July 2020 hospital admission
Gallstones diagnosis
21. Mrs O presented to hospital on 3 July with abdominal pain and the clinical team diagnosed her with gallstones. Mr O is concerned the Trust should have diagnosed gallbladder cancer instead and removed her gallbladder. We understand why Mr O was so concerned about this given his wife’s later diagnosis.
22. Our surgeon adviser explained the symptoms of gallbladder cancer are similar to the symptoms of gallstones. They explained that gallbladder cancer is uncommon and that 70 to 80 percent of patients with a diagnosis of gallbladder cancer also have gallstones.
23. The NICE gallstone guidance explains what doctors should do if they suspect a patient has gallstones. It advises to offer an ultrasound to people with suspected gallstone disease. It also says to consider an MRCP.
24. We can see that following admission to hospital on 3 July, Mrs O had a CT scan which showed she had a dilated biliary tree. She had an ultrasound scan the same day followed by an MRCP scan on 7 July. The ultrasound scan and the MRCP scan both showed that Mrs O had gallstones and common bile duct stones.
25. Both our surgeon adviser and our radiologist adviser agreed that the diagnosis of gallstones was correct. Our radiologist adviser also confirmed that none of the scans taken during this admission showed Mrs O had gallbladder cancer.
26. Our radiologist adviser explained the radiologists reported on the scans correctly and in line with the radiology guidance. This guidance says a radiology report should be actionable and prompt appropriate care for the patient. It says it should answer the clinical question and include a tentative or differential diagnosis when an abnormality is seen.
27. Mr O feels that more testing should have occurred at this time to check if Mrs O had cancer in her gallbladder. In particular, he feels that a biopsy should have occurred.
28. The NICE suspected cancer guidance states that an urgent ultrasound scan should be done within two weeks to assess for gallbladder cancer if a patient has an upper abdominal mass. We can see no evidence that Mrs O had an abdominal mass and so we would not have expected the Trust to carry out any further testing to check for gallbladder cancer.
29. In summary, we consider the Trust acted in line with the NICE gallstone guidance in diagnosing Mrs M’s gallstones. The radiologist also reported on the scans correctly and there was no indication that Mrs O had cancer at the time. The national guidance would not have required the Trust to carry out any further testing at this point. We have not found any failings in this area of the complaint.
30. We were incredibly sorry to hear that Mrs O did go on to be diagnosed with cancer in March 2021. We can see how painful this was for Mr O.
Care following diagnosis of gallstones
31. Mr O feels the Trust should have removed his wife’s gallbladder during the admission to hospital in July 2020. He feels his wife’s requests to have this surgery were ignored. We were sorry to hear that Mr O felt his wife’s wishes were not respected.
32. The NICE gallstone guidance for managing gallstones in the bile duct recommends treating teams should offer bile duct clearance and surgery to remove the gallbladder.
33. We can see that during the admission, the clinical team performed an ERCP in line with the NICE gallstone guidance. The Trust discharged Mrs O’ home with the intention to arrange a follow up appointment. This was to decide on surgery for gallbladder removal.
34. The NICE gallstone guidance does not provide any timeframes for when removal of the gallbladder should occur following diagnosis. Outside the COVID-19 pandemic our adviser said the surgical team would ideally plan an operation within the first six to 12 weeks.
35. However, in April 2020, the NHS released the surgical prioritisation guidance in response to the COVID-19 the pandemic. This guidance describes levels of surgical priority ranging from level 1 (where an operation is required within 24 hours) up to level 4 (where surgery can be delayed for more than three months).
36. Based on this guidance, Mrs O’s surgery would have fallen into level 4 priority which means the Trust could delay it for more than three months. Mr O tells us Mrs O requested the surgeons perform the surgery whilst she was still an inpatient.
37. Our surgeon adviser said it was an acceptable plan to discharge Mrs O from hospital and arrange an outpatient appointment to discuss surgery. We can see that at the time, Mrs O’s life was not in immediate danger and so Mrs O did not need emergency surgery.
38. Taking this advice and guidance into account, we do not consider it was a failing for the clinical team to discharge Mrs M with a plan for a follow up. They could discuss Mrs O’s views about her care and treatment during this appointment. However, following discharge the Trust did not arrange this appointment. This means the Trust never offered Mrs M gallbladder removal surgery.
39. We consider this was a failing as this was not in line with the NICE gallstone guidance. The Trust has already acknowledged this did not happen and apologised. We discuss the impact of this in the ‘impact of failings’ section of this report.
Suspected cancer referral October 2020
40. Mrs O’s GP referred her back to the Trust on a suspected two-week cancer pathway on 14 October 2020. This was to rule out oesophageal or stomach cancer as she was suffering from difficulty swallowing. Again, we understand why Mr O is concerned the Trust did not diagnose cancer at this time and that it did not perform the correct tests.
41. The NICE suspected cancer guidance advises doctors should offer an urgent upper gastrointestinal endoscopy within two weeks to assess for oesophageal cancer in people with difficulty swallowing.
42. The Trust attempted the gastroscopy initially on 23 October in line with this guidance. In the medical records, it is documented this was poorly tolerated and so another gastroscopy was performed on 7 November. This diagnosed a non-cancerous oesophageal stricture (narrowing of the oesophagus).
43. Our surgeon adviser said the GP made the referral to exclude upper gastrointestinal cancer. They advised the Trust performed the correct test which cleared Mrs O of this form of cancer in line with the NICE suspected cancer guidance.
44. The treating team also recommended a follow up in the surgical clinic. It is not clear from the records why the Trust requested this. However, our surgeon adviser explained this likely would have been to discuss the ongoing management of Mrs O’ known gallstones.
45. Having considered this advice, we do not consider there were any failings in the initial care the Trust provided to Mrs M following this referral. We were also reassured the Trust acted in line with national guidance when it removed Mrs O from the suspected cancer pathway.
46. However, the Trust has acknowledged it did not arrange a follow up appointment for Mrs O. This was not in line with the GMC guidance which says to promptly arrange suitable advice, investigations, and treatment where necessary. We consider this a further failing.
Impact of failings
47. We have found the Trust missed two opportunities to arrange follow up appointments for Mrs O to explore the possibility of gallbladder removal surgery. We understand why this has left Mr O concerned the Trust missed an opportunity to diagnose Mrs O’s cancer sooner.
48. Our surgeon adviser explained that if Mrs O had these appointments, the Trust would have offered her elective gallbladder removal surgery. He explained the Trust would likely have diagnosed her gallbladder cancer during surgery.
49. It is now difficult for us to say at what stage Mrs O would have had these follow up appointments. It is also difficult to say when the Trust would have arranged the gallbladder removal surgery following these. This is because the events occurred during the COVID-19 pandemic.
50. As mentioned earlier, the surgical prioritisation guidance meant Mrs O’s surgery would been considered level 4 priority. This meant the Trust could delay it for more than three months and so Mrs M would not have had the surgery until October at the earliest, but possibly even later.
51. We asked the Trust how long its wait times were at the time. The Trust said it was unlikely Mrs O would have had an outpatient appointment and elective surgery by the time she was readmitted and diagnosed in March 2021. It said that in 2020, it had backlogs on routine gallbladder surgery.
52. Our oncologist adviser agreed that Mrs O was unlikely to have had gallbladder surgery prior to her diagnosis in March 2021. He explained this surgery was low priority and hospitals were not performing it during the pandemic.
53. In summary, we have found it was unlikely Mrs O would have had her gallbladder removed prior to her cancer diagnosis in March 2021. This means the Trust would not have diagnosed her cancer any sooner even if the failings in her care had not occurred.
54. We appreciate this will be a disappointing outcome for Mr O. We would like to reassure him we are in no way underestimating how much these events have affected him. We were reassured the Trust has taken action to improve its service and ensure staff book appointments when needed going forward. We hope this investigation provides Mr M with the answers he needs.