January 2018
15. Mrs E complains the Trust dismissed Miss L’s symptoms and did not properly investigate her abdominal pain when she presented at one of its EDs on 4 January 2018.
16. The Health Service Commissioners Act 1993 is the law that gives us our power to investigate complaints about the NHS. In line with this law, people must bring their complaint to us within 12 months of becoming aware of the problem. We can sometimes put this time limit to one side where there are good reasons for the delay, such as delays in complaint handling or extenuating personal circumstances. However, if there are any periods of unexplained delay in approaching our service, we are less likely to put the time limit to one side.
17. Miss L would have become aware of her symptoms being dismissed in January 2018. She did not raise a complaint about this at the time. We have seen nothing to indicate Miss L was unable to raise a complaint after attending the ED in January 2018.
18. Mrs E approached our service with this complaint on 3 October 2023. This means the complaint came to us four years and ten months outside our time limit.
19. Because the delay in approaching our service was so extensive, we would need to see exceptional circumstances to conclude we should put the time limit to one side. We have not seen evidence of compelling circumstances that could have prevented Miss L or Mrs E from raising a complaint with the Trust far sooner. Therefore, we are taking no further action on this part of Mrs E’s complaint.
Scan 20. Mrs E complains the Trust would not offer Miss L a scan, in January 2021, to check for cancer until she demanded one.
21. There is no record of Miss L asking for a scan, though we know she did have one after she presented at the Trust’s ED on 4 January. She had an ultrasound on 5 January, which found lesions in her liver. She then had a CT scan of her abdomen on 7 January. This complaint appears to relate to a comment made by the doctor in the ED, prior to these investigations taking place.
22. The Trust has apologised for the comment made by the doctor, and we consider this is sufficient to put right the impact of what may have happened here. This is because Miss L went on to have a scan the following day. She also had the investigations required to diagnose her cancer within the two-week national target in place at that time. This means that there was no clinical delay arising from the doctor making this comment. For one-off instances of poor service that have no wider impact, our Severity of Injustice scale says an apology is sufficient to put things right.
23. We do not know whether the doctor made this comment; however, the Trust has acknowledged that this is not behaviour it would expect of a doctor and apologised for the comment. There is nothing further we should ask the Trust to do to put things right, and this is why we are not taking further action.
Cancer symptoms 24. Mrs E complains the Trust failed to consider cancer as being behind her daughter’s symptoms due to her age, despite all her symptoms indicating she had cancer.
25. There is no record of Miss L approaching the Trust with these symptoms until 4 January 2021. She had previously attended the Trust’s ED in 2018 with chest pain, but between January 2018 and January 2021 she did not approach the Trust again.
26. It may be the case that Miss L had approached her GP during this time, but the Trust would not be aware of these symptoms unless her GP referred her to its services.
27. Aside from the comment from the ED doctor reported by Mrs E on 4 January 2021, there is nothing to indicate that the Trust failed to consider cancer. Miss L was diagnosed with cancer within three days of presenting at the ED. The results of the liver ultrasound clearly raised concerns about cancer and the further tests needed were arranged and completed within two days.
28. As all tests and investigations were completed within three days, and her cancer identified quickly, we cannot say the Trust failed to consider cancer may be behind Miss L’s symptoms. The Trust appears to have swiftly acted on her ultrasound results, which had revealed she may have cancer, and it undertook the required investigations as soon as it possibly could. There are no indications of service failure.
Surgery 29. Mrs E complains the Trust failed to prioritise and repeatedly cancelled Miss L’s surgery to remove a tumour from her colon, causing a delay of six months in undertaking this surgery.
30. We asked our surgical adviser whether there was a failure to prioritise surgery and whether there are any indications of a delay. They explained that, sadly, at the point of diagnosis Miss L had stage four cancer which had metastasised to her liver. By 30 March the Trust’s oncology team had identified that the tumour in her colon was inoperable, and chemotherapy commenced instead. Whilst there was some hope that if the chemotherapy improved her tumour size she may become eligible for surgery, this was not considered a suitable treatment option when the oncology team commenced treatment.
31. NICE guideline NG151 (colorectal cancer) provides national guidance on managing colorectal cancer. These guidelines state that pre-operative anti-cancer therapies (such as chemotherapy) should be considered before surgery. They explain that for people, like Miss L, who have a primary colon cancer with liver metastasis, surgery should be considered once a person is receiving systemic anti-cancer therapy (in this case, chemotherapy). This indicates it was appropriate to commence chemotherapy first, even if surgery had been a suitable option for Miss L.
32. Miss L was referred for palliative chemotherapy in March 2021, after the investigations revealed what type of cancer she had. These tests included biopsies and scans. These were important because the type of cancer will inform the type of treatment needed, and different treatments work better for different types of cancer.
33. Sadly, Miss L’s tumours remained stable despite treatment, meaning they did not get larger but they also did not improve. This meant her cancer remained inoperable.
34. She did have surgery on 2 August, but this surgery was emergency surgery to repair a perforation to Miss L’s bowel. It was not surgery to remove her tumour.
35. Our surgical adviser explained that there was no delay in undertaking this emergency surgery. Surgery took place within four hours of identifying the bowel perforation, which was in line with guidelines from the Royal College of Surgeons. This guidance recommends that high-risk surgeries should take place within six hours.
36. There are no indications of a delay in undertaking surgery whilst Miss L was being treated for colon cancer.
PICC line 37. Mrs E complains the Trust inserted a PICC line in April 2021 that was contaminated with soil.
38. In June, Miss L was admitted to hospital with a suspected infection. A microbiology swab taken from her PICC line identified an infective agent (bacteria). Our physician adviser explained that isolation of an infective agent taken from blood in a PICC line does not necessarily mean the line itself was the source of contamination. The blood in a PICC line includes blood that has already travelled all around the body and which may have picked up the infective agent from other areas inside the body.
39. PICC lines are plastic tubes that are inserted into blood vessels, and infective agents within the blood can stick to this plastic tube. Infections can also entre the blood via the PICC line. These are both recognised complications of PICC insertion, and Miss L was informed of this before consenting to the PICC line insertion.
40. Because the sample of blood from the PICC line included blood from other areas of Miss L’s body, it is not possible to know whether an infective agent entered through the line (contamination) or whether the infective agent came from inside Miss L’s body. Both options are equally plausible.
41. Because infection is a recognised complication of PICC line insertion, unless there was clear evidence of poor technique on insertion, it is impossible to say how the infective agent became present on the PICC line, even on the balance of probabilities. We have seen nothing to indicate the PICC line was not inserted correctly.
42. What we can say is infection is a recognised complication of PICC line insertion and Miss L was made aware of this. She consented to insertion of the PICC line with this knowledge. Our physician adviser also explained that once Miss L presented with symptoms of infection and an infective agent was isolated from the PICC line, it was removed as a precaution. This was in line with the GMC’s Good Medical Practice guidance and we have seen no indications of service failure.
Sepsis 43. Mrs E complains the Trust delayed in providing the correct treatment when Miss L was admitted to hospital with sepsis in June 2021.
44. Our physician adviser explained that Miss L had two admissions to hospital in June 2021 and did not meet the diagnostic criteria for sepsis.
45. Sepsis is a dysregulated response to infection where the person’s organs stop functioning properly. Clinicians use the NEWS2 tool to assess patients’ level of organ dysfunction. According to NICE Guideline NG51 (sepsis) a score of less than five indicates a low risk of organ dysfunction. Diagnosing sepsis requires clinical judgement, but clinicians use the NEWS2 scoring system to inform this and will usually suspect sepsis if this score is five or above.
46. Our physician adviser also explained that sometimes people use the word ‘sepsis’ when they are talking about an infection. It is important to be clear that sepsis and infection are not the same thing. The correct treatment for both sepsis and an infection are the same, however. The first-line treatment for suspected sepsis is to treat the underlying infection with broad spectrum antibiotics, with supportive treatment such as fluids.
47. Miss L was admitted to hospital on 5 June due to a high temperature and a positive blood culture. Her NEWS2 score was two, which indicated a low risk of organ dysfunction and did not indicate she may have sepsis. The Trust treated her infection with antibiotics, which was in line with NICE Guideline NG51 and the GMC’s Good Medical Practice guidance.
48. She was admitted to hospital again on 23 June due to high inflammatory markers on a routine blood test. Her NEWS2 score was between three and four, which was below the threshold for suspecting sepsis. The Trust treated her symptoms with intravenous antibiotics, which was in line with NICE Guideline NG51 and the GMC’s Good Medical Practice guidance.
49. The evidence indicates Miss L did not have sepsis in June 2021. The doctors treated her for an infection twice that month, which may have become confused with the term ‘sepsis’. The treatment provided was in line with the relevant guidance and there are no indications of service failure.
Chemotherapy 50. Mrs E complains the Trust delayed in providing chemotherapy due to incorrect and inadequate information about freezing Miss L’s eggs before undergoing treatment.
51. Miss L had her first oncology appointment on 30 March and commenced chemotherapy within two weeks of this appointment. Prior to this, the Trust were undertaking necessary investigations into her cancer to inform treatment options.
52. Fertility was referenced in clinic letters dated: • 15 March (reference to fertility considerations at multidisciplinary meeting, whilst diagnostics were ongoing) • 8 March (clinic letter from the colorectal surgery department briefly references she may want to have children in future, and she was going to discuss this with the oncologist).
53. There is only one reference to the option for freezing Mrs L’s eggs in her records, which is in the oncology appointment notes for 30 March. The oncologist noted Miss L had discussed freezing her eggs with the multidisciplinary team prior to attending the oncology appointment. At the appointment on 30 March, the oncologist noted Miss L ‘was not keen’ on this option.
54. The time between when Miss L was first diagnosed with cancer and her first oncology appointment was approximately 2.5 months. During that time, she was undergoing diagnostic procedures that were not related to freezing eggs for future pregnancies. The topic was discussed in the first appointment with the oncologist, and Miss L said she did not want to freeze her eggs. Chemotherapy then proceeded as planned.
55. The evidence indicates that there were no delays in commencing chemotherapy that could be attributed to fertility considerations. Based on the evidence we have seen, the 2.5 months between diagnosis and the first oncology clinic was spent identifying the specific type of cancer Miss L had and identifying where it may have metastasised to. This is important to do before starting treatment because not all types of cancer are the same (even if they are in the same place) and different treatments work best for different cancers.
56. We can understand why this must have felt like such a long wait for Miss L and her family. It is natural to want treatment to start as soon as possible whenever a person discovers they have cancer. The evidence indicates the time taken to start treatment was because of diagnostic procedures, and not conflicting fertility information.ICU 57. Mrs E complains the Trust moved Miss L from its ICU on 3 August 2021, and failed to readmit her to the ICU when it was clear she needed intensive observation and treatment.
58. Our physician adviser explained that when Miss L was discharged from the ICU on 3 August, she was clinically stable and her NEWS2 scores were below five. This is important because for people with a NEWS2 score under five, standard ward-based care is recommended, in line with the guidelines from the Royal College of Physicians. This means that her clinical condition did not require ICU treatment, or any enhanced or critical care at that time.
59. Following discharge from ICU, she was reviewed on 3 and 4 August by the Critical Care Outreach team, which noted she was stable and her NEWS2 score was four. This indicated that standard, ward-based care should continue. Between 5 and 10 August, her NEWS2 score ranged from one to four, which meant this care should continue. Our physician adviser explained that this indicates she was clinically stable and did not need an ICU admission at that time.
60. Based on the evidence in Miss L’s medical records, her clinical condition was stable from 3 August and her NEWS2 scores indicated she needed standard, ward-based care. Therefore, there are no indications of service failure with regards to the decision to step down her care. She also remained clinically stable, meaning she did need to be cared for in the ICU at that time.
Blood clot 61. Mrs E complains the Trust failed to appropriately prevent a blood clot that developed in Miss L’s arm in August 2021.
62. Our physician adviser explained that the Trust should have managed Miss L’s risk of blood clots in line with NICE guideline NG89 (VTE in over 16s). In line with this guidance it should have:
• completed a risk assessment as soon as possible on admission to hospital • considered medications to reduce the risk of developing a VTE.
63. The Trust undertook a VTE risk assessment on 2 August, when Miss L was admitted to hospital. It also prescribed heparin (Enoxaparin), which is a type of medication that reduces the risk of blood clots, from 4 August. The dose was increased from 9 August. This was in line with NICE Guideline NG89. The nurses documented that the medication was administered as prescribed.
64. The interventions undertaken prior to identifying Miss L’s blood clot in August 2021 appear to have been in line with the national guidance and there are no indications of service failure.
Follow-up treatment 65. Mrs E complains the Trust delayed in actioning follow-up treatment after Miss L developed peritonitis on 9 August 2021.
66. Peritonitis is inflammation of the lining of the inner wall of the abdomen. There are a number of reasons why a person may develop peritonitis, including infection. Miss L had emergency surgery for a perforated bowel on 2 August. Following this surgery, she was prescribed antibiotics.
67. On 6 August the Trust noted Miss L’s abdomen was tender and queried whether she may have faecal peritonitis, which may have occurred due to the perforation in her bowel. The Trust documented a discussion with microbiology colleagues around whether a different type of medication should be used to treat this on 6 August. The same day the microbiology team recommended changed the type of antibiotics she was taking if she did not improve.
68. Our surgical adviser explained there was no delay in treating Miss L’s peritonitis. This appears to be in line with the GMC’s Good Medical Practice guidelines, which state appropriate treatment should be provided promptly. We have seen no indications of service failure.
Pain relief 69. Mrs E complains the Trust delayed in providing Miss L with appropriate pain relief after stopping her morphine infusion on 10 August 2021.
70. Our physician adviser explained that there is no specific guidance as to what medication should have been prescribed; however, we would expect the Trust to have provided suitable treatment and referred Miss L to another practitioner, if needed, in line with the GMC’s Good Medical Practice guidelines.
71. On 6 August the Trust’s Pain Management team reviewed Miss L’s pain relief and discussed switching her from the patient-controlled morphine infusion to an oral, slow-release form of pain relief. Miss L agreed to this change in medication. Quick release oral (liquid) morphine was also prescribed in case she had any breakthrough pain (pain that ‘breaks through’ the prescribed pain relief, which is common in cancer patients).
72. The Pain Management Team reviewed Miss L again on 9 August, and Miss L told them she did not like the liquid morphine, and this was switched to a drug called oxycodone (another strong painkiller). A further review took place on 10 August, and the Pain Management Team recommended that the clinical team re-start the patient-controlled morphine infusion. This remained in place until Miss L’s death. Our nurse adviser has confirmed that all medications were given as prescribed up until her death.
73. Based on the evidence we have seen, there was no delay in providing pain relief after Miss L’s patient-controlled morphine infusion stopped in August 2021. The doctors obtained specialist pain management advice on multiple occasions, and whilst this did result in changes to Miss L’s pain management plan, there were no gaps or delays in providing pain relief. When her patient-controlled infusion was stopped, this was because the specialist pain team recommended a different painkiller to manage her pain. The Trust appears to have acted in line with the GMC’s Good Medical Practice guidelines, and there are no indications of service failure.
Observations 74. Mrs E complains the Trust failed to undertake regular observations of Miss L whilst in hospital.
75. Our nurse adviser explained that the frequency of observations is usually informed by a patient’s NEWS2 score. This national framework measures six physiological parameters assess acute illness severity and enables monitoring of a patient’s condition throughout their hospital stay.
76. The guidance from the Royal College of Physicians sets out how frequently a person should be observed based on their NEWS2 score:
• score of zero – 12 hourly observations • score of one to four – four to six hourly observations • score of five or six – hourly monitoring • score of seven or more – continuous monitoring.
77. Our nursing adviser reviewed Miss L’s NEWS2 scores and told us that she was observed more frequently than required by the Royal College of Physicians’ guidance. We have not listed each time her observations were monitored and her NEWS2 score at that time as this would not be proportionate for such a long period of care. Our nursing adviser confirmed they had reviewed all pages in Miss L’s medical records where her observations and NEWS2 scores were recorded, and has confirmed Miss L was observed frequently and in line with the guidance from the Royal College of Physicians.
78. The evidence indicates Miss L was regularly observed during her hospital admissions and her observations were undertaken more frequently than required by the national guidance. We have seen no indications of service failure.
79. We recognise that Miss L’s diagnosis and her short prognosis must have been devastating for her family, especially her young son. When someone dies so young from such an unexpected illness, it is natural for families to have serious concerns about whether something went wrong. We hope our primary investigation helps to reassure Mrs E that there are no indications of service failure in the care provided to her daughter during this difficult time.