King's College Hospital NHS Foundation Trust

8. Mr P complains about the following aspects of the care and treatment provided by the Trust to his late brother, Mr L, between November 2019 and November 2020.

9. Specifically, Mr P complains the Trust:

• Did not perform appropriate tests from November 2019 to determine if his brother’s brain tumour was cancerous. Mr P says the Trust also did not consider information from tests undertaken in Tenerife which had found the tumour was cancerous. As a result, Mr L’s care was considered non-urgent, and his care was not prioritised during the pandemic.

• Did not appropriately monitor the brain tumour from March 2020 and missed further opportunities to recognise the cancer and treat this sooner.

• Decided to proceed with surgery when the tumour was inoperable. Sadly, Mr L did not recover from this. Mr P feels other options should have been explored, which may have prolonged his brother’s life.

10. Overall, Mr P says the Trust’s delays and failure to recognise the severity of the tumour meant that his brother was denied opportunities for treatment which may have extended his life. He says his brother was left waiting for a year for treatment, which caused him and his family considerable distress.

11. Mr P is seeking apologies, an acknowledgment of failings, service improvements and a financial remedy.

12. Mr L was taken to hospital on 22 November 2020, whilst on holiday in Tenerife, as he was experiencing right-sided weakness.

13. He underwent a head CT scan, a head CT scan with contrast, and an MRI of the brain. A CT scan uses several X-ray images and computer processing to create cross-sectional images. An MRI uses strong magnetic fields and radio waves to produce detailed images of the inside of the body.

14. The diagnosis at this time was of a left-sided glioblastoma (a cancerous brain tumour, also referred to as a high-grade glioma). Gliomas are graded based on how aggressively or rapidly the cells divide. The higher the grade, the more aggressive the brain cancer is.

15. High-grade gliomas are Grades 3 and 4. A glioblastoma is always a Grade 4 glioma, which is the most aggressive type of glioma. It is life threatening and has an average survival time of 14 months.

16. Mr L was brought back to the UK on 3 December 2019, with medical advice for surgery as soon as possible. He was taken to Hospital A (not part of the Trust complained about) who referred Mr L to the Trust, as it was the specialist centre to consider his onward care.

17. The Trust asked that Hospital A repeat some of the images taken in Tenerife, as these were not clear. Hospital A arranged a CT scan on 6 December 2019 and an MRI scan with contrast on 9 December 2019.

18. Hospital A discharged Mr L on 9 December 2019. Its referral to the Trust’s neuro-oncology department noted that the imaging was suggestive of brain metastases (where cancer spreads from one area of the body to another). Hospital A noted the MRI scan results were in keeping with a high-grade glioma.

19. The Trust held a multi-disciplinary team (MDT) meeting on 13 December 2019. The MDT reviewed the Tenerife imaging taken on 27 November 2019 and the CT and MRI scans completed by Hospital A.

20. The MDT’s diagnosis differed to the diagnoses made by the hospital in Tenerife and Hospital A, as it felt Mr L had a non-cancerous meningioma. This is a typically slow growing and (usually) non-cancerous tumour which develops from the membrane that surrounds the brain and spinal cord. A craniotomy was to be arranged, which is an operation to open the head to expose the brain, so the tumour could be removed if possible.

21. Mr L attended the Trust on 16 December 2019, for review and pre-assessment tests for a possible craniotomy. These tests showed that Mr L had a deep vein thrombosis (DVT). This is the term used to describe the formation of a thrombus (blood clot) in a deep vein, which partially or completely obstructs blood flow. This meant Mr L was not suitable for surgery at this time.

22. The Trust started Mr L on medication for the DVT and arranged to review him again in January 2020, to re-assess his suitability for surgery.

23. Mr L was reviewed on 22 January 2020 and had further scans to assess his DVT. This showed he still had a DVT, despite being on medication for this. It was agreed that the surgery could proceed with a filter in place to prevent any clots from reaching the lungs.

24. Mr L’s craniotomy was initially scheduled for mid-February 2020. This was unfortunately delayed due to priority cancer cases.

25. Mr L raised concerns about the delays in arranging his surgery on 17 March 2020. Sadly, at this time, the Trust were starting to feel the impact of the COVID-19 pandemic and advised there would likely be delays with this. Mr L was not classed as a priority patient during the pandemic, as the MDT had felt his tumour was non-cancerous.

26. Mr L chased the Trust again on 1 July 2020 as he was concerned at the delay and felt he should have had an interval MRI scan. The Trust explained to Mr L that he had a meningioma, and therefore this was slow growing. The Trust agreed to consider his concerns at its next MDT meeting.

27. Mr L called the Trust again on 6 July 2020 and was noted to be very unhappy. He was told the Trust needed to prioritise ‘unwell’ cases and suspected cancers, and Mr L was felt to be clinically stable. The Trust arranged further scans to check on his progress and an MDT took place on 11 September 2020 to decide the next stage of treatment.

28. The MDT agreed surgery was needed and a pre-embolisation procedure took place on 5 October 2020 to manage Mr L’s risk of clots.

29. Mr L underwent a left-sided craniotomy on 7 October 2020. A biopsy of the tumour was taken and sent for testing. This was reported on 20 October 2020, and the diagnosis was of a glioblastoma with extensive vascular abnormalities.

30. Sadly, Mr L suffered massive bleeding during the operation on 7 October 2020, and needed substantial blood transfusions. He was transferred to the intensive care unit (ICU) following surgery. Scans completed in the days after the surgery showed extensive further bleeding and brain damage. Mr L also developed severe respiratory (breathing) failure, renal (kidney) failure, a further DVT, and lung clots.

31. On 23 October 2020, a discussion took place with the clinical team, Mr L’s partner and his mother. It was agreed to see if Mr L woke up after stopping sedation, but that cardiopulmonary resuscitation (CPR - chest compressions and rescue breaths to give a person the best chance of survival following a cardiac arrest) would not be appropriate.

32. Sadly, Mr L died at 6.20am on 5 November 2020.

Diagnosis

37. We sought advice from our neuroradiology adviser to consider the information available at the MDT, to understand if the diagnosis of meningioma and the prioritisation of Mr L’s care was appropriate.

38. Our neuroradiologist explains there was sufficient evidence to support a diagnosis of a malignant (cancerous) tumour at the time of the MDT on 16 December 2019. We recognise that the position of the tumour may have led to some uncertainty as to the diagnosis. However, our neuroradiology adviser explains the tumour also had other features which were not suggestive of a meningioma (bleeding and irregularity) which do not appear to have been considered. We explain this further below.

39. Our neuroradiology adviser explains the scans from November to December 2019 (taken in Tenerife and the initial hospital) are suggestive of an aggressive complex brain tumour and there are specific appearances on MRI which suggest the lesion was bleeding and had neovascularisation (formation of new blood vessels) which also increases the risk of bleeding.

40. The scan also noted peripheral irregular enhancement and heterogeneity. Enhancement refers to how the area shows up on the scans after a contrast substance has been used. Heterogeneity refers to areas appearing non-uniform with various intensities.

41. For meningiomas, the area is usually enhanced more regularly and is more uniform throughout the area, without significant variations in intensity or pattern. Therefore, the fact that Mr L’s tumour had irregular enhancement and heterogeneity suggests this this was an aggressive neoplastic (cancerous) lesion. In addition, meningiomas are not typically associated with internal bleeding.

42. The location of Mr L’s lesion could also suggest different types of type of tumour.

Mr L’s lesion was within the brain (intraaxial). Meningiomas are outside the brain but within the skull (extraaxial) and arise from the dura (a layer of the meninges external to the surface of the brain).

43. Meningiomas occur over the parts of the brain which lie in contact with the flat bones of the skull and or as in this case along the dura of the falx (separation in the midline). Meningiomas are also described as broad based with a thin enhancement extending along the dura.

44. We recognise the position of Mr L’s tumour would have made the diagnosis difficult, as it did extend to the surface of the brain and was in close contact with the dura. However, this should have been considered along with the additional features of bleeding and the enhancement pattern, which did not support a typical meningioma.

45. In light of the advice from our neuroradiologist adviser, we sought further input from our neurosurgeon adviser and oncology adviser. They also consider there was sufficient evidence to consider a diagnosis of a malignant tumour at the time of the MDT on 16 December 2019.

46. We have considered that the Trust’s view of the tumour was different to that reached by both the hospital in Tenerife and the initial UK hospital. In light of the differences of opinion as to the type of tumour, our advisers explain the Trust should have arranged further investigations to clarify this.

47. The need for further investigations is in line with the NICE guidance ‘Brain tumours (primary) and brain metastases in over 16s’. This says clinicians should:

‘Consider advanced MRI techniques, such as MR perfusion [a type of MRI scan which measures the amount of blood in different parts of a brain tumour] and MR spectroscopy [a type of MRI scan which takes images of the brain and also creates graphs that show the activity of the brain tissue], to assess the potential of a high-grade transformation in a tumour appearing to be low grade on standard structural MRI’.

48. We have not seen this happened and have not seen any rationale to suggest why this was not considered. Had such a consideration been made during the MDT, this should have been recorded, in line with the GMC guidance, ‘Good Medical Practice’. This says doctors should record their work clearly, accurately and legibly, and include any relevant clinical findings, the decisions made, and actions agreed, and who is making the decisions and agreeing the actions.

49. Our oncology adviser explains if the further investigations recommended in the NICE guidance had been completed (MR perfusion and MR spectroscopy), it is more likely than not that a change in the diagnosis would have been made to recognise that the tumour was a high-grade glioma/glioblastoma.

50. On the balance of probabilities, we consider this action would more than likely have meant the treating team would have considered Mr L’s care as urgent.

51. We therefore consider there was a failing in the decision reached by the MDT to diagnose Mr L’s brain tumour as a meningioma, which led to the decision to consider his care as non-urgent. We have considered the impact of this on his overall care and prognosis, and the impact of this on his care and reviews during the COVID-19 pandemic below.

Impact

52. We sought advice from our oncology adviser, to consider the impact of the failing in the diagnosis reached by the MDT.

53. Our oncology adviser explains that had the above failings not occurred, Mr L would have undergone a craniotomy earlier, likely by mid to end January 2020. This timescale is in line with the NHS guidance ‘Clinical guide to surgical prioritisation during the coronavirus pandemic’. Mr L would have been considered as a level two priority, which says surgery can be deferred for up to four weeks.

54. Had the surgery taken place in January 2020 and Mr L recovered well after this, his next stage of care would have been considered in line with the NICE guidance ‘Brain tumours (primary) and brain metastases in over 16s’. As he was under the age of 70 (aged 53), this guidance suggests Mr L would have been offered six weeks of brain radiotherapy with oral chemotherapy at the same time, followed by six cycles of oral chemotherapy as a maintenance.

55. If Mr L was not fit after surgery, alternative options of treatment could have been discussed. The above NICE guidance suggests this would have included options such as increasing doses of radiotherapy alongside temozolomide (an anticancer medication used to treat brain tumours such as glioblastoma), six cycles of temozolomide alone, or best supportive care alone.

56. Sadly, our oncology adviser explains the prognosis of Grade 4 glioma (glioblastoma) remains very poor even if a patient has surgery, radiotherapy, and chemotherapy. In line with the study ‘Survival and quality of life analysis in glioblastoma multiforme with adjuvant chemoradiotherapy: a retrospective study’, the average overall survival is 14 months.

57. Therefore, had Mr L’s glioblastoma been recognised in December 2019, he would have had the opportunity to undergo treatment, which more likely than not on the balance of probabilities could have extended his life. This is a significant injustice to his family.

58. We cannot know how Mr L would have responded to these treatments. We note the significant impact these types of treatment can have on a patient’s quality of life. We therefore cannot say if Mr L would have continued with all the available treatments, or if he would have made decisions to have stopped these earlier and instead receive palliative care to ensure his comfort at the end of his life.

59. We can say however say that had Mr L been aware of his diagnosis, he would have been better prepared for the poor prognosis. He would have been able to make choices around informing his family of his diagnosis and had more time to consider his treatment options and prepare for the end of his life.

60. We also note the further scans had followed a number of calls from Mr L to the Trust in July 2020, as he was increasingly concerned that he had not had a review since March 2020. We do not underestimate the distress he and his family will have experienced during this time.

61. We have made recommendations at the end of our report to address the impact of the failings we have seen, and to ensure the Trust takes action to improve its service.

Further scans from July 2020

62. As a result of the incorrect meningioma diagnosis, Mr L was on the non-urgent list during the COVID-19 pandemic and did not have a review until July 2020. There was no further imaging after the MDT meeting in December 2019 until July 2020, seven months after the initial diagnosis was made.

63. Mr L underwent an MRI scan in July 2020, which showed the tumour had progressed. The Trust then arranged a CT scan and cerebral angiogram to consider this further, prior to his surgery on 7 October 2020. A cerebral angiogram is where a dye is injected into an artery through a fine plastic tube called a catheter and then X-ray images of the head and neck are taken immediately afterwards.

64. We have considered the scans and investigations leading up to Mr L’s surgery, to consider the conclusions reached and if it was appropriate to proceed with surgery. We have also considered whether there was evidence at this time to suggest Mr L’s tumour was a high-grade glioma/glioblastoma, rather than a meningioma.

65. The scan in July 2020 showed Mr L’s tumour had progressed, but this was still thought to be a meningioma at this time. The Trust arranged a CT scan on 8 September 2020 and a cerebral angiogram on 9 September 2020, in advance of his surgery on 7 October 2020. A cerebral angiogram is where a dye is injected into an artery through a fine plastic tube called a catheter and then X-ray images of the head and neck are taken immediately afterwards.

66. Our interventional radiology adviser has considered the CT scan and angiogram and explains the results of these should have led to reconsideration of Mr L’s diagnosis. This is because the tumour did not present as a meningioma, and the findings of both scans suggest its features were more typical of a high-grade glioma. We explain this further below.

67. The CT scan showed a large vascular brain tumour in one of the brain’s major lobes, which was also affecting the functional tissue of the brain. The imaging findings are suggestive of a high-grade glioma and do not support a diagnosis of meningioma.

68. We have next considered the cerebral angiogram performed on 9 September 2020. This also showed a highly vascular tumour in the left parieto-occipital region.

69. The angiogram showed the tumour’s blood supply was predominantly from the pial vessels (vessels on the surface of the brain) and their main function is to supply brain tissue. There was also a small supply from the left middle meningeal artery (MMA). This is a vessel which mainly supply the dura (outer lining of the brain).

70. The angiogram also shows an abnormal connection between the artery and vein which can lead to altered blood flow.

71. In a meningioma, the blood supply will be predominantly from a dural artery (artery supplying the lining of the brain). Mr L’s tumour lacks all the typical angiographic appearance to support a diagnosis of meningioma. They are instead indicative of a high-grade glioma, in line with our earlier findings.

Surgical decision

72. We sought advice from our neurosurgeon adviser, to consider our views of the CT scan and angiogram in line with the decisions made for Mr L’s treatment.

73. We have not seen evidence to suggest these scan results were considered. Had the scans been considered, any discussion or view of these should have been documented. If the MDT still felt Mr L had a meningioma, it would be in line with GMC guidance to document this, to explain and justify its decision.

74. In the absence of this evidence, and in line with the findings of the scans, it seems more likely than not that these scans were not appropriately considered. This is a failing. On the balance of probabilities, a consideration of these scans would have led to a reconsideration of Mr L’s diagnosis of meningioma and led to a diagnosis of a high-grade glioma.

75. In his complaint to us, Mr P raises concerns about the decision to proceed with surgery when the tumour was inoperable. He says other options should have been explored. We agree as we consider there was a failure to consider all the relevant evidence before a decision to proceed to surgery was made.

Impact

76. We consider the above failing had a clinical impact. This is because Mr L did not have the opportunity to discuss the change in diagnosis and the prognosis and possible treatment options, including surgery or palliative care. Palliative care would not have prolonged Mr L’s life as such but would have allowed him to make plans to ensure his comfort and dignity.

77. We cannot know what option Mr L might have chosen, and he may still have wished to proceed with surgery. However, had Mr L been aware of his diagnosis, he would have been better prepared for the poor prognosis, and he would have had more time to discuss this with his family if he chose, and prepare for the end of his life.

78. We consider this is a significant injustice and will add to his family’s distress around these events and add to their concern about the care provided by the Trust. We make recommendations to address this at the end of our report.

Embolisation prior to surgery

79. On 5 October 2020, Mr L underwent a partial pre-operative embolisation, which reduced some of the blood flow to his tumour.

80. Based on the CT scan and angiogram findings, our interventional radiologist says this embolisation would not have been needed. This is because embolisation of a high-grade glioma is not clinically indicated and there is no evidence to support this treatment. This is in line with the NICE guidance ‘Brain tumours (primary) and brain metastases in over 16s’.

81. Our interventional radiologist adviser explains embolisation for a high-grade glioma is also a high-risk strategy. This is because it can cause a major stroke by unintended embolisation of normal feeding vessel to the brain. There is also a risk of blocking off a normal draining vein which can cause elevated blood pressure in the veins) and/or steady bleeding from a vein into the brain parenchyma (the essential functional tissue of the brain).

82. Our neurosurgeon adviser has also considered the above and agrees with the view of our interventional radiologist adviser.

83. We consider the decision to proceed with this procedure was a consequence of the likely failure to fully consider the results of the CT scan and angiogram. Had these been appropriately considered, we consider it is more likely than not that this procedure would not have gone ahead. This is in line with the above NICE guidance and the views of our interventional radiologist adviser and neurosurgeon adviser.

Impact

84. Our neurosurgeon and neuro-interventional radiology advisers have considered the pre-embolisation undertaken on 5 October 2020. They have not seen any failings in this procedure which contributed to Mr L’s outcome or the complications of his craniotomy surgery on 7 October 2020.

85. We therefore consider the failure to fully consider the results of the CT angiogram led to Mr L undergoing a surgery which was more than likely unnecessary. We consider this will have caused Mr L unnecessary distress and discomfort.

86. We also consider this failing will add to the Mr L’s family distress about the care he received. We make recommendations below to address this.

1. Mr P complains about the care the Trust gave his brother, Mr L, following his repatriation to the UK after becoming ill on holiday. Mr L underwent tests at a hospital abroad which showed he had a likely cancerous brain tumour.

2. We have found failings at two crucial points in Mr L’s care. Firstly, we consider there were failings in the Trust’s initial decision to downgrade the tumour and consider this was non-cancerous. We consider there was sufficient evidence to suggest this was cancerous. Had this been recognised, we think Mr L would have been offered earlier brain surgery and likely other cancer treatments such as chemotherapy and radiotherapy. His care would also not have been considered ‘non urgent’ during the COVID-19 pandemic.

3. Secondly, we consider there was also a further missed opportunity to recognise the tumour was cancerous when Mr L had further tests from July 2020 onwards. We consider the decision to proceed to surgery in October 2020 did not appropriately take into account this further evidence and we consider a pre-operative procedure was not appropriate for Mr L’s type of tumour.

4. Sadly, this type of brain tumour has a very poor survival rate. Therefore, even if the above failings had not occurred, Mr L would still more than likely have died. We recognise Mr P feels his brother was not given his best possible chance to be the exception for this type of tumour. However, on the balance of probabilities, we consider Mr L’s life would likely have only been extended for a few months, had the failings not occurred.

5. We consider the failure to recognise the tumour was cancerous meant Mr L missed opportunities to prepare for his poor prognosis and to discuss this with his family if he chose. We think this caused considerable distress to him and his family.

6. We therefore uphold this complaint.

7. We have not seen these failings and the impact of these have been recognised in the Trust’s own complaint review. We therefore make recommendations to address this, including a financial recommendation of £3,500. This amount reflects the impact of the two key failings we have identified and the unnecessary pre-operative procedure.

87. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

88. We recommend that within one month of the date of the final report the Trust write to Mr P to acknowledge the failings we have identified in this report and apologise for the impact of these. This relates to:

• the clinical and emotional impact of the MDT decision in December 2019, which led to Mr L’s tumour being considered as ‘non-urgent’ • the clinical and emotional impact of the failure to appropriately review the scans in August and September 2020, before the decision to proceed to surgery (including pre-operative embolisation) was made.

89. Our principles say that public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service.

90. In line with this, we recommend that within three months of the date of the final report the Trust produce an action plan setting out what action it will take or has taken to prevent a repeat of these events, who is responsible for those actions, and the timeframe for completion of them. The Trust should send this action plan to Mr P, us, NHS Improvement, and the Care Quality Commission (CQC).

91. Our principles state that public organisations should put things right and, 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.

92. 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, our current thinking is the organisation should pay Mr P £3,500. This is in recognition of the clinical and emotional impact of the two key failings we have identified (as summarised in paragraph 88).

93. Whilst we recognise our report cannot change the failings in Mr L’s care, we hope this goes some way to reassuring his family that his care has been fully considered and appropriate learning has been taken from this.