CT scans
15. Firstly, as Mrs A is concerned that Mr A’s CT scans on 18 April, 10 May and 4 June 2022 failed to identify that he may have cancer, we have asked our radiologist adviser to review the relevant images.
16. Our radiologist adviser says all three CT scans show evidence of previous upper abdominal procedures with metallic densities present in the region of the pancreatic bed indicating previous Interventional radiology or surgery. They also demonstrate fluid collections/cysts related to the same area. There is evidence of extensive oedematous change (tissue swelling) related to the area surrounding the pancreatic bed including the distal stomach and duodenum.
17. On the scan from 18 April 2022, there is dilation of the bile ducts in the liver indicating obstructive compression of the lower bile duct related to swelling and one of the cysts. A small area of enhancing tissue is noted in the area of the pancreatic head with a further small area of tissue at the very tip of the pancreatic tail. There is no evidence of any other pancreatic tissue or mass.
18. Some mild swelling of lymph nodes is also noted in the upper abdomen related to the same area. Incidental note is also made of aneurysmal swelling of the left common iliac artery. There is no other significant or relevant finding on the scans.
19. Our radiologist adviser says the scans demonstrate evidence of significant previous disease, most probably necrotising haemorrhagic pancreatitis. Therefore, it is reasonable to surmise that Mr A had previous very severe pancreatitis leading to necrosis (destruction) of most of the pancreatic tissue and that the fluid collections, compatible with pseudocysts, had formed in relation to this. There are also embolization coils implying that at least one interventional procedure had been performed to stop a related haemorrhage. Pseudocysts may persist and not resolve following resolution of previous severe acute pancreatitis.
20. In addition to this, the tissue swelling, and the swelling of Mr A’s lymph nodes is most compatible with and would suggest ongoing or recurrent inflammation, most probably related to persisting or recurrent acute pancreatitis. The enhancing areas in the pancreatic head and at the tip of the tail would be entirely consistent with residual islands of viable (living) pancreatic tissue that had escaped the previous necrotising pancreatitis. Neither area shows any characteristic to suggest a cancer.
21. Mrs A’s final CT scan on 4 June 2022 shows that his bile duct dilation had resolved and there was significant improvement of his swelling/inflammation. There was no evidence of any progressive lesion or worsening of the Mr A’s condition on the final scan.
Clinical management
22. We have considered if Mr A received appropriate care from the Trust for his pancreatic-related symptoms when he was in hospital, between 17 and 28 April 2022, 7 and 18 May 2022, and on 4 June 2022.
23. Firstly, our consultant adviser has commented that it can be almost impossible to see pancreatic cancer on CT scans when a patient has severe chronic pancreatitis like Mr A. This is because the pancreas can become swollen or inflamed due to any acute-on-chronic pancreatitis and will be very scarred/fibrotic. This reflects what our radiologist adviser has said about swelling/inflammation around Mr A’s pancreas.
24. On 17 April 2022, the records indicate that Mr A had moderately severe jaundice. His bilirubin level was 127 umol/L, which our consultant adviser says was high enough for him to have been noticeably yellow in colour. Bilirubin is a yellowish pigment found in bile; a fluid made by the liver. High levels of bilirubin may indicate liver or biliary disease. Mr A had a CT scan on 18 April 2022 which our consultant adviser says showed no signs of cancer. The records indicate that Mr A’s jaundice then self-resolved during this first episode of care, but our consultant adviser suggests this may have blindsided the Trust’s subsequent management of his condition.
25. The NICE guidance on pancreatic cancer in adults’ states ‘People without jaundice who have pancreatic abnormalities on imaging: 1.1.5, if the diagnosis is still unclear, offer FDG-PET/CT and/or EUS with EUS-guided tissue sampling.’ Also, ‘Specialist pancreatic multidisciplinary teams: 1.2.1, a specialist cancer multidisciplinary team should decide what care is needed and involve the person with suspected or confirmed pancreatic cancer in the decision. Care should be delivered in partnership with local cancer units.
26. Mr A had an anaesthetic assessment locally on 22 April 2022. He was due to be admitted to a hospital in London which is not part of the Trust, to have an Endoscopic Ultrasound (EUS) procedure in accordance with the NICE guidance. This is a procedure to examine the inside of the digestive tract - ultrasound scanning internally by an endoscopic probe.
27. The records indicate that Mr A’s EUS procedure was “postponed” on 27 April 2022 as there was no anaesthetist available (at the hospital in London) to deliver anaesthesia for the procedure. It then appears that the EUS procedure was “cancelled,” apparently by the team in London, as Mr A’s jaundice had resolved. Therefore, Mr A was discharged by the Trust on 28 April 2022.
28. Our consultant adviser says that, while the investigations carried out/planned by the Trust were appropriate and what we would expect to see during this episode of care, the expectation for a patient with Mr A’s history of pancreatitis would still be that he would be called in for the EUS procedure later by the hospital in London, perhaps as a day patient or with an overnight stay in hospital. There is no evidence this happened or was followed up by the Trust at the time.
29. We consider this to be a failing by the Trust contrary to the relevant NICE guidance. It causes Mrs A some worry and uncertainty about the Trust’s management of Mr A which is emotionally distressing for her. We have made recommendations to the Trust about this.
30. It is noted that Mr A had an upper gastrointestinal (GI) endoscopy on 18 April 2022. Our consultant adviser says there were no suspicious appearances in the region of the distal stomach, pylorus, or duodenum. The abnormal findings were severe oesophagitis and a large 5 cm hiatus hernia. On Mr A’s second admission from 7 to 18 May 2022, the records indicate time was taken up during this period in chasing up the team at the London hospital regarding next steps, but not much progress was made. Mr A had a repeat CT scan on 10 May 2022 which our consultant adviser says showed no signs of cancer. There is evidence that Mr A’s case was discussed with the London team on 11 May 2022.
31. Mr A had another endoscopy on 16 May 2022. Having analysed the findings from this investigation, our consultant adviser says there is some suspicion of pancreatic malignancy from the findings: “possible pyloric malignancy.” The pylorus is the junction between the distal stomach and the first part of the small intestine, the duodenal bulb, and is adjacent to the head of the pancreas. The Trust again carried out appropriate investigations for Mr A. We considered in hindsight if the local team may have been blindsided by the settling of Mr A’s jaundice and discharged him prematurely instead of considering the suspicious area on Mr A’s endoscopy further. Our consultant adviser had said that as Mr A’s jaundice had self-resolved and the repeat CT scan had shown no signs of cancer, the team discharged him on 18 May 2022.
32. However, the Trust has explained that the report from Mr A’s endoscopy on 16 May 2022 showed findings of mild oesophagitis and small hiatus hernia as well as small food reside in fundus. Mr A’s pre-pyloric area was thickened with friable villus appearance, which was causing some pyloric narrowing, but it was passable with a scope. Therefore, multiple biopsies were taken.
33. Mr A’s case was discussed at multi-disciplinary team (MDT) by the Trust on 24 May 2022. The discussion stated that no malignancy was found on the recent gastric biopsy, but an urgent gastrointestinal outpatient appointment was required. Mr A was then seen on the 31 May 2022 in the outpatient clinic. The summary letter from this clinic (dated 20 July 2022) stated that the Upper GI Team were briefly involved as there was a possibility of malignant change seen on the CT scan, he had during his hospital stay (in May 2022) in the gastric pylorus. This is supported by what our consultant adviser has said about the findings of Mr A’s endoscopy on 16 May 2022. The summary letter added that biopsy has since showed reassuringly that this is no more than an inflammatory reaction. Nevertheless, Mr A was referred for a fairly urgent gastrointestinal opinion. Having considered this account with support from our consultant adviser, we are satisfied there is evidence that the suspicious findings on Mr A’s endoscopy of 16 May 2022 were subject to further appropriate consideration by the Trust.
34. On Mr A’s third and final admission (4 June 2022), Mr A had a repeat upper GI endoscopy. Our consultant adviser says the appearances were of “pyloric oedema” which is much less suspicious than the appearances on the endoscopy of 16 May 2022. Biopsies were taken but the histology report was not available until after Mr A’s death on 10 June 2022. It did not show any signs of cancer. Mr A’s abdomen is reported as ‘soft’ rather than swollen/ distended or tender at this time. He also had another CT scan which our consultant adviser says was appropriate, but it did not show any signs of cancer.
Impact of failing and conclusion
35. Overall, we acknowledge that the Trust carried out all locally available relevant pancreatic investigations during these three episodes of care. Unfortunately, Mr A had an invisible tumour on the head of his pancreas which could not been seen on his CT scans.
36. While we consider the Trust could have been more proactive in its communication with the London hospital to rearrange and carry out the EUS procedure, our consultant adviser says there is no guarantee that cancer would have been identified from this procedure. According to the NLM article, at least 1 in 4 EUS procedures would not have identified cancer in the setting of existing chronic pancreatitis which Mr A had. Therefore, although the Trust would have had a better chance of identifying Mr A’s cancer after carrying out an EUS procedure, we cannot say with any certainty that this would have identified his cancer. Therefore, we consider the impact of this failing in Mr A’s management is limited to some worry, uncertainty, and related emotional distress for Mrs A.
37. In summary, both our advisers agree that distinguishing between pancreatitis and pancreatic cancer can be challenging. They also both agree that there were no signs of cancer on any of Mr A’s CT scans. The only suspicious finding was on 16 May 2022, but a repeat endoscopy on 4 June 2022 showed less suspicious findings that did not warrant further consideration. Based on the available evidence including the post mortem, our consultant adviser says it is not entirely clear that Mr A died on 10 June 2022 directly from pancreatic cancer. Our consultant adviser says that Mr A’s system had to deal with multiple clinical investigations between April and June 2022 and he had a significant background of pancreatic problems which could have weakened him. Mr A had renal impairment, metabolic alkalosis and hypokalaemia, a low potassium (2.5 mmol/L on 9/6/22), within 24 hours of his death. He was given some intravenous potassium replacement therapy. He was also diabetic. The post mortem also states that he had 50% narrowing of his arteries which our consultant adviser says indicates ischemic heart disease and the risk of a sudden cardiac event. Therefore, it is possible that an arrhythmia (sudden cardiac rhythm irregularity) may have led to his death rather than it being caused directly by cancer.