Issue 1 – Missed diagnosis
17. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
18. GMC guidance (paragraph 15) says clinicians must assess a patients’ condition, taking into account their symptoms and history and undertake suitable investigations if necessary.
19. Mrs Z feels that the Trust missed the opportunity to diagnose her mother with cancer at the earliest opportunity, after she presented to the Trust in May and July 2019. She does not feel the Trust adequately considered her mother's long-term pain or that she had previously had cancer.
20. We know Mrs Z feels that an earlier diagnosis might have saved her mother’s life, which must be difficult for her.
21. The Trust says Mrs G initially presented with abdominal issues in May and was investigated by the surgical team based on her symptoms and presentation. It found an issue with her bowel and advised based on this. The Trust explains Mrs G presented with musculoskeletal pain in July, and it assessed and discharged her as there was no surgical intervention needed. It says it gave appropriate advice on discharge.
22. The Trust says there was no reason for it to investigate Mrs G's lungs during either admission and so would not have been able to make a diagnosis of lung cancer.
23. The records show Mrs G was presented to the Trust on 2 May with abdominal pain which had started in January and got progressively worse. Mrs G also complained of loss of appetite and constipation. The Trust completed a CT scan of her abdomen, which our adviser confirmed was an appropriate investigation based on her symptoms. This appears to be in line with GMC guidance (15b)
24. The CT showed an issue with the splenic flexure (part of the colon) and some constipation. The Trust arranged for Mrs G to undergo a colonoscopy, which after an initial failed attempt, was completed on 13 May. Our adviser felt this was an appropriate next step in investigating what was wrong with Mrs G, in line with GMC guidance.
25. The colonoscopy showed Mrs G had an ulcer and inflammation in her colon. Our adviser confirmed that this appeared to be the cause of Mrs G’s pain and symptoms. Having considered her records, our adviser did not feel there were any symptoms that would have suggested to the Trust Mrs G had cancer at this time.
26. Mrs G returned to the Trust on 25 July having been referred by her GP. She was triaged by the Surgical Admissions Unit, which assess patients who have recently been in hospital under the care of the surgical team.
27. Mrs G complained of pain in her lower back, rib and shoulder when she moved. She explained she had recently had a fall which had made these symptoms significantly worse.
28. The Trust did not admit Mrs G but gave advice on pain management and physiotherapy and to speak with her GP if there was no improvement in her symptoms.
29. Our adviser considered this information and agreed Mrs G appeared to have a musculoskeletal issue and confirmed there was no surgical management needed. They explained that back pain is a common complaint for people who come to hospital, but rarely leads to admission unless they are considered immediately life threatening, which was not the case for Mrs G.
30. Our adviser felt the advice to speak with her GP if there was no improvement was appropriate and we cannot see she returned to the Trust with this issue again.
31. Considering the evidence, including our adviser’s opinion, it appears the Trust assessed Mrs G and arranged for appropriate investigations and advice. We consider this to be in line with GMC guidance.
32. It is worth noting that when Mrs G presented to the Trust in November, she complained of a four-week history of chest pain, which is a different site of pain, and this symptom started after her previous attendance to the Trust. Our adviser felt that these symptoms were unrelated to her attendance in May and July.
33. We also understand Mrs Z was concerned that the Trust did not properly consider the fact her mother had previously had cancer.
34. We can see in the records from her admission in May, that the Trust recorded Mrs G had had a hysterectomy in 2009 due to ovarian cancer. This suggests to us that the Trust was aware and had considered Mrs G had a previous cancer diagnosis.
35. Our adviser gave context that this cancer diagnosis would not have been significantly relevant to her consideration in 2019. They explained that a significant amount of time had passed, and cancer is less likely to return as time goes on. This view is supported by Cancer Research UK (Why some cancers come back) which explains most cancers that return do so within two years and after ten years some patients might be considered to be cured.
36. Having considered all this, we think the Trust did consider Mrs G’s history of cancer and understand why this might not have caused concern that her cancer had returned.
37. In summary, we think the Trust assessed and advised Mrs G based on the symptoms she presented with.
38. We think the care was in line with GMC guidance and we will not take further action.
Issue 2 – Pain management
39. GMC guidance says clinicians must take all possible steps to alleviate a patients’ pain (paragraph 16c). It says clinicians must be satisfied they have valid consent before delivering treatment (paragraph 17).
40. Mrs Z says during her mother’s final admission, she was left without adequate pain relief for several days. She says it was clear to clinicians Mrs G was in significant pain and needed a syringe driver. Mrs Z explained some family members were against her mother getting a syringe driver but feels the clinicians should have acted in Mrs G’s best interests.
41. The Trust does not appear to have given a formal response on this point.
42. Having considered the records following Mrs G’s admission, we can see numerous examples of Trust staff regularly monitoring and assessing Mrs G’s pain. For example, on 30 January where Mrs G was noted as screaming when being turned and was clearly in significant pain. The following morning the Trust recorded she was ‘comfortable in bed’.
43. On 3 February the clinician records Mrs G told them she was not in pain, but she was also, ‘displaying pain at times… wincing, painful noises made and looks distressed’. We think this shows the clinicians were not just asking Mrs G but also using their observations and judgement to assess her pain. Our adviser also felt the Trust was regularly monitoring her pain.
44. Having looked through these records we can appreciate how distressing it must have been for Mrs Z to see her mother in such a bad condition.
45. The records show that the Trust had a ‘long discussion’ with the family in the morning of 30 January regarding pain relief. A second conversation appears to have been initiated by Trust clinicians that evening, but the family confirmed they would like to talk this over before making any decisions about fitting a syringe driver.
46. From the subsequent records it appears there was some disagreement within the family about the management Mrs G’s pain, but crucially Mrs G declined to be fitted with a syringe driver.
47. As the records show that Mrs G was clear she did not want a syringe driver to be fitted, our adviser explained the clinicians could not deliver this care as they did not have the patient’s consent. They therefore appear to have acted in line with GMC guidance (paragraph 17).
48. The Trust did take some steps in managing Mrs G’s pain as it prescribed her with morphine (a strong pain medication) on a PRN (as needed) basis. She received between one and four doses per day between 30 January and 3 February.
49. It seems the Trust continued to assess Mrs G’s pain and the need for a syringe driver regularly. We can see it recognised the difficult circumstances and on 2 February escalated the matter to a consultant to speak with the family again. Without Mrs G’s consent, it is difficult to see what else the Trust could have done in this situation. Our adviser felt the Trust’s overall approach was in line with GMC guidance (16c).
50. We can understand Mrs Z’s feeling that, given her mother was clearly in significant pain, the clinicians should have fitted a syringe driver in line with her best interests.
51. Our adviser explained that a best interest assessment would only apply to a patient who lacked capacity to make decisions or was unable to communicate. We can see from the records that Mrs G was involved in the decision making of her care and, while sometimes only by squeezing a finger, was able to communicate her wishes.
52. On 3 February, clinicians spoke with Mrs G and recorded she ‘declined analgesia (pain relieving medication) again’ as she ‘wants to remain in control’. We think this shows she was able to understand and refuse to give consent to treatment and having the syringe driver fitted. We therefore think the Trust acted in line with GMC guidance (17).
53. A few minutes after initially declining further pain medication, Mrs G spoke with the clinician again and requested the syringe driver. Within around 40 minutes it was fitted which our adviser found to be appropriate. It appears this management was in line with GMC guidance (16c).
54. In summary, we can see Mrs G was able to refuse consent for the syringe driver. Despite this, the Trust continued to assess her pain and repeatedly gave her the option to take up this treatment. Once Mrs G communicated she wanted the syringe driver, the Trust appear to have fitted it promptly.
55. We think the Trust acted in line with GMC guidance in the management of Mrs G’s pain.
56. We do not wish to diminish the obvious impact and upset that was felt by Mrs Z and would like to pass on our sincere condolences for the loss of Mrs G.