Failure to diagnose Mr Y’s cancer in August 2021 25. Ms X complains the Trust failed to diagnose her father’s cancer on the CT scan carried out on 13 August 2021. The Trust’s investigation found that there had been a perceptual error. Our radiologist adviser explained a perceptual error means failure to identify an important finding on the initial detection phase (the first scan).
26. Our radiologist adviser said the radiologist’s report commented on the majority of the abdominal organs including the colon, but there was no mention of the small bowel. They added it is uncertain whether the radiologist looked at the small bowel or did not include it in the report because they did not note an abnormality.
27. Our radiologist adviser confirmed there was a small bowel lesion and said the lesion itself could be missed due to its small size. They said its appearance likely represents a small bowel neuroendocrine tumour (a rare tumour) causing early or small bowel obstruction. Neuroendocrine tumours of the small bowel are tumours of the hormone secreting cells of the gut and can produce symptoms either because they cause obstruction (as in this case) or release hormones into the circulation which can have effects such as flushing or dizziness.
28. We understand that this type of cancer can be difficult to identify. Our radiologist adviser said the small bowel lesion with very early sign of small bowel obstruction was missed on the CT scan in August. The finding was subtle but visible. We also note from the Trust’s investigation report that the scan was reviewed at a radiology and discrepancy meeting. During the meeting 6 out of 7 radiologists identified the lesion. We recognise that these radiologists would have been made aware that something was missed on the scan but even so, nearly all of them noted the lesion.
29. We understand that there is no specific guideline on the interpretation of small bowel lesion on imaging. However, the above Royal College of Radiologists standards for interpretation and reporting of imaging investigations state that “the purpose of an imaging report is to provide an accurate interpretation of images in a format that will prompt appropriate care for the patient”. This did not happen. The small bowel lesion was not reported and this was failing. This meant that there was a delay in the diagnosis of the bowel obstruction and surgery to treat the problem. We have considered the impact of this failing on Mr Y and Ms X in more detail below.
Failure by Trust to thoroughly investigate and identify the cause of Mr Y’s abdominal pain 30. Ms X complains that her father attended the Trust’s emergency department (ED) on several occasions during September and October 2021 and the doctors failed to identify the cause of his abdominal pain. The Trust has addressed each of Mr Y’s attendances in its investigation report.
31. Mr Y attended the ED on 12 September 2021. The Trust said in its investigation report that the review and management plan was reasonable although best practice would have been to discuss his case with an ED consultant before discharge.
32. The relevant guidance that applies here is the GMC (Good Medical Practice 2014 paragraph 15) which states that doctors 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.
33. A triage nurse assessed Mr Y. The Trust recorded observations and took a series of blood tests. An ED doctor then assessed Mr Y in line with the above GMC guidance. The doctor recorded a relevant history, conducted an appropriate examination and necessary investigations were performed. Our EM adviser said the doctor’s working diagnosis of longstanding abdominal pain with no acute concerns can be justified by Mr Y’s three-month history of pain, the lack of any significant abnormalities in his observations, examination and blood tests, and the recorded information that he was in the process of being investigated for his symptoms as an outpatient. The decision to discharge him was justifiable on this basis and in the knowledge that he already had an appointment with the surgical team on 16 September.
34. However, we note the Royal College of Emergency Medicine (RCEM) national guidance recommends that patients aged over 70 who present to the ED with abdominal pain should be reviewed by a senior doctor or ED consultant prior to them being discharged. This guidance was not followed on this occasion. Mr Y was not reviewed by a consultant or senior doctor. The Trust acknowledged this in its investigation. Our decision is there was a failing on the part of the doctor in not discussing Mr Y’s case with a senior doctor in line with RCEM guidance. However, taking into account our EM adviser’s advice it appears the junior doctors decision to discharge Mr Y was reached in line with GMC guidance and it is unlikely that if this senior review had taken place that any significant change in Mr Y’s management plan would have happened.
35. Mr Y attended a surgical outpatient appointment on 16 September. The management of his care on this attendance was in line with the above GMC guidance in that his symptoms were appropriately reviewed and his previous investigations had shown no abnormality. Our surgeon adviser said it was appropriate to arrange a colonoscopy to rule out colon cancer.
36. The Trust said the colonoscopy on 23 September following the outpatient appointment showed diverticulitis and benign polyps and Mr Y was referred back to the surgical team. The colonoscopy ruled out any colonic explanation for the pain and he had already had a ‘normal’ CT and gastroscopy. There is no indication in the records of any further surgical follow up scheduled after that procedure.
37. Our surgeon adviser said there was no explanation for Mr Y’s pain but it was severe, recurrent and resulted in weight loss so a further surgical review was required. Our surgeon adviser said there is no guidance for this particular situation but a reasonable timescale would have been 4-6 weeks review in clinic with advice to attend ED if things worsened. There is evidence that Mr Y attended hospital on 12 October, within that timescale, for a surgical review. However, before that attendance Mr Y continued to suffer pain and he attended the ED again.
38. Mr Y attended the ED on 29 September 2021. The Trust said on this occasion there was no discussion with a consultant as per the RCEM guidance above. Mr Y’s pain was also not being managed which was reflected by him regularly attending the ED. The Trust said it should have considered a repeat CT scan or referral to the surgical team.
39. Taking into account our clinical advice, the assessment conducted by the doctor in ED was consistent with the above GMC guidance. The doctor took a relevant history, conducted an appropriate examination and arranged for Mr Y to have necessary investigations including blood tests.
40. The doctor discharged Mr Y with advice for him to recontact his GP. The records also show the doctor spoke to Ms X on the phone and noted she ‘is very distressed with the whole situation’. As indicated above and recognised by the Trust, Mr Y’s case was not discussed with a senior ED doctor in line with the above RCEM guidance. The Trust’s investigation report indicated it is possible that had this discussion taken place that Mr Y may have been referred back to the surgical team for further investigation and/or admission.
41. Our EM adviser agreed that a discussion with a senior consultant may have resulted in further investigation. However, they said there is no national guidance relevant to this and it is possible that even if the ED doctor had discussed Mr Y’s case with a senior ED doctor he may still have been discharged home. Our EM adviser explained that decisions such as this are clinical ones and based on the judgement of the clinicians involved. Our EM adviser said there were no significant abnormalities on Mr Y’s observations, investigations or examination which would have mandated his referral to the surgical team.
42. Our view is there was a failure on the part of the doctor in not discussing Mr Y’s case with a senior doctor in line with RCEM guidance. Whilst we are unable to say if this would have changed the decision to discharge Mr Y it was a missed opportunity for his care to be reviewed and potentially changed. We have considered the impact of this below.
43. Mr Y attended the Trust again on 12 October for a general surgery review. Staff recorded that Mr Y told the doctor that he was still having lower abdominal pain for 3-4 months and was having difficulty coping with the situation. The doctor recorded that he explained to Mr Y and Ms X that investigations had not shown any abnormality. The doctor added that Mr Y should treat his symptoms with pain killers. Mr Y had a liver scan on 15 October but no abnormality was found.
44. Mr Y continued to suffer with pain. His GP wrote to the Trust’s general surgeons on 27 October. This letter reflected that Mr Y had attended the GP surgery on numerous occasions and continued to suffer with severe abdominal pain at night. The GP also said Ms X was ‘distraught’ and could not cope with her father’s deterioration. The GP said, “I am afraid he needs observation and assessment to really work out how to get him better or diagnose what on earth is going on.”
45. Mr Y attended the ED again on 28 October 2021. The Trust said Mr Y was referred by an EM doctor to the surgical team for review. On this occasion the records show that Mr Y was assessed by a triage nurse, an ED doctor and a surgical doctor. The ED doctor’s assessment was consistent with GMC guidance. The ED doctor took a history, examined Mr Y, arranged investigations and referred him to the surgical team. Our EM advice supports that this was in accordance with the guidance.
46. The surgical team reviewed Mr Y and arranged an abdominal X-ray. The scan suggested a bowel obstruction. A surgical doctor discharged Mr Y and there is no evidence of the X-ray being reviewed before this happened. The Trust said in its investigation report that a surgical registrar should have reviewed this and admitted Mr Y due to the persistent nature of his pain, multiple attendances and findings on his X-ray. This would have been in line with GMC guidance but this did not happen and our view is this was a failing. We have considered the impact of this below.
47. Mr Y continued to suffer with severe abdominal pain and attended the ED again on 31 October 2021. The Trust said Mr Y was appropriately assessed by an ED doctor and referred on to the surgical team. The records confirm the ED doctor’s history, examination, investigations and decision to refer to the on-call surgical team are all in line with GMC guidance. This is supported by our EM clinical advice. Mr Y was admitted on 31 October and following further scans the Trust decided to operate on the obstruction in the small bowel. It also noted that he had a ‘prostatic mass’ which was referred to the urology team. This decision has been considered below.
48. We have found there were failings on the part of Trust regarding Mr Y’s attendances on 12, 29 September and 28 October 2021. We have considered the impact of these on Mr Y and Ms X below.
Management of Mr Y’s pain 49. Ms X complains that the Trust failed to manage her father’s pain during attendances to hospital in September and October and following his operation in November 2021. The Trust has explained its management of Mr Y’s pain in its investigation report.
50. When Mr Y attended the ED on 12 September, the triage nurse recorded he had taken pain relief (codeine) before he attended the ED. However, the nurse also recorded that Mr Y had a pain score of 8 at triage at 10.02am. The above RCEM guidance for management of pain in adults states a pain score or 8 indicates severe pain. Under this guidance our EM adviser said Mr Y should have been offered strong pain relief e.g. morphine with the effect of this re-evaluated 15 minutes later. There is no evidence in the notes that Mr Y was provided with any pain relief in the ED in line with this guidance. However, the records show that at 12.24pm this had seemed to resolve itself as staff recorded he was in no pain.
51. There is no further evidence of Mr Y complaining of pain in the notes. The doctor has recorded in his discharge plan to Mr Y’s GP a request for the GP to consider prescribing buscopan which is a medication which helps with abdominal pain caused by stomach cramps. As indicated in paragraph 40 above we do not have any concerns regarding the discharge plan itself. There appears to have been a failing on the part of the Trust regarding the initial management of Mr Y pain and this seems to have resolved itself within a short period.
52. Regarding Mr Y’s pain management on 29 September the triage nurse documented that he had taken paracetamol just over 10 minutes prior to his assessment and that his pain score was 3 at that time. Staff documented a further pain score of 2 approximately 90 minutes later. Staff gave Mr Y further paracetamol at 9.18am. We consider that on this occasion Mr Y’s pain management was in line with the above RCEM national guidance.
53. Mr Y attended the ED on 28 October at 9.43am. The triage nurse did not record his pain score at triage. An EM doctor then assessed him. The Trust recorded a pain score of 10 at 12.33pm. However, Mr Y did not receive any pain relief at all during his stay in the ED. Our EM advice is that Mr Y should have had his pain score recorded at triage, been offered pain relief and the effect of this pain relief re-evaluated within 15-30 minutes. The RCEM guidance recommends that patients with a pain score of 10 should be given strong analgesia such as intravenous morphine and their pain then re-evaluated within 15-30 minutes. This did not happen. Furthermore, there is no evidence he received pain relief prior to his discharge. This was a failing.
54. On Mr Y’s attendance on 31 October, the triage nurse noted that Mr Y had taken paracetamol over 2 hours prior to his attendance and that his pain score was 10. A nurse administered further paracetamol at 3.59pm. Pain scores of 3 were then recorded at 5.33pm and 6.10pm. Intravenous morphine was administered at 8.02pm. Our EM adviser said Mr Y’s pain management was therefore not consistent with national guidance quoted above. The guidance recommends that patients with a pain score of 10 should be given strong analgesia such as intravenous morphine and their pain then re-evaluated within 15 minutes. This did not happen when Mr Y first attended the ED. We find this this was a failing. However, the records show that Mr Y’s pain score did improve in the subsequent period prior to his transfer to the surgical team.
55. Following Mr Y’s operation in November 2021 our surgical adviser explained that nurses gave him regular paracetamol at the maximum dose from the day after surgery until his discharge. He was also given oromorph on 6, 10, 12, 13 and 15 of November. The Trust prescribed gabapentin (a drug used for nerve pain) on 15 November and Mr Y had this until his discharge. He was also given codeine. He had an epidural in place following his surgery and the pain team reviewed him on 4 and 5 November. The medical team noted he was pain free on 10 and 11 November. His pain scores were monitored regularly and ranged from 0 (most of the time) to 4 or 5 on a couple of occasions.
56. On the day of discharge the scores were 0. The records and our surgical clinical advice indicate that the pain relief during his stay was adequate and monitored appropriately and consistent with guidelines (Para1.6 Recommendations | Perioperative care in adults | Guidance | NICE.)
57. We note that Ms X has questioned the accuracy of these records as she believes the Trust did not manage her father’s pain during this period. We are unable to reconcile the discrepancy between the records and Ms X’s views. We do not discount what Ms X told us of her observations and do not doubt it was distressing to see her father in pain and be concerned this was not well managed. In the circumstances, we consider it reasonable to give weight to the records indicating pain was managed as it should have been at that time.
58. The doctor discharged Mr Y on 17 November with regular paracetamol and codeine to be used as required. This is what he had been taking as an inpatient and our surgeon adviser said it was therefore appropriate to provide a supply of this on discharge.
59. Mr Y had a surgical follow up appointment on 1 December. This appointment was likely made to discuss the histology (study of the removed cancer) and the next steps for his treatment. The histology showed this to be a neuroendocrine tumour of the small bowel. This is a rare tumour and a separate MDT deals with the management of these tumours (Neuroendocrine MDT) once they have been diagnosed. The results of the MDT discussion were not available at this clinic appointment, but the records show the diagnosis was explained to Mr Y at the appointment. Our surgical adviser indicated it was appropriate for the doctor to schedule a further appointment once the MDT outcome was known. There is no record of Mr Y complaining of pain at this appointment.
60. A urologist saw Mr Y on 6 December. The clinic letter reports that Mr Y’s main concern was a burning pain at the end of his penis. He was also suffering from urinary frequency, urgency and urge incontinence. The treatment plan was to start Mr Y on tamsulosin (a drug to treat enlargement of the prostate gland) and solifenacin (treatment for an over active bladder).
61. Our urologist adviser said the management plan only partially addressed Mr Y’s ongoing pain. They explained that pain at the penile tip and urinary symptoms can be caused by chronic prostatitis (a condition that causes inflammation of the prostate gland) and Mr Y should have been assessed and managed in line with NICE Clinical Knowledge Summaries: Diagnosis of chronic prostatitis. Recommendations include several types of treatment including pain relief and offering an alpha-blocker.
62. The urologist did advise starting the alpha-blocker (tamsulosin) but this was in regard to the urinary symptoms and there is no evidence regarding pain relief to address his pain. Options recommended for pain relief include paracetamol and/or a nonsteroidal anti-inflammatory drug (NSAID), to seek advice from a pain specialist, refer for physiotherapy which might help with pain related to pelvic floor dysfunction and/or acupuncture.
63. Mr Y was already on paracetamol and naproxen, but was still complaining of pain. Our urologist adviser said it would have been appropriate to plan to seek advice from a pain specialist, or physiotherapy or acupuncture as per the guidance above. This did not happen.
64. Mr Y then had a further telephone consultation with a urologist on 10 December 2021. The long standing penile pain was again noted. No addition or change was made to the treatment plan to address this. Our view is this was a failing.
65. We have identified that Mr Y’s pain was not managed in line with guidance on 12 September, 28 and 31 October, 6 and 10 December 2021. Our decision is that these are failings on the part of the Trust and we have considered the impact on Mr Y and Ms X below.
Failure by the Trust to investigate a mass in Mr Y’s pelvic region identified during his admission for his operation 66. Mr Y’s CT scan on 31 October 2021 showed a problem with his prostate and the Trust’s impression was this was an abscess or tumour. The surgical team referred him to the urology team who deal with prostate cancer and other prostate problems. A urologist saw Mr Y on 6 December 2021.
67. Our surgical adviser has confirmed it was appropriate for the surgical team to refer Mr Y for his prostate abnormality to the urology team . This was an incidental finding on the CT scan and not related to his small bowel tumour. This was in line with NICE guidance (Recommendations organised by site of cancer | Suspected cancer: recognition and referral | Guidance | NICE para 1.6.)
68. A urologist saw Mr Y on 6 December. He was started on medication and the urology MDT was also to review the CT scan of 31 October to decide whether to perform prostate biopsies and whole body bone scan. This is in line with NICE clinical guideline [CG97] Lower urinary tract symptoms in men: management and NICE guideline [NG131] Prostate cancer: diagnosis and management.
69. In summary, decision is the surgical team’s decision to refer Mr Y to the urology team was in line with GMC guidance. A urologist reviewed Mr Y and their plan was for an MDT to review his case to determine the management of the prostatic mass. This was in line with the above NICE guidance. We find there were no failings regarding this aspect of the complaint.
Summary of key clinical failings
70. We have found there were failures to treat Mr Y in line with Good Medical Practice and other relevant guidance. These were: • failure to identify the small bowel lesion/obstruction on the CT scan in August 2021 • failure to seek input from a senior doctor prior to Mr Y’s discharge on 12 and 29 September 2021 • failure to admit Mr Y for further assessment and investigation on 28 October 2021 • failure to manage Mr Y pain on 12 September, 28 and 31 October, 6 and 10 December 2021
71. In the circumstances, we partly uphold the complaint. We have summarised below the impact of these failings on Mr Y and Ms X.
Impact
72. We have looked at what would have happened if Mr Y’s CT scan of 13 August been reported within a reasonable time frame of 2 weeks (as suggested in the Trust’s investigation). The advice from our surgical adviser is that had the small bowel abnormality been identified on that scan then it is likely that his case would have been discussed at the colorectal cancer multi-disciplinary team (MDT) meeting and scheduled for surgery.
73. We recognise the time scale for the surgery is difficult to predict but Mr Y’s surgery would likely have been scheduled for an elective (planned) list and performed within 31 days of the decision to operate i.e. by the end of October (2 weeks for reporting the scan and 31 days for scheduling). This would have been in line with the NHS guidance NHS Interim Management and Support Delivering Cancer Waiting Times – A Good Practice Guide. This would have been more or less the time when Mr Y’s actually had his surgery (end of October/November).
74. However, we note that Mr Y attended the ED on the 12 September with ongoing pain and this should, with the knowledge of a small bowel abnormality on the CT scan that the Trust should have noted in August, have prompted review by the surgical team and likely re-scan and emergency surgery within 24 –48 hours which is what happened in October 2021. Therefore, the earliest it would be reasonable to estimate Mr Y’s surgery taking place, had the abnormality in the small bowel been detected on the first scan, would have been 13/14 September. This would have been approximately six weeks sooner. The impact of having earlier surgery would have meant that he may have had six weeks less pain and diarrhoea.
75. The delay in surgery for the bowel obstruction also meant that there was a delay in identifying the prostatic mass which was found prior to his surgery in November 2021. It is evident that this too was contributing to Mr Y pain. Earlier diagnosis may have resulted in his pain being better managed. Earlier treatment may have improved Mr Y’s mental wellbeing which was affected by his ongoing pain and uncertainty about the cause of his pain. This is evidenced by the records showing Ms X reporting to Trust staff on several occasions the impact on her father. The GP letter from 27 October also sets out the impact on Mr Y and Ms X and reflects the strain on the family.
76. We have also identified failings regarding Mr Y’s attendance on 29 September 2021. Whilst we are unable to say for certain that a review by a senior doctor would have resulted in his admission it will be a source of upset to Ms X that this was a missed opportunity to potentially have changed her father’s care and treatment.
77. The failure to admit Mr Y on 28 October 2021 resulted in a further short delay in diagnosing the small bowel obstruction. Furthermore, there were failures to manage his pain on 28 and 31 October which had a huge impact on him. These failings would have added to Mr Y and Ms X belief that his problem was being ignored. This again would have added to the impact on their mental wellbeing.
78. Finally, there is no evidence of a plan following his urology appointments on 6 and 10 December 2021 to manage his pain. Mr Y had said he was still suffering from pain but there is no evidence of any steps being taken to address this. This ongoing pain affected his mental wellbeing.
79. Mr Y sadly died by suicide on 15 December indicating in a written note that he could no longer deal with the pain. We have identified failings in the management of his pain and recognise that the delay in diagnosing his cancer caused him prolonged pain. We cannot be certain that Mr Y would not have taken this step if there had been no failings in care but based on what Mr Y wrote his note it is reasonable to conclude that the failings in care were probable contributory factors.
80. Ms X will be left with ongoing distress from the knowledge of this and from the uncertainty about whether or not her father would have chosen the path he did had there been no failures in his pain management. We cannot underestimate how difficult and distressing this will be for her. We know Ms X is heartbroken by the loss of her father and this has impacted on her mental wellbeing with her requiring professional support. We have therefore considered what the Trust needs to do to provide a personal remedy to Ms X. We note that the Trust has not apologised to Ms X for the significant impact she has experienced due to the identified failings. Furthermore, we consider that a financial remedy is also appropriate in this case to acknowledge this. We have therefore made recommendations below to address this.
81. The Trust has recognised failings in its investigation report and has taken the following actions:
• An audit to review practice in patients over 70 presenting with abdominal pain being seen by a senior clinician (Royal College Guidelines) • Elderly patients with persistent pain should be considered for further or repeat investigations • Elderly patients should be reviewed pre-operatively and post-operatively by a frailty physician in line with NELA guidelines • Patients who re-present more than 3 times in ED should be seen by a Consultant or referred to a specialist team
82. We consider that these actions are reasonable in addressing those identified failings. However, we also consider that the Trust should take further steps regarding the failings we have identified in paragraph 70 above relating to, • the radiology error • pain management in the Emergency Department • discharge on 28 October without reviewing the X-ray • pain management in the Urology Department