University Hospitals of Leicester NHS Trust

7. Mrs F complains about University Hospitals of Leicester NHS Trust’s failure to diagnose her late mother, Mrs G, with cancer in a timely way.

8. Mrs G had a CT scan in November 2017 to investigate a possible liver problem. Although nothing significant was found in that regard, the image showed a possible pulmonary embolism and a nodule on her left lung.

9. The hepatobiliary team referred Mrs G to the respiratory team for the pulmonary embolism and advised Mrs G’s GP to refer her for a further scan in three months’ time to investigate the nodule. The GP failed to do this, but Mrs F says the Trust should not have asked the GP in any case: the hepatobiliary team should have done a referral themselves. She says there was also a lost opportunity for this to be done during the pulmonary embolism clinic later that month.

10. A follow up CT scan, which led to the cancer diagnosis, did not take place until May 2018 after a hospital doctor realised the error. Mrs F says that treatment was delayed by several months. She understands her mother’s cancer was not curable but believes he could have lived longer and with her symptoms managed more effectively. She also says that she and her mother experienced additional distress from the uncertainty of why the diagnosis was delayed.

11. Mrs F recognises the Trust has acknowledged errors and apologised. However, she is still left with uncertainty about whether it has fully recognised its failures and the effect they had and whether it has taken appropriate action to avoid a recurrence.

12. Mrs F wants the Trust to fully acknowledge its failures and apologise for the effect they had, and to make improvements to its service. She thinks a financial remedy would be appropriate for the distress caused.

13. Mrs G was admitted to hospital in summer 2017, soon after returning from a holiday abroad. She was diagnosed and treated for pneumonia. Her recovery was slow and she continued to have bowel symptoms and weight loss, and she felt generally unwell. She saw her GP several times over the next few months.

14. Mrs G was investigated for her bowel problems. An ultrasound scan in early November 2017 showed suspicious shadowing, which required further investigation and a CT scan of Mrs G’s abdomen and chest took place on 24 November. The Trust hepatobiliary team (specialists in treating conditions of the liver) reviewed the results at a multidisciplinary meeting on 6 December. While they were reassuring regarding a liver problem, it showed Mrs G had a pulmonary embolism (a blocked blood vessel in the lungs) and a nodule in her left lung. A lung nodule is a small, dense area of the lung which appears on an X-ray or CT scan.

15. The hepatobiliary team referred Mrs G urgently to the respiratory clinic for treatment of the pulmonary embolism and the hepatology consultant wrote to Mrs G’s GP on 5 December explaining the findings of the CT scan and asked the GP to refer her for another CT scan in three months’ time to investigate the nodule. This was not done.

16. On 19 April 2018, Mrs G saw a respiratory consultant at the Trust’s Glenfield Hospital for a review at the pulmonary embolism clinic. The consultant noted the follow up scan had not been carried out as requested. She therefore arranged for an urgent CT which was done on 25 May. This confirmed Mrs G had lung cancer.

17. Mrs G started treatment and sadly died on 28 February 2019.

22. Mrs F’s complained the Trust did not diagnose her mother’s cancer in a timely way. This originated when it did not act appropriately on the incidental findings of the liver CT scan of 24 November 2017.

23. Our adviser explains that the British Thoracic Society’s (BTS) Guidelines for the investigation and management of pulmonary nodules recommend that when a lung nodule is first noticed, the risk of it being lung cancer should be calculated. (Its website includes a calculator tool for this, to be used in conjunction with clinical judgement.) If it is over 10%, an urgent PET scan and biopsy are required. (From the website of Macmillan.org ‘A PET scan uses a low dose of radiation to check the activity of cells in different parts of the body. It can give more detailed information about cancer or abnormal areas seen on X-rays, CT scans or MRI scans.) In this case, the risk is calculated as 13%.

24. As such, a direct referral to the Trust’s respiratory team should have been done immediately by the hepatobiliary team after the MDT meeting. It should not have been referred back to the GP for a CT scan in three months’ time. We consider the radiology advice to liver team was wrong and not in line with the BTS guidance.

25. Mrs G’s cancer should have been diagnosed in December 2017. Given she was diagnosed in the following June, this represents a delay of around six months.

26. In its response the Trust acknowledged this and said as part of its investigation there had been a discussion between the patient safety team and radiology consultant and it was felt that Mrs G should have been flagged directly to the lung MDT on a two-week pathway. It apologised to Mrs F that that this was not done.

27. We have considered what effect this had on Mrs G’s death.

28. Our adviser said that given the type of cancer Mrs G had - small cell lung cancer, which is the most aggressive form of lung cancer – a six-month month delay in diagnosis and treatment would have made a significant difference to her prognosis.

29. The size of a cancer and how far it has grown is described by ‘staging’. This helps to determine how it is treated. Our adviser explained that at the time of the CT scan in November, Mrs G’s cancer was at stage 1. The Cancer Research website explains that this ‘usually means that a cancer is small and contained within the organ it started in’. By the time Mrs G had the next scan in May 2018, she had stage 4 disease. This means the cancer has spread from where it started to another body organ. This is also called secondary or metastatic cancer. There is a simple system to stage small cell lung cancer: limited disease (stage 1 to 3) or extensive disease (stage 4).

30. If Mrs G had been investigated urgently in December 2017, it is very likely she would have still been at the limited stage. Survival for limited stage small cell lung cancer in the short-term is generally twice as high as for extensive stage. This depends on whether treatment starts at stage 1, 2 or 3. We consider it reasonable to say that it would possibly still have been stage 1, given it would have been very soon after the CT scan showing a nodule.

31. Long-term survival (up to five years) for this type of cancer is rare. BMJ Best Practice quotes five-year survival rates for small lung cell cancer as approximately 12% to 24% for limited stage and 1% to 5% for extensive stage. In other words, if Mrs G had been diagnosed in a timely way, this could have given her a 12 to 24% chance of surviving the next five years, rather than a 1 to 5% chance.

32. If the cancer had still been at stage 1, it would have increased her chances. We also recognise that Mrs G was 80 years old and had a medical history of chronic obstructive pulmonary disease (COPD), breast cancer and cervical cancer and was a current smoker. These factors would have reduced chances of survival. So while we consider Mrs G could have survived longer, we cannot say how long. We recognise that the uncertainty will continue to cause additional distress to Mrs F.

33. There was also an opportunity when Mrs G attended appointment for the pulmonary embolism on 24 November when the team organised PE clinic follow up. They should have organised a respiratory follow up for the lung nodule. She had a clot because she had cancer. We recognise that further investigation should have been arrange before then. In its response, the Trust acknowledged this and said the junior doctor did not appreciate the incidental finding of the nodule. The doctor had later received feedback from a respiratory consultant about this. We recognise the referral for urgent investigation should have been done before this.

34. The Trust’s response to Mrs F’s complaint included an action plan of what it was going to do to avoid a recurrence. It said a learning bulletin would be sent to all CMG Quality and Safety board meeting accompanied by refreshed national guidance on consultant-to-consultant referrals and for Mrs G’s care to be discussed at hepatobiliary, Radiology and Respiratory Morbidity and Mortality Meetings.

35. We consider these are reasonable actions and in line with our Principles of Good Complaint Handling, which say ‘There is a wide range of appropriate responses to a complaint that has been upheld. These include: an apology, explanation and acknowledgement of responsibility…; remedial action, which may include… revising procedures, policies or guidance to prevent the same thing happening again…’. And; ‘public bodies should ensure that all feedback and lessons learnt from complaints contribute to service improvement.’

36. In its response, the Trust acknowledged its failures, apologised to Mrs F and showed it has taken appropriate action to learn from them. These are reasonable actions and in line with our Principles. The Trust was open and honest in acknowledging it got things wrong.

37. Our Principles also say that public organisations should, if possible, return the person affected to the position they would have been in if the poor service had not occurred. If that is not possible, they should compensate them appropriately. NHS Resolution considered the Trust did not have liability for Mrs F’s death: its decision is not part of our investigation.

38. We consider the Trust should have offered Mrs F a financial payment in recognition of the distress she suffered from knowing her mother should probably have survived longer. We therefore find that the Trust has not fully put things right, and we uphold the complaint.

1. We carefully considered Mrs F’s complaint about University Hospitals of Leicester NHS Trust’s care and treatment of her late mother, Mrs G. We uphold the complaint.

2. We found the Trust failed to appropriately follow up an incidental finding of a lung nodule that showed on a CT scan in November 2017, which had been done to investigate a possible liver problem.

3. We found this failure led to a delay in diagnosis and therefore treatment of small cell lung cancer. This should have been diagnosed in December 2017 but was actually diagnosed in June 2018.

4. Mrs G died in February 2019. While we cannot say exactly what would have happened, we consider there is evidence she may have survived longer had the diagnosis been made in a timely manner. This uncertainty about how much longer her mother could have lived will continue to cause Mrs F distress.

5. In its response to Mrs F’s complaint, the Trust acknowledged its failures, apologised, and took appropriate remedial action to avoid a recurrence for other patients. However we consider that the Trust did not fully put things right as it did not offer Mrs F a financial remedy.

6. We therefore recommend the Trust pay a financial remedy on £3,300 to Mrs F in recognition of the distress caused by the probable premature death of her mother.

39. We recommend the Trust pay a financial remedy to Mrs F.

40. To decide on a level of financial remedy, we review similar cases where the person has experienced similar injustice, along with our severity of injustice scale. Following this review, we recommend that within a month of our final report, the Trust should pay Mrs F £3,300 in recognition of the distress and uncertainty she has suffered knowing that her mother should have been diagnosed earlier and received treatment that would have extended her life.