of its investigation, another radiologist reviewed this X-ray and saw the cavitating lung lesion.

41. The records show doctors were aware of Mr O’s history of smoking and exposure to asbestos, as well as his exiting diagnoses of COPD and pleural plaques. No additional action was required regarding this. The diagnosis on this attendance was atrial fibrillation, which is a heart problem. Symptoms can include shortness of breath.

42. If the cavity had been noted at the time, the Trust would probably have arranged for Mr O to have a CT scan as an outpatient. Our respiratory adviser explains that scans in this situation are normally completed within two weeks, so in this case it would have been around the end of December.

43. When Mr O attended clinic in early January (which we describe below), the chest physician reviewed the image, saw the cavity and arranged an urgent CT scan. Therefore, the CT scan took place within a week or two of when it would have if the cavity had been picked up. We understand why Ms D would be concerned about this omission. We can reassure her that our advisers explain that the delay was not so significant as to impact her father’s treatment and prognosis.

Investigations and diagnosis from January 2021

44. On 30 December 2020, Mr O’s GP referred him again to the Trust for suspected lung cancer due to recent weight loss. At the time, the NHS had a target of two weeks for a person to see a specialist after being referred for suspected cancer. Over 90% of people referred for investigations this way are not diagnosed with cancer. (www.cancerresearchuk.org/cancer-symptoms/what-is-an-urgent-referral) In accordance with this target, Mr O was seen in the respiratory clinic on 4 January 2021 and had a CT scan on the same day.

45. The CT scan showed a cavitating mass in the right lung containing fluid and gas. Our radiology adviser says this was reportedly appropriately and a diagnosis of a lung abscess was made. This is a collection of pus within the lung that leads to a cavity. Abscesses are most commonly caused by infections. Given Mr O had a recent history of weight loss and previous history of smoking and exposure to asbestos, our radiology adviser says the reporting radiologist should have suggested lung cancer as a possible alternative diagnosis. However, an abscess was a reasonable main diagnosis given its appearance and the fact that that recent blood results showed raised CRP and white cell count levels, which suggested the presence of infection. Therefore, after this CT scan it was reasonable to treat the abscess with antibiotics in the first place, with a plan to repeat the CT scan at a later date. BMJ Best Practice says that the main treatment for lung abscess is antibiotic therapy.

46. Due to his emphysema, Mr O was at high risk of complications, such as collapsed lung, from a lung biopsy. (This is a procedure where tissue samples are taken and examined in order to establish the presence of disease.) It was reasonable not to perform the lung biopsy at this time because investigations pointed to lung abscess as the most likely diagnosis. It was appropriate to treat Mr O with antibiotics to see if they resolved the problem.

47. The next CT scan took place on 17 February 2021 to establish what if anything, had changed after Mr O had been taking antibiotics. The mass was still present, so doctors arranged for him to have a lung biopsy on 9 March. They also undertook a mediastinal lymph node biopsy on 12 April. Our respiratory adviser says these investigations were in line with the NICE guidance, which says:

1.3.2 Offer people with known or suspected lung cancer a contrast-enhanced chest CT scan to further the diagnosis and stage the disease.

1.3.15 Offer image-guided biopsy to people with peripheral lung lesions when treatment can be planned on the basis of this test 1.3.16 Biopsy any enlarged intrathoracic nodes (10 mm or larger maximum short axis on CT)

48. The biopsy led to the diagnosis of lung cancer.

49. With regard to a drain, our respiratory adviser explains the lesion contained fluid, which is commonly due to a lung abscess rather than lung cancer. Inserting a drain for was in line with BMJ best practice guidance. In addition, the drain allowed for additional samples to be taken from within the lesion, which were sent for testing. We appreciate this was a painful and distressing procedure for Mr O, but it was appropriate action to take.

50. Mr O’s asbestosis was revealed during the post mortem. Our radiology adviser said there is no evidence on the scans for the diagnosis to have been made when he was alive.

51. When he was diagnosed with cancer, Mr O was unfortunately not suitable for radical treatment. This was because of his co-morbidities, that is to say his other health problems, the most significant of which was his severe emphysema. Furthermore, the cancer was large and had spread elsewhere in the right lung. We do not consider there was an undue delay in diagnosing Mr O, but if the cancer had been diagnosed sooner in 2021, it is very unlikely that he could have received further treatment or that the outcome would have been different.

Communication

52. Ms D told us she was unhappy with the lack of information her father received about this diagnosis. In its first response, the Trust noted discussions with Mr O about the possibility of cancer were recorded on 5 January, 16 March and 8 April.

53. We saw than after the appointment of 4 January 2021, the consultant wrote to the GP saying ‘I had the pleasure of meeting Mr O and his daughter Gillian this morning.’ Having seen images from a CT scan that morning, the consultant said ‘I advised him that there is a fluid filled thick-walled cavity in his right lung. I advised him it may relate to infection or malignancy.’ Mr O was copied in to this letter.

54. After a phone appointment on 1 March 2021, the same consultant wrote to the GP ‘I had the pleasure of speaking to Mr O and his daughter Gillian over the phone this morning. I advised them we plan for a CT guided lung biopsy/aspiration of his right ling mass lesion. I briefly explained the procedure and its rationale.’

55. After a clinic on 16 April 2021, the chest consultant wrote to a consultant oncologist at Freeman Hospital (which is managed by a different Trust) saying ‘I met Mr O and his daughter in clinic this afternoon… I advised Mr O about the diagnosis of squamous cell carcinoma of the lung. I advised him that the plan of the multi-disciplinary team is to refer him to clinical oncology for consideration for radiotherapy. He is keen to meet you to discuss treatment options.’ In its response, the Trust apologised for not sending a copy of this letter to Mr O. It had been unable to establish why this did not happen but presumed it was due to human error.

56. We note that on 29 April 2021, Mr O saw the oncologist at Freeman Hospital, who wrote back to the chest consultant at Sunderland saying ‘I met with Mr O in oncology today alongside his daughter, Ms D. I explained that he has an advanced lung cancer which is currently stage III and due to his comorbidities and the size of the tumour, that cure is unlikely.’

57. Good Medical Practice tells doctors: ‘You must give patients the information they want or need to know in a way they can understand’. Records of discussions cannot always be verbatim accounts of what was said and we cannot say exactly how the conversations went. We recognise that such encounters can be difficult emotionally patients and any relative with them. Evidence showed that the chest consultant considered he had explained to Mr O the purpose of investigations and what they were considering in terms of possible diagnosis and treatment. This appears to be in accordance with Good Medical Practice. We recognise that communication fell below the family’s expectations but we do not see that we can conclude there was a failure in this regard.

1. Ms D complained to us about her late father’s care and treatment and principally about what she considers to be a failure by Tyneside and Sunderland NHS Foundation Trust to diagnose him in a timely manner.

2. We found that Mr O’s lung condition was investigated and diagnosed appropriately between 2015 and 2021. We did not see any evidence that there was a lost opportunity for an earlier diagnosis of cancer or for a better outcome. Therefore, we do not uphold the complaint.