Referral on 13 March
29. NICE guidelines on suspected upper GI cancer explain patients who are suffering from dysphagia (difficulty swallowing) or are over the age of 55 with weight loss and upper abdominal pain or dyspepsia, should be referred under the urgent pathway.
30. The Trust’s guidance on suspected upper GI cancer explains patients who have haematemesis (vomiting blood or coughing up blood) or are over the age of 55 with vomiting and dyspepsia (difficulty digesting food causing pain), upper abdominal pain, or weight loss should be referred under the non-urgent pathway.
31. NICE guidelines on recognition and referral explain that patients who are referred under the non-urgent pathway do not have a set timescale for seeing a clinician, but generally this will not be within two weeks. Patients referred under the urgent pathway should be seen by a clinician within two weeks of the referral.
32. Mr A’s GP had already made a non-urgent referral to the upper GI consultant on 25 February. When Mr A attended the Practice on 13 March, the ANP should have considered if his symptoms now required an urgent referral.
33. At the time, Mr A was 52 years old and was not suffering from dysphagia. He was suffering from significant weight loss, upper abdominal pain and dyspepsia. This meant he did not meet the criteria under NICE guidelines for suspected upper GI cancer to be referred under the urgent pathway.
34. This shows us the ANP should not have referred Mr A to be seen by an upper GI clinician within two weeks. However, we can see the ANP accidentally filled in the lower GI referral form rather than the upper GI form. The ANP marked that Mr A met part of the criteria for a lower GI urgent referral.
35. When the lower GI consultant reviewed the referral, they recognised Mr A had upper GI symptoms, so they redirected the referral to the upper GI team instead. The upper GI consultant reviewed Mr A on 1 April which was sooner than would normally be expected for someone on the non-urgent pathway.
36. Based on the evidence we have seen, although the ANP did make an administrative error in filling out the incorrect form, this appears to have sped up Mr A’s consultation with an upper GI consultant, rather than delaying it. For this reason, we have not identified any failings that impacted Mr A negatively here.
37. We recognise that Mrs A feels her husband would have had a greater chance of survival if the upper GI consultant saw him sooner. To help provide Mrs A with some answers to her concerns, we have commented on this in paragraphs 62 and 66 of this report.
Clinical assessment on 1 April
38. Mrs A is concerned the ANP did not fully assess Mr A’s clinical condition on 1 April. She explains the ambulance service had advised her to take Mr A to the Practice, which shows his condition was deteriorating and he needed clinical assessment as soon as possible.
39. At the time, the ANP could see Mr A had already received an urgent appointment for suspected cancer. The upper GI consultant had also reviewed Mr A’s clinical condition earlier that day and had scheduled a CT scan to further investigate his symptoms.
40. As the upper GI consultant was already reviewing Mr A on an urgent basis, the ANP should have assessed if he required a very urgent or immediate referral instead.
41. NICE guidelines recognition or referral explain that patients who need very urgent care should be seen within 48 hours. Patients who need immediate care should be seen or admitted into the hospital within a couple of hours.
42. Our ANP adviser explained staff should refer a patient under the immediate or very urgent pathway for suspected upper GI cancer when they have an upper GI bleed. This is bleeding from the digestive tract. NICE guidelines on acute upper GI bleeding says symptoms of upper GI bleeding include vomiting blood or passing dark, sticky stools that contain blood.
43. At the time, Mr A was not vomiting or coughing up any blood. His bladder and bowel movements were also normal and did not contain any blood. Mr A was alert, walking normally, had normal skin colour, normal blood pressure and pulse. He had pain over his stomach, but no tensing or swelling of the abdominal wall.
44. Our ANP adviser explained this showed Mr A was stable at the time and did not have any symptoms that would require the very urgent or immediate pathway. He was correctly advised to contact his upper GI consultant or GP to enquire about his next appointment.
45. We can see the ANP’s actions during this consultation are in line with NICE guidelines on recognition and referral and NICE guidelines on upper GI bleeding. For this reason, we have not found any failings.
Concerns about the delay in cancer diagnosis and carrying out a laparoscopy
46. Mrs A is concerned there was a delay in diagnosing Mr A with stomach cancer. She says her husband may have had more treatment options available if the upper GI consultant diagnosed him sooner.
47. As detailed by the NHS Long Term Plan, patients should receive a definitive diagnosis or ruling out cancer within 28 days of a referral. If cancer is confirmed, clinicians should begin treatment within 31 days of diagnosis.
48. Mr A was referred on 13 March. The upper GI consultant should have diagnosed him by 10 April, within 28 days of the referral being made. The CT scan carried out on 6 April showed signs of cancer and that this appeared inoperable. This was not confirmed until 20 April when staff carried out an endoscopy which is a delay of 10 days.
49. Normally, in line with NICE guidelines on suspected upper GI cancer, patients will undergo an endoscopy first. However, on 11 March 2020, the World Health Organisation declared COVID-19 a pandemic. The spread of the COVID-19 virus was increasing, as were the number of deaths associated with it.
50. To help reduce the risk to patients, BSG promptly issued guidance on 23 March recommending a six-week pause on carrying out endoscopies. This is because invasive procedures, such as endoscopies, posed a greater risk of spreading COVID-19. Only emergency endoscopies were allowed.
51. NHS England’s website on stomach cancer explains CT scans can also be carried out to assess the spread and size of the cancer. As this non-invasive investigation could also be used to investigate symptoms of cancer, clinicians carried out CT scans first instead of an endoscopy.
52. Mr A received a CT scan on 6 April. Had the Trust been able to carry out an endoscopy, it would likely have diagnosed the incurable linitis plastica and would have been within the 28 days of the referral being made.
53. Because of the COVID-19 pandemic, the endoscopy was delayed. Instead, the upper GI consultant carried out a CT scan first. This also showed the significant spread of linitis plastica which appeared inoperable, and this was confirmed after the endoscopy was carried out on 20 April.
54. The upper GI consultants’ actions are in line with the BSG guidelines and NHS England’s website on stomach cancer. Although the confirmed diagnosis did not occur within 28 days of referral (instead it occurred 10 days later), we must take into consideration the significant impact of the COVID-19 pandemic.
55. In light of the above consideration, we do not find a failing in the upper GI consultant diagnosing Mr A slightly outside of the 28 day timeframe. We can see the upper GI consultant acted promptly in carrying out safe investigations to help diagnose Mr A.
56. After this, the upper GI consultant discussed Mr A’s case at the next MDT meeting on 1 May. Clinicians confirmed Mr A’s cancer was uncurable and inoperable. They felt Mr A should start chemotherapy to attempt to reduce the size of the tumour which may allow them to operate. It was hoped this would help to alleviate his symptoms, rather than cure the disease.
57. Mr A tested positive for COVID-19 on 30 April. Our upper GI adviser explained that chemotherapy must be administered in a clinical sitting shared with other patients also undergoing chemotherapy. These patients are vulnerable and must be protected from being exposed to the COVID-19 virus.
58. This meant clinicians could not begin chemotherapy treatment for Mr A until he tested negative for COVID-19. Mr A tested negative for COVID-19 on 19 May and began chemotherapy soon after this on 22 May.
59. Even though there was a delay starting chemotherapy because Mr A was COVID-19 positive, treatment was started within the 31 days of diagnosis. The upper GI consultant’s actions here are in line with the timescales set by NHS Long Term Plan.
60. From this point, Mr A underwent chemotherapy treatment in an attempt to reduce the size of his tumour. Following the completion of this treatment plan, the upper GI consultant discussed his case again at another MDT meeting on 27 July and confirmed they should refer Mr A for a laparoscopy to assess if his cancer was now operable.
61. We can see the upper GI consultant referred Mr A soon after the MDT meeting, on 29 July. There is no delay in referring Mr A here. Staff then carried out open surgery (rather than a laparoscopy) on 27 August, one month later. Our upper GI adviser says the time taken for Mr A to receive open surgery appears reasonable and does not indicate delay.
62. Our upper GI adviser says at this stage Mr A’s cancer was already uncurable. The purpose of the laparoscopy was not to consider if his cancer could be cured, but to restage the disease (to check if the stage of the cancer has changed) and to check if any other procedures could be undertaken to alleviate his symptoms.
63. Mr A had a rare form of stomach cancer where the tumour infiltrates extensively within the muscle of the stomach. Our upper GI adviser explains this type of cancer is difficult to detect even after it has become malignant (spread within the walls of the stomach). Symptoms usually occur after the cancer has become inoperable.
64. According to the NCBI study, in cases where linitis plastica is operable, the median survival rate is between 5 to 17 months from diagnosis. This study shows treatment for linitis plastica does not extensively prolong life.
65. In Mr A’s case, the CT scan he underwent on 6 April already showed his cancer had spread significantly. The type of cancer was then confirmed on 20 April. Both tests showed it was not curable at the time. We can also see the tumour did not reduce after a course of chemotherapy.
66. Taking this into consideration, had Mr A received treatment sooner than he did, it would not have impacted his chances of survival. Mr A’s cancer appeared incurable before he was referred under the suspected upper GI cancer pathway.
67. We are mindful the events described in our report continue to cause Mrs A upset and distress. We know we cannot change what happened or take away the pain she has suffered but we hope this report will provide her with some reassurance around her husband’s care and treatment.