A practice in the Greenwich area

L&G Trust

4. Miss N complains about aspects of the care and treatment doctors at Queen Elizabeth Hospital gave to her mother between November 2020 and January 2022. Specifically, she says:

• there were delays in arranging an ultrasound scan from November 2020 • doctors should have investigated further based on the results of the scan • there was a delay in doctors acting on a scan in November 2021 • doctors failed to recognise and treat an infection in January 2022.

Circle Health Group 5. Miss N complains about the way doctors at the Hospital treated her mother between February and June 2021. She says they did not investigate her mother’s health problems fully and did not give her the treatment she needed.

KCH Trust 6. Miss N complains that doctors delayed communicating the outcome of a multidisciplinary team (MDT) meeting from 20 December 2021 to 5 January 2022.

GST Trust 7. Miss N complains that clinicians at Guy’s Hospital did not give her mother the medication she needed during her admission in January 2022.

All four organisations 8. Miss N believes failures by doctors led to delayed diagnosis and treatment of cancer. She questions whether her mother would have had a better chance to survive her illness. She says she may have lived longer and had a better quality of life with reduced pain.

9. Miss N wants the organisations to acknowledge their failings and take action to ensure other patients do not have the same experience.

10. On 3 November 2020 Mrs N called her GP because of problems when urinating (pain and frequency). The GP diagnosed a urinary tract infection (UTI) and prescribed antibiotics. A urine test confirmed this diagnosis. Mrs N continued to have these problems over the following weeks. The GP made a referral to the Queen Elizabeth Hospital for an ultrasound scan to look for possible causes of infection on 25 November.

11. At the end of January 2021 Mrs N’s GP made a referral to urologists at the Hospital. This was because her problems with urination were still ongoing. She had a telephone consultation with Mr N (Consultant Urological Surgeon at the Hospital) on 18 February. He arranged an ultrasound scan and planned to follow her up afterwards.

12. Mrs N’s ultrasound took place at Queen Elizabeth Hospital on 17 February 2021. This did not highlight any significant concerns and the sonographer sent a report to her GP.

13. Mrs N had a further ultrasound scan of her urinary tract and pelvis at the Hospital on 23 February 2021. She then saw Mr N on 4 March. The scan did not identify any concerns with Mrs N’s kidneys and Mr N planned to see her again in six weeks.

14. In March 2021 Mrs N returned to her GP because of further urinary problems. The GP confirmed she had a UTI and prescribed antibiotics. Mrs N had a telephone consultation with Mr N on 15 April. He changed her medication and requested a cystoscopy (where a clinician uses a scope to look inside the bladder).

15. Mrs N attended the Hospital for a cystoscopy on 26 May 2021. Mr N carried out the procedure and found no issues of concern. He had a telephone consultation with her on 3 June. As there were no significant problems he discharged her from his care.

16. On 27 October 2021 Mrs N contacted her GP about abdominal pain and two weeks of indigestion symptoms. She felt pain on her right side. The GP examined her and suspected she had gallstones. They arranged for an ultrasound scan. This took place on 5 November at Queen Elizabeth Hospital. The scan confirmed she had gallstones, but it also showed an area of the liver that could have been cancer and needed further investigation. The sonographer sent a report to Mrs N’s GP on 8 November 2021.

17. Mrs N’s GP made an immediate referral for suspected cancer to the gastroenterologists at the Queen Elizabeth Hospital. This led to Mrs N having a telephone consultation with Dr R (Consultant Gastroenterologist) on 17 November 2021. A face to face appointment was not possible because of COVID-19 restrictions. A CT scan took place on 9 December. This showed Mrs N had extensive cancer in her liver. Her GP advised her of this in a call on 13 December and pointed out this would need to be confirmed by a biopsy.

18. On 17 December 2021 clinicians at the Queen Elizabeth Hospital discussed Mrs N at an MDT meeting. The outcome was to arrange a biopsy to assist with further diagnosis. On 23 December Dr H (Consultant Gastroenterologist) called Mrs N to discuss the scan results. The doctor explained that Mrs N’s cancer, of the bile ducts, was difficult to diagnose and treat. They also explained how the cancer appeared to have spread.

19. Mrs N had a biopsy at the Queen Elizabeth Hospital on 24 December 2021. The doctors at the Queen Elizabeth Hospital sent a referral to the hepatobiliary and pancreatic service at King’s College Hospital. They discussed Mrs N’s case at an MDT on 5 January 2022. They concluded that Mrs N should have palliative chemotherapy because her cancer could not be cured. They shared this information with the doctors at the Queen Elizabeth Hospital on 9 January 2022.

20. On 11 January 2022 Miss N accompanied her mother to a consultation with Dr H at the Queen Elizabeth Hospital. Dr H explained how treatment would be focused on managing symptoms as the cancer was not curable. By this point Mrs N had developed jaundice because bile was not flowing properly from her liver. The plan was for Mrs N to attend Guy’s Hospital for further tests before chemotherapy could start.

21. On 21 January 2022 Mrs N attended Guy’s Hospital. Doctors there were concerned she had signs of infection and decided to admit her. They considered the cancer originated in the gallbladder. They gave Mrs N intravenous fluids and antibiotics. However, Mrs N was too unwell to consider starting chemotherapy. After a week in hospital doctors discharged Mrs N home.

22. Sadly, Mrs N died on 1 February 2022.

23. Miss N first complained to the L&G Trust in May 2022. They co-ordinated a complaints investigation involving the other organisations who had been involved in Mrs N’s care and treatment. The complaints investigations ended in July 2023. Miss N remained dissatisfied, so she complained to us.

L&G Trust

Ultrasound request in November 2020

27. Miss N says her mother’s GP requested an ultrasound scan at Queen Elizabeth Hospital on 25 November 2020. She says it took until 17 February 2021 for the scan to take place.

28. Good Medical Practice says doctors must provide a good standard of care. This includes carrying out adequate assessments, taking account of the patient’s history and examining them if necessary. Doctors should also arrange timely treatment and appropriate investigations or referrals if needed.

29. The Medical Adviser said there were no specific standards in place in November 2020 about the time taken to process requests for scans.

30. The records show Mrs N’s GP made a routine referral for an investigation into Mrs N’s UTI on 25 November 2020. The Medical Adviser told us there was no clinical suspicion of cancer at that stage. Her GP noted they had counselled Mrs N there would be a long wait. This happened during the COVID-19 pandemic and the Medical Adviser said there were delays for most investigations at that stage.

31. We recognise that it took longer than expected for clinicians at the Trust to arrange the appointment for Mrs N’s ultrasound scan. Clearly this would have been a source of anxiety for Miss N and her mother. We find that what happened did not fall below Good Medical Practice in terms of doctors providing timely treatment.

Results of the scan on 17 February 2021

32. Miss N believes doctors at the Queen Elizabeth Hospital should have done more to try and find the cause of her mother’s problems following the scan on 17 February 2021. She says the cancer could have been identified sooner if more investigations had taken place.

33. The doctors at the Queen Elizabeth Hospital should have followed Good Medical Practice as explained above.

34. The scan on 17 February 2021 was normal. The Medical Adviser told us it is important to realise the scan was only focused on Mrs N’s kidneys and bladder. This was clinically appropriate. The GP had asked the Trust for an investigation relating only to symptoms relating to UTIs. There was no request for clinicians to consider any liver problems and there were no suggestions at that stage that Mrs N had any of the symptoms that she later had which led to suspicions of cancer.

35. Mrs N was due to have a consultation with the urologists at the Hospital the day after the scan. There was no requirement for doctors at the Queen Elizabeth Hospital to take any further action at that stage. Their role was to report back to the referring GP, and this is what they did.

36. We can see no evidence to suggest clinicians at the Queen Elizabeth Hospital needed to take further action following the scan on 17 February 2021. We find that what happened did not fall below Good Medical Practice.

Response to the scan on 5 November 2021

37. Miss N believes doctors should have taken more urgent action when they confirmed her mother had cancer on 5 November 2021. She says there were delays in her mother being able to see specialists.

38. The NHS Handbook includes government targets for waiting times. It says there should be a maximum 62 day wait from referral for cancer to the first definitive treatment. It says all people referred with suspected cancer should see a specialist within two weeks.

39. Again, doctors should have followed Good Medical Practice as we have explained earlier in this report.

40. We can see the first reference in clinical records to Mrs N complaining of abdominal pain on 27 October 2021 at a GP appointment. Before that date her concerns related to urinary problems. The GP suspected she had gallstones and made a referral for an ultrasound scan to check whether this was the cause of her pain.

41. Mrs N had the scan on 5 November 2021. Clinicians at the Queen Elizabeth Hospital sent a report to the referring GP on 8 November. This highlighted gallstones and also an abnormal area in Mrs N’s liver. The GP then made a referral for Mrs N to see gastroenterologists under the two-week cancer guideline that GPs are expected to follow. Mrs N then had a telephone appointment with a gastroenterologist within two weeks, on 17 November. This was in line with the NHS Handbook.

42. The Medical Adviser told us it is common for CT scans to provide a more accurate view of the extent of cancer than an ultrasound scan. This is what happened with Mrs N. The CT scan on 9 December 2021 identified a six by seven centimetre mass in Mrs N’s liver and evidence of other areas of cancer that were both inside and outside the liver (peritoneal metastasis). The cancer was incurable at that stage.

43. The Medical Adviser said the biopsy from 24 December 2021 confirmed Mrs N had bile duct cancer (cholangiocarcinoma). Doctors offered Mrs N palliative treatment, which initially consisted of pain relief. This was within the 62 day target set out in the NHS Handbook. The Medical Adviser told us most NHS organisations struggle to meet some of the cancer targets. The evidence suggests the doctors at the Queen Elizabeth Hospital treated Mrs N in a timely manner without undue delay.

44. We find doctors followed Good Medical Practice and the NHS Handbook in the care and treatment they gave to Mrs N from 5 November 2021 onwards. We can see no evidence of any delays.

Infection in January 2022

45. Miss N says her mother had obvious signs of infection when she saw Dr H on 11 January 2022. She says Dr H did nothing to address this and this meant her mother had to be admitted to Guy’s Hospital ten days later.

46. The Medical Adviser told us there are no specific standards relating to when doctors should intervene to treat jaundice. Doctors would be expected to follow Good Medical Practice by providing appropriate and timely treatment.

47. The clinical records do not suggest there were any signs of infection at the appointment on 11 January 2022. Dr H was aware there was a scheduled appointment at Guy’s Hospital ten days later. At that stage there was no requirement for Dr H to treat the jaundice. This had worsened by the time Mrs N attended Guy’s Hospital and she also developed an infection.

48. The Medical Adviser noted that doctors at Guy’s Hospital treated the jaundice by inserting a stent. But this was not effective and Mrs N’s jaundice continued until she died. The Medical Adviser considered there was no delay in doctors recognising and responding to Mrs N’s health problems.

49. We find Dr H followed Good Medical Practice at the consultation in January 2022.

Circle Health Group

50. Miss N says the scan on 23 February 2021 at the Hospital did not show any concerns about her mother’s health. Despite this she says her mother was clearly unwell. She believes Mr N and his colleagues should have done more to try and find the cause of the problem rather than prescribing more antibiotics. She believes the cancer could have been identified sooner if more investigations had taken place.

51. The Urology Guideline contains recommendations for the prevention and treatment of UTIs. It says extensive investigation is not usually required for recurrent UTIs unless the case is not typical. In cases where kidney stones, urinary blockages or cancer are suspected clinicians should arrange a cystoscopy and scans. The Urology Guideline recommends prescribing low-dose antibiotics for an extended time to try and reduce recurrent UTIs.

52. The clinical records show Mr N arranged for an ultrasound scan and cystoscopy at the Hospital. The focus at that stage was on finding a reason for the recurrent UTIs and there was no suggestion of any liver problems. Mr N’s investigations related to the bladder, kidneys, and urinary tract. The Urology Adviser told us this was in line with the Urology Guideline.

53. Mr N also arranged a bladder scan and carried out a vaginal examination. He concluded that Mrs N’s symptoms related to a urinary problem with no indication of any other cause.

The Urology Adviser said these investigations did not show any significant abnormalities in the urinary tract. The liver was not scanned as there was no need to do so at this point. There was no cause to suspect cancer in Mrs N’s liver or elsewhere.

54. Mr N recommended several treatments including a hormone replacement cream, Dmannose (a sugary supplement that can help prevent UTIs), extended low-dose antibiotics and mirabegron (used to treat an overactive bladder). The Urology Adviser said these were all appropriate treatments in line with the Urology Guideline.

55. We find Mr N followed the Urology Guideline at his consultations with Mrs N. His focus was, correctly, on diagnosing and treating Mrs N’s urinary problems and he did this appropriately. There was no reason for him to suspect Mrs N had any other problems between February and June 2021.

KCH Trust

56. Miss N complains that doctors delayed communicating the outcome of a multidisciplinary team (MDT) meeting from 20 December 2021 to 5 January 2022.

57. Doctors should have followed Good Medical Practice in terms of providing timely treatment. They should also have treated Mrs N in line with the NHS Handbook.

58. We can see there was a slightly longer wait than normal for the MDT to review Mrs N’s investigations because of the Christmas holiday period. Clinicians at the Queen Elizabeth Hospital made the referral on 20 December 2021 and the MDT meeting took place on 5 January 2022. The outcome was referred back to the Queen Elizabeth Hospital four days later.

59. The Medical Adviser told us the longer than usual timescale was unavoidable. It had no impact on Mrs N’s cancer or the treatment options that were available for her. The timing was still in line with the 62 day target set out in the NHS Handbook.

60. We find there were no failings by clinicians at the KCH Trust. They followed Good Medical Practice and the NHS Handbook and gave Mrs N timely treatment.

GST Trust

61. Miss N complains about an incident on 21 January 2022 when her mother was left without pain relief and other medication for several hours. GST Trust has accepted this was an error and said it happened because of a failure in computer systems. Miss N says she is surprised there was no manual process for nurses to follow if the systems failed.

62. The NMC Code says nurses must deliver the fundamentals of care effectively. It says they should ensure that any treatment, assistance or care they are responsible for is given effectively.

63. This incident happened when doctors decided to admit Mrs N to Guy’s Hospital at her outpatient appointment on 21 January 2022. The clinical records show a nurse assessed Mrs N’s pain at 1.32pm. The nurse noted Mrs N had mild pain at rest and moderate pain on movement.

64. Mrs N arrived on the cancer ward at approximately 4.30pm. At 4.56pm a nurse reviewed Mrs N and noted she had already contacted doctors twice to ask them to review Mrs N to prescribe fluids and pain relief. A doctor then reviewed Mrs N at 7.49pm. They prescribed antibiotics, pain relief and fluids.

65. GST Trust explained how it used an electronic prescribing system for medication. This system was not working at the time of Mrs N’s admission. This meant there was a delay in clinicians giving Mrs N the medication she needed. GST Trust agreed with Miss N that nurses should have acted sooner to address Mrs N’s pain.

66. The Nursing Adviser told us nurses should have responded to Mrs N’s pain during the afternoon of 21 January 2022. If they were awaiting a prescription, they should have escalated this to the doctors. While there is a reference to one nurse making attempts to contact doctors, this was insufficient.

67. We agree with Miss N that there should have been a manual process for nurses to follow to ensure medication could be prescribed quicker than it was, particularly when her mother was clearly in pain. We consider that responding to pain is a fundamental aspect of nursing care. Nurses did not ensure Mrs N received the care she needed. They did not follow the NMC Code. We can see how this led to Mrs N experiencing pain that could have been reduced.

68. GST Trust has accepted this failing. It has apologised to Miss N and explained how it has taken action to try and ensure this issue is not repeated in future. GST Trust explained how the incident had been shared with the nursing teams so they are reminded about how to contact senior clinicians if doctors do not attend to review patients in a timely manner.

69. We consider GST Trust has taken appropriate action in response to Miss N’s complaint. We recognise how distressing it must have been for Miss N to witness her mother’s distress for several hours. Our view is GST Trust has addressed this sufficiently and has apologised to Miss N. No further action is needed in this regard.

Conclusion

70. Miss N has clearly explained how distressing it was for her to witness her mother’s illness. We recognise she believes doctors could have done more to investigate Mrs N’s symptoms over several months and that they could have acted more quickly. We find doctors followed the relevant standards throughout the period we have considered. We have not seen any evidence to suggest opportunities were missed that could have led to Mrs N living longer or having a better quality of life.

71. We have seen how clinicians at GST Trust delayed giving Mrs N the medication she needed on 21 January 2022. We find this led to pain and distress that could have been avoided. But we consider GST Trust has taken appropriate action in this respect and have not recommended any further action.

72. We do not uphold Miss N’s complaint.

1. Miss N complains about how four different NHS organisations cared for and treated her mother, Mrs N, between November 2020 and her death in February 2022. We can see how devastating these events have been for Miss N. We offer her our sincere condolences for her loss.

2. We have found no failings relating to three of the four organisations we are investigating. While we have seen evidence of failings and an injustice relating to GST Trust, we consider it has already put things right with the action it has taken. We do not uphold Miss N’s complaint.

3. We recognise Miss N believes doctors should have done more for her mother in the months before she died. We hope she is reassured that we have fully investigated her concerns and seen no evidence of any significant failings that could have changed the tragic outcome for her mother.