East Cheshire NHS Trust

Trust A

4. Mrs H complains Trust A delayed referring her husband, Mr H to an MDT meeting by 7 days in July 2021 when he first received his pancreatic cancer diagnosis.

5. Mrs H also complains that when the Trust found a mass in Mr H’s lungs in July 2021 it failed to carry out further investigations, such as a CT scan.

6. Mrs H says the Trust’s delay regarding an MDT referral meant Mr H did not receive treatment for his cancer as soon as he should have. Mrs H says the Trust denied her husband an opportunity to prolong his life. She has told us of the catastrophic impact losing her husband has had on her.

7. Mrs H says the failure to carry out further investigations in relation to Mr H’s mass, meant it missed an opportunity to provide Mr H with clot management treatment and this caused him to suffer two strokes and a heart attack.

8. To resolve her complaint, Mrs H would like service improvements to ensure this does not happen to others.

Trust B

9. Mrs H complains Trust B delayed obtaining a biopsy of her husband’s bile duct in August 2021.

10. Mrs H says the Trust’s delay meant Mr H was not able to have a stent he required in his bile duct and did not receive further treatment for his cancer as soon as he should have. Mrs H says the Trust denied her husband an opportunity to prolong his life. She has told us of the catastrophic impact losing her husband has had on her.

11. To resolve her complaint, Mrs H would like service improvements to ensure this does not happen to others.

12. This background is only intended to place the key events related to this complaint in context, not to provide a detailed chronological account of everything that happened.

13. Mr H attended his GP surgery on 13 July 2021 with symptoms of jaundice and abnormal liver function. His GP had referred him to a specialist under the 2 week wait pathway (when cancer is suspected this is a fast route to get further tests and specialist advice to diagnose or rule out cancer). On 19 July 2021, Mr H attended Trust A’s Accident and Emergency department (A&E) as his symptoms were worsening.

14. Mr H told Trust A he was feeling nauseous and had occasional headaches. He also explained his stools were pale and he was passing dark urine. Trust A examined Mr H and noted his abdomen was mildly tender. It admitted Mr H and requested further investigations including blood tests, a chest x-ray, a CT scan (imaging taken to see inside of the body) and an ECG (a test to record heart activity).

15. On 20 July, Trust A received the results of Mr H’s CT scan. The scan revealed Mr H had pancreatic cancer and it had metastasised (spread), along with a 5mm indeterminate node (a growth within his lung). Trust A reported no other nodes. It planned to review Mr H’s growth in 12 months via another CT scan and determined no immediate action was required in relation to the node. Trust A undertook additional investigations into the cancer.

16. On 22 July, Trust A obtained a special MRI scan (internal detailed imaging) also known as a MRCP scan (images taken of liver, gallbladder, bile ducts and pancreatic duct) for Mr H.

17. Mr H’s records show on receipt of the CT scan, Trust A referred Mr H to Trust B and its speciality pancreatic multidisciplinary team (MDT). Records show it made the referral on 23 July 2021 and sent Trust B the results of Mr H’s scans.

18. Trust B reviewed Mr H at its MDT meeting on 28 July 2021. The MDT considered Mr H’s cancer diagnosis and requested further investigations for him. On 30 July, Trust A discussed the MDT outcome with Mr H. It advised Mr H to return to the Trust B three days later for a scan, a brush biopsy (a procedure used to check for abnormal cells) and a procedure which involved fitting a stent to help clear the blockage in his bile duct.

19. On 2 August Trust B admitted Mr H and attempted to insert a stent. This was unsuccessful and so Trust B attempted to insert a second stent two days later. Mr H’s records show during these procedures clinicians also obtained brush biopsies and sent these samples for a review.

20. Mr H’s records show Trust B was not successful in any of its attempts to fit a stent. Mr H was discharged on 5 August from Trust B and transferred back to Trust A. Trust B wrote to Trust A to explain what had happened. It said Mr H’s bile duct was too narrow due to the presence of scar tissue.

21. Regarding the brush biopsies it had collected from Mr H, Trust B said the initial sample it collected did not contain cancer cells. It repeated the biopsy when it attempted to insert the second stent for Mr H. It later reported that the second sample it had collected was insufficient.

22. Mrs H explains that Trust B rescheduled Mr H’s biopsy for mid-August. We can see from Mr H’s records Trust A reviewed him at this time as it identified he had multiple pulmonary embolisms (a serious condition where a blood clot blocks a blood vessel in your lungs). Due to this, Trust B postponed his biopsy until early September.

23. Mrs H considers the delays with the biopsies to be unacceptable as she says it left her husband unable to receive the treatment he needed for his cancer and the clots he developed.

24. Sadly, Mr H died on 31 October 2021. His cause of death was metastatic pancreatic cancer, pulmonary embolism, hypertension and stroke.

28. 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. We will explain the reasons for our decision in more detail below.

Delayed referring to MDT

29. Mrs H complains Trust A failed to refer her husband to Trust B’s MDT meeting in a timely manner. Mrs H says that her husband received his diagnosis on 20 July 2021 which was a Tuesday, and she was aware Trust B’s MDT meetings were held on a Wednesday. She is concerned Trust A did not ask Trust B to review her husband in its meeting the day after he received his diagnosis.

30. As we have explained in paragraphs 17 and 18, we can see from Mr H’s records Trust A referred Mr H to Trust B’s MDT meeting on 23 July 2021. Trust B reviewed Mr H at its MDT on 28 July 2021.

31. Trust A’s complaint response explained the MDT was co-ordinated by Trust B and meetings are usually held on a Wednesday. The deadline to submit a case for discussion is the preceding Friday. Trust A said it could not add patients to this list after each weekly deadline.

32. NHS England’s guidance on implementing a timed HPB (Hepato-Pancreato-Biliary) cancer diagnostic pathway explains that having clear guidelines for referring patients to specialist MDTs can help manage their treatment more efficiently. (HPB cancers are a group of cancers that affect the liver, pancreas, bile ducts and gallbladder).

33. NHS England’s guidance on implementing a timed HPB pathway does not specify timescales but says by day 10 from when clinicians identify a possible cancer diagnosis that requires specialist care, booking of further diagnostic testing should be carried out at the point of clinical assessment. This means doing more tests to help clinicians have a clearer picture of a patient’s condition and to allow them to decide on the best treatment plan. The guidance also explains the patient should be supported to discuss the next steps and prepare for a further investigation appointment.

34. Mr H’s records show Trust A obtained a CT scan of his chest, stomach and pelvis within 24 hours of his presentation with jaundice. On 22 July, Trust A also obtained an MRI scan to confirm Mr H’s diagnosis of metastatic pancreatic cancer. Mr A’s records show Trust A informed him of his suspected diagnosis on 23 July, four days after he attended its A&E department. We can see from Mr H’s records, the timing of the discussion at Trust B’s MDT meeting was nine days after he presented at Trust A.

35. As outlined in paragraph 31 Trust A submitted a referral for Mr A to be reviewed at Trust B’s next available MDT.

36. Our adviser told us Trust A referred Mr H to Trust B’s specialist MDT meeting in line with NHS England’s guidance we have referred to in paragraph 32. Our adviser explained Trust A carried out investigations which were required for an informed view to be given at the MDT meeting. We can see from Mr H’s records the Trust obtained these investigations within the 10-day timescale recommended by guidance and he was reviewed by Trust B’s MDT nine days after he attended Trust A.

37. We can understand why Mrs H would question the timeliness of Mr H’s MDT referral knowing there was a meeting to be held the day after he received his diagnosis. We have carefully reviewed Mr H’s medical records and have not identified any indication Trust A delayed its referral to Trust B. This means we see no indication of a failing here.

Further investigations for Mr H’s lung mass

38. Mrs H complains Trust A did not do enough when it identified a mass in Mr H’s lung in July 2021. Mrs H says the Trust should have monitored this more closely and carried out further investigations such as blood tests and a repeat CT scan. Mrs H told us because of the lack of monitoring of Mr H’s lung mass, he suffered clots which resulted in a pulmonary embolism (PE). A PE occurs when a blood clot blocks one of the arteries in your lungs.

39. British Thoracic Society guidance for lung nodules explain if a mass measuring less than 6mm is identified in a patient, clinicians should repeat a CT lung scan in 12 months.

40. Mr H’s records show Trust A obtained a CT scan on 20 July 2021. The scan identified a mass of 5mm.

41. Our adviser explained there was no indication for Mr H to undergo a repeat CT scan given the size of the mass found. They told us it was appropriate for Trust A to plan for a repeat CT scan of Mr H’s chest by 20 July 2022. Taking into account the guidance and the views of our adviser we cannot see any indication of failings on the part of Trust A in relation to the care and treatment of Mr H’s lung mass.

Delays with biopsy

42. Mrs H told us she has concerns Trust B delayed obtaining a biopsy of her husband’s bile duct. In her complaint to Trust B, Mrs H questions why it was unsuccessful during its initial attempts in August 2021. Mrs H also questions why she and Mr H were not told before the procedure, there is a 40% chance the sample collection would not be successful.

43. Mrs H told us the delays were unacceptable and left Mr H without access to treatment he needed. We have explained the timeline of events in paragraphs 19 to 22.

44. We can see this was a difficult time for Mrs H and her husband. We understand why she is concerned about what happened in relation to Trust B’s biopsy procedures, knowing Mr H sadly died over two months later.

45. Trust A referred Mr H to Trust B to undergo a procedure to fit a stent to his gall bladder which had narrowed. Along with this, Trust B were to carry out an ERCP procedure (a medical procedure which is used to treat conditions affecting the bile duct) and take a brush cytology of Mr H’s gallbladder for further investigation (a brush cytology is a medical technique used to collect cells for examination under a microscope and is a less invasive type of biopsy).

46. Mr H was admitted to the Trust at the start of August. Its first two attempts to take a biopsy were not successful. It arranged for a further biopsy in mid-August, but this was postponed. Trust B repeated Mr H’s biopsy at the start of September. We can see this was approximately a one-month delay.

47. Sadly, Mr H’s records show his successful biopsy in September confirmed he had adenocarcinoma (a type of cancer that starts in a certain type of cells lining the gallbladder).

48. BMC Gastroenterology publication relating to success of ERCP explains there are recognised limitations of ERCP procedures and being able to obtain bile duct access for a biopsy. It explains this can fail in 5-10% of cases.

49. On 2 August we can see from Mr H’s records Trust B said it did not have enough access to his bile duct to carry out the biopsy. It explained this was because Mr H’s bile duct was too narrow.

50. BMJ Journal has published research relating to the impact of brush cytology. It also explains there are known restrictions to ERCP procedures. It describes a case study where out of 162 patients only 55% of patients were diagnosed as having cancer based on the type of biopsy Mr H needed (biliary cytology). It explains how this type of biopsy procedure is less invasive, but sometimes has poor results due to insufficient samples.

51. On 4 August, Trust B said it did obtain access but did not collect a sufficient sample. In its response to Mrs H, it explains it is a known risk and in 40% of cases this happens.

52. GMC guidance explains when assessing and treating patient’s doctors must adequately assess the patient’s conditions. It also explains when providing clinical care, doctors must provide effective treatments based on the best available evidence.

53. We can see from Mr H’s records unfortunately after the second biopsy was taken, he was diagnosed with pulmonary venous thrombosis (a condition where blood clots form in veins carrying blood from the lungs to the heart).

54. Our adviser reflected on Mr H’s records and Trust B’s actions in relation to the biopsies it had taken from Mr H on 2 August, 4 August and its decision to delay the biopsy procedure on 22 August. They said the relevant standards were correctly followed by Trust B when it made attempts to obtain biopsies for Mr H. This was because as the guidance we have referred to explains, there are known complications with the type of biopsy Mr H needed.

55. In relation to Trust B’s decision to delay the biopsy our adviser told us it was appropriate to wait until Mr H had received treatment for his blood clot as this is a severe life-threatening condition.

56. Considering the views of our adviser and the publications we have seen, we consider Trust B acted in line with GMC guidance described in paragraph 51. We have not concluded there was an indication of failing with Trust B in relation to delays obtaining biopsies for Mr H.

57. We are very sorry to hear of how distressing this time was for Mr H and for Mrs H to see her husband become so unwell, and we understand why she believes different treatment could have changed the outcome for him. We hope our decision provides Mrs H with assurance about what happened with her husband’s care.

1. Mrs H complains about aspects of the care and treatment provided to her husband, Mr H by: East Cheshire NHS Trust (Trust A) and Manchester University NHS Foundation Trust (Trust B) in July 2021.

2. We have considered the evidence carefully and we do not see any indication of failings in the complaints raised about either of the Trusts’ care and treatment.

3. As we have seen no indication of wrongdoing, we have decided not to investigate further. We recognise how important this complaint is to Mrs H, and we extend our condolences to her on the loss of her beloved husband.