Pleural effusion diagnosis 16. Mrs B says Dr A failed to diagnose her mother with pleural effusion between March 2021 and March 2022. She says Dr A did not complete a physical examination of her mother despite her attending several clinics between this time and having regularly having fluid drained from her lungs. She says Dr A ignored the test results between this period which clearly showed she had pleural effusion.
17. The BTS guidance explains pleural effusion diagnosis and monitoring requires imaging of a patient by chest X-ray and/or ultrasound or CT scans. Our adviser explains a clinical examination alone is not sensitive enough for this purpose.
18. The records show in the clinic on 25 March 2021, Mrs D’s daughter reported her mother had leg oedema (swelling), painful legs and a dry mouth, having recently been diagnosed with a leg deep vein thrombosis (DVT).
19. There is no mention of breathlessness, which our adviser explains would have been present if Mrs D had a significant pleural effusion at that time. There is no mention that Mrs D had breathlessness in any of the other clinic appointments she had. Her clinic letter from 23 July says Mrs D was doing well from a respiratory point of view and her main issue was leg and back pain. The pleural effusion was picked up as incidental finding on the routine follow CT scan done on 25 August 2021.
20. Following the diagnosis, the clinical records show Mrs D was seen regularly between September 2021 and March 2022 in the pleural effusion clinic, had pleural fluid drained on several occasions and her management was discussed by an MDT.
21. During the local resolution meeting with the Trust, Dr A acknowledged he did not carry out a physician examination or listen to Mrs D’s chest during some clinic appointments. Mrs B explained how difficult it was to hear this, and we do not doubt how upsetting the knowledge of this would be to her. Our adviser explains based on Mrs D’s presenting symptoms between March 2021 until the diagnosis in August 2021, there was no clinical indication to undertake a chest X-ray or physical examination at this time. Based on this we cannot be critical of Dr A’s decision to not listen to Mrs D’s chest during the clinic appointments.
22. Overall, we consider there is no evidence Dr A failed to diagnose Mrs D with pleural effusion any earlier than when it was diagnosed on 25 August 2021. We are satisfied Dr A carried out appropriate investigations into Mrs D’s presenting conditions prior to this date and then treated the pleural effusion in line with the guidance following this, and our clinical advice supports this view.
Oesophagitis 23. Mrs B says the Trust failed to appropriately manage her mother’s symptoms of oesophagitis including the pain radiating from the oesophagus into her back and chest, between March 2021 and March 2022. She says the Trust only advised her to take paracetamol and inappropriately referred her for physiotherapy as treatment. She says the Trust should have referred her to a gastro-specialist in March 2021 as she was unable to swallow.
24. The GMC guidance explains clinicians must provide a good standard of practice and care. If you assess, diagnose or treat patients, they must: • adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.
25. Oesophagitis is inflammation of the lining of the oesophagus which can cause pain, difficulty in swallowing or chest pain.
26. The clinical records show Mrs D was seen in clinic on 26 March 2021. The doctor suspected she had radiation induced oesophagitis at this point and had difficulty swallowing and prescribed paracetamol for the pain. She was seen again in clinic on 30 March 2021 and she explained her swallowing had improved. We consider Mrs D did experience symptoms of oesophagitis in March 2021, and the Trust provided Mrs D with paracetamol to treat her pain in line with the GMC guidance. Our clinical advice supports this view.
27. We have also considered whether Mrs D should have been referred to a gastro-specialist at this point. A clinic letter from a different Trust explains Mrs D underwent a barium swallow, which did not show a stricture (a physical narrowing of the oesophagus). Our adviser explains with this in mind, there is nothing more a gastroenterologist could have done for Mrs D. We consider there was no reason to refer Mrs D to a gastro-specialist in March 2021 and our clinical advice supports this view.
28. She was seen again by the speech and language and dietitian team on 6 July. The letter from this appointment outlines that Mrs D was taking a ‘largely regular diet and fluids with no sign of aspiration (coughing, choking or throat clearing). She explained some throat discomfort she had experienced in the past had also resolved’. Our adviser explains the findings from this appointment suggests Mrs D did not have oesophagitis at this time, as she would not be able to take a near normal diet and fluids if she had.
29. Mrs D was next admitted to the Trust between 26 December and 31 December 2021 as she required treatment for pleural effusion and had difficulty swallowing. Tests showed that she had a stricture, which was likely related to her prior radiation treatment. Doctors felt she was well enough to be discharged and treated as an outpatient for a barium swallow and a further gastroenterology review as an outpatient.
30. During this admission we can see the Trust promptly assessed Mrs D’s symptoms in hospital, it arranged investigations and tests which confirmed a diagnosis of an oesophageal stricture and arranged for further treatment as an outpatient. This course of action was in line with the GMC guidance on providing an adequate assessment of a patient’s condition and providing appropriate treatment, and our clinical advice supports this view.
31. It must be very difficult for Mrs B and her family to have concerns about the Trust’s management of her mother’s oesophagitis during this period. In conclusion, the evidence shows the Trust managed Mrs D’s oesophagitis appropriately. We hope this reassures Mrs B and her family.
Tumour growth
32. Mrs B says Dr A incorrectly advised her mother in November 2021 that her test results showed a tumour had grown and spread through her lungs and spine and could only be treated palliatively. She considers the results from these tests showed the tumour had reduced in size, and her cancer did not show any signs it had spread. Mrs B questions the treatment options available to her mother.
33. The Trust explained that following an MRI on 15 September, it showed there was a significant progression in the size of the tumour and it had spread to 55mm. The CT scan also confirmed the tumour had become necrotic (the death of cells within a tumour) and invaded the spine. An MDT meeting was held on 16 September and it decided as Mrs D was very unwell and she would not be fit for chemotherapy.
34. The GMC guidance explains clinicians must work in partnership with patients, sharing with them the information they will need to make decisions about their care, including their condition, its likely progression and the options for treatment, including associated risks and uncertainties.
35. Mrs D’s CT scan from August 2021 was reviewed at the lung MDT meeting on 16 September 2021. The comments and conclusion from the review were that the scan showed changes in the spine and increased pleural fluid which were in keeping in metastatic disease (spread of the cancer). These changes were not present on the previous scan.
36. Our adviser reviewed the scan results and told us that whilst the primary tumour in Mrs D’s lung had shrunk with radiotherapy, unfortunately her cancer had spread to other areas (her pleura, which is a membrane that lines the lung and her spine) between March 2021 and November 2021. Based on this advice, we are satisfied the Trust correctly interpreted the test results and appropriately explained to Mrs D that her cancer had sadly spread. This is in line with the GMC guidance.
37. Given Mrs B’s concerns about the treatment options, we also looked if there were any other treatment options available in November 2021 aside from palliative management (care to provide comfort).
38. The BMJ information on non-small-cell lung cancers explains treatment regimens vary depending on the stage of cancer. For patients with stage four disease the goal of treatment is to reverse, delay or prevent symptoms due to the local or metastatic tumour as well as to prolong survival. It explains the fitness of the patient can be a major factor in the decision-making process.
39. The NHS drugs fund guidance explains patients must have a World Health Organisation (WHO) performance status of zero or one (mobile, active and capable of light work) to meet the criteria for chemotherapy. They are unsuitable if they have a score of two (mobile and capable of all self-care but unable to carry out any work activities) or above.
40. Our adviser explains unfortunately, once lung cancer has spread outside of the lung, as was the case for Mrs D, this represents advanced (stage four) lung cancer and all treatment options are palliative.
41. The records show after the lung cancer MDT meeting in September 2021, the focus was on trying to improve Mrs D’s pain control via the palliative care team, and breathlessness via the pleural clinic. The notes from the MDT meeting also outline she had a WHO performance status of two, which as explained above means she was mobile and capable of all self-care but unable to carry out any work activities. The records go onto explain her condition deteriorated and in November 2021 she required the assistance of family to attend hospital appointments.
42. The evidence shows Mrs D was not strong enough to benefit from palliative chemotherapy which is generally only offered to patients of good performance status. This is because palliative chemotherapy is potentially toxic treatment with only limited benefits on survival, which is why the treatment is reserved for patients who are mobile, active and capable of light work. Unfortunately Mrs D did not meet this criteria. With this in mind, sadly Mrs D’s cancer could only be managed palliatively. We consider the Trust correctly explained the treatment options to Mrs D, and our clinical advice supports this view.
43. Overall, we have seen no failings in relation to the care and treatment provided by the Trust to Mrs D. We understand how important Mrs B’s complaint is to her and how much she continues to be impacted by the death of her mother. We do not underestimate how difficult this period was for Mrs B and her family, we hope our work goes some way to reassure Mrs B and her family about the care her mother received.