Mrs A’s back pain 24. NICE guidelines on low back pain explain clinicians should help manage lower back pain by prescribing ibuprofen and paracetamol. If these are not effective, then clinicians can prescribe weak opioids (co-codamol). Clinicians should also consider referring a patient to a more specialist setting (such as the musculoskeletal team or physiotherapy team) if their pain persists.
25. Mrs A initially raised concerns about suffering from low back pain with the ANP on 30 September. The ANP advised her to take paracetamol and ibuprofen. This was in line with NICE guidelines on low back pain.
26. At the time, Mrs A’s main concern was abdominal pain which made it difficult for her to lie down. The ANP was worried this may indicate ovarian cancer so they referred her for an urgent ultrasound scan and carried out a blood test, which showed her CA125 levels were 143.
27. NICE guidelines on suspected cancer explain when ovarian cancer is suspected clinicians should carry out a blood test to check a patient’s CA125 level. Levels over 35 indicate a patient may have ovarian cancer.
28. Mrs A underwent the ultrasound scan on 13 October which showed large masses on her ovaries. She also underwent another blood test later that same day, which showed her CA125 level had increased to 311. The Practice referred Mrs A to see the gynaecology team for further investigation for suspected ovarian cancer.
29. The ultrasound scan also showed mild hydronephrosis in the right kidney. This is when the kidney swells as urine does not fully empty from the body. As the Practice had already referred Mrs A to the gynaecology team for suspected cancer, it was appropriate for the gynaecology team to consider if there was a link between this and her ovarian cancer.
30. The gynaecology team held a multidisciplinary team (MDT) meeting on 18 October to discuss Mrs A’s ultrasound and blood test results. They confirmed she had ovarian cancer. They arranged for her to undergo a CT scan and further blood tests to help stage her cancer. She also needed a blood test to check her kidney function.
31. NICE guidelines on suspected cancer explain CT scans can help assess the spread of cancer. This will help stage the disease to see what treatment would likely be beneficial for the patient.
32. NICE guidance on AKI also shows that to test a patient’s kidney function, staff should carry out a blood test known as an estimated glomerular filtration rate (eGFR). This test measures the level of waste product called creatinine in the blood. Healthy kidneys should be able to filter more than 90ml/min.
33. Mrs A underwent a CT scan and further blood tests on 21 October to check her CA125 and eGFR levels. This was in line with both NICE guidelines on suspected cancer and NHS England’s guidance on chronic kidney disease.
34. Mrs A’s blood test showed her CA125 marker had increased to 600 but the eGFR test showed her kidney function was normal. The CT scan also showed she had stage 3c/4 ovarian cancer but this had not spread to her right kidney. As her kidney function was normal and her cancer had not spread, staff did not consider this further.
35. The gynaecologist discussed Mrs A’s case at the next MDT meeting on 1 November and referred her for surgery at another Trust for her ovarian cancer. They also referred her to the oncologist for post-surgery treatment.
36. On 24 November Mrs A raised concerns about her back pain again with her GP. She explained the ibuprofen and paracetamol were not helping with the pain. Her GP prescribed co-codamol and advised her to contact them again if she had further concerns. This was in line with NICE guidelines on low back pain.
37. On 15 December, 13 days after her surgery, Mrs A had a telephone consultation with her GP where she raised concerns about her back pain again. Her GP advised her to try paracetamol and ibuprofen again (as she did not tolerate the co-codamol) and to book an appointment with the musculoskeletal team once she had recovered from her surgery. This was in line with NICE guidelines on low back pain.
38. On 4 January Mrs A told her oncologist she was suffering from back pain. The oncologist explained she had undergone significant surgery so the back pain may be due to the procedure and her positioning on the operating table. The oncologist felt the back pain was not related to Mrs A’s ovarian cancer.
39. Mrs A attended another GP appointment on the 5 January where she explained her low back pain had persisted. At this stage medication had not helped ease Mrs A’s back pain. The Trust’s earlier investigations had also not found any kidney disease which could have caused her back pain.
40. As a result of this, the GP referred her to a physiotherapy team for further investigations. This was in line with NICE guidelines on low back pain. The physiotherapist also felt Mrs A’s back pain may have been related to problems with her spine, unrelated to her ovarian cancer.
41. GMC guidelines explain doctors must listen to their colleagues and recognise their skills and contributions. They must work collaboratively when caring for a patient.
42. Our GP adviser explained staff at the Practice considered the advice they were given by specialists in physiotherapy and oncology. As a result of this, it was appropriate for staff at the Practice to not suspect that her lower back pain may have been connected to ovarian cancer. This was in line with GMC guidelines.
43. Overall, until this point, we have seen staff at the Practice and the Trust acted on Mrs A’s back pain in line with national guidelines. We have seen no failings here.
44. During a telephone consultation with the oncologist on 11 January, Mrs A raised concerns about her back pain again. She explained it had been present for several weeks prior to her surgery and she was worried the pain may be linked to ovarian cancer.
45. The oncologist explained if her back pain was related to her cancer, this would have got better after the surgery. This is because the surgery would have removed all of the cancer cells. The oncologist also explained the CT scan carried out in October did not show any evidence of her cancer spreading to her bones, which may have caused her pain.
46. The oncologist advised Mrs A to continue taking ibuprofen and paracetamol, and to contact her GP if this persisted as it may have been caused by a problem with her spine. They also began further post-surgery chemotherapy treatment.
47. As detailed by the NCBI study on the spread of ovarian cancer, if a patient suffers from back pain post-surgery, this may be due to the recurrence of cancer which has spread to nearby areas. Our oncology adviser explained the type of cancer Mrs A had frequently behaves aggressively and back pain is a strong indication of recurrence.
48. In addition to this, the CT scan carried out in October shows evidence of cancer close to Mrs A’s left psoas muscle (the long muscle located in the lower region of the spine). Although this did not indicate a blocked ureter at the time, if the cancer had reoccurred and spread, this may have been the cause of her back pain.
49. Advising Mrs A to take paracetamol and ibuprofen was in line with NICE guidelines on low back pain. But, at this stage, the oncologist should also have considered if her cancer had reoccurred and if it had spread to her ureter.
50. As detailed above, NICE guidelines on suspected cancer show us the oncologist should have carried out a blood test to check Mrs A’s CA125 level and a CT scan.
51. We can see the oncologist did carry a blood test which showed Mrs A’s CA125 level was 499. Although this is slightly lower than before the surgery (600), it was significantly higher than when cancer was first suspected several months prior (143).
52. The NCBI study on CA125 level shows that having a CA125 level of 499 post-surgery strongly indicated the cancer had reoccurred. The Trust did not recognise the elevated level of CA125 was a cause for concern at this stage. We identify this as a failing.
53. The blood test also showed Mrs A’s eGFR level had fallen to 68ml/min. This is below the 90 ml/min threshold for normal kidney function, showing a mild reduction in her kidney function at the time. This could have indicated her ureter was becoming blocked leading to obstructive uropathy.
54. Mrs A’s CA125 and eGFR markers indicated her cancer may have reoccurred and spread to her ureters in line with NICE guidelines on suspected cancer. The Trust should have carried out a CT scan here. As it did not do so, we identify this as a failing.
55. We have identified several failings in considering if Mrs A’s back pain was linked to her ovarian cancer. As a result of this, we have gone onto consider the possible impact this had on Mrs A’s clinical condition in our ‘impact of failings’ section.
Concerns about doctors not carrying out a bilateral nephrostomy
56. NICE guidance on AKI explain nephrostomies or stenting should be used to treat upper tract urological obstruction in adults with acute kidney injury. This should be carried out as soon as possible and within 12 hours of diagnosis. This timeframe for prompt treatment highlights the importance of quick insertion of stents or nephrostomies.
57. In addition to this, Mrs A’s neutrophil count (a type of white blood cell) and platelets (blood cells that help stop bleeding by forming clots) had begun to fall post chemotherapy treatment. This meant she was at an increased the risk of developing a life-threatening infection. Our oncology adviser explained treatment should have been carried out promptly to reduce this risk.
58. Upon admission, staff promptly recognised Mrs A’s cancer had reoccurred and blocked her ureters. They considered providing Mrs A with a bilateral nephrostomy, in line with NICE guidelines on AKI.
59. Nephrostomies are carried out by specialist interventional radiologists. Our oncology adviser explained not all hospitals have an interventional radiology services available to provide nephrostomies. If they do have these services, some services are only set up on specific days. This can cause a delay in patients being seen.
60. The Trust explains it only had an interventional radiologist working on Tuesdays and Fridays at the time, which could cause a delay in some patients receiving nephrostomies. However, as detailed by GMC guidelines on referral, when a patient needs care and treatment, clinicians can refer them onto clinicians if they cannot facilitate care themselves.
61. We can see Mrs A was admitted on 25 January, which was a Wednesday. This meant she had to wait until 27 January, a Friday, to have the bilateral nephrostomy. This would have been significantly outside of the 12-hour time frame stipulated by NICE guidelines on AKI.
62. As the Trust did not have the facility to carry out the bilateral nephrostomy promptly, staff attempted to expedite Mrs A’s treatment by contacting another Trust to see if they could carry out the bilateral nephrostomy sooner. This was in line with GMC guidelines on referral.
63. At this stage, Mrs A’s potassium levels were very high. This meant she was not stable enough to be transferred to the other Trust for treatment. To help alleviate pressure on her kidneys and reduce her potassium levels, staff provided her with dialysis treatment.
64. Our urology adviser explained dialysis was appropriate here as a temporary treatment to help filter waste products from Mrs A’s kidneys. But she needed the bilateral nephrostomy as a more permanent treatment to unblock her ureters.
65. Mrs A’s eGFR at the time had fallen to 3. NICE guidelines on AKI say patients with an eGFR lower than 15 are suffering from active kidney failure and require urgent treatment.
66. Staff recognised this so, on 25 January, they referred her to the urology surgeons to consider if they could insert stents instead. The study on malignant ureteric obstruction intervention shows stents can normally help relieve pressure on the kidneys and improve a patient’s renal function.
67. Our oncology adviser explained as Mrs A had previously undergone radical surgery including partial resection of the bladder, this made it very difficult to insert ureteric stents. She also had widespread compression of both the ureters and stents would not have provided a long-lasting solution.
68. The urology surgeons considered Mrs A’s case. On Friday 27 January they decided that stenting would not be beneficial or provide long lasting relief for Mrs A. They recommended she undergo a bilateral nephrostomy instead. This was the initial treatment option staff had considered.
69. Sadly, due to the time it took for the urology surgeons to confirm this, it was too late for Mrs A to then receive the bilateral nephrostomy at the Trust on the same day.
70. Our oncology adviser explained that because of Mrs A’s clinical condition, it should not have taken several days to confirm she was not suitable to have stents. We identify this delay as a failing.
71. On 28 January, the doctor referred Mrs A onto the other Trust again for a bilateral nephrostomy, as she had not yet undergone this internally. The other Trust explained it could not carry this procedure out on an urgent basis as Mrs A was not septic at the time.
72. Mrs A sadly developed neutropenic sepsis on 29 January. At this stage her condition had deteriorated significantly, and she met the criteria to be referred on an urgent basis. However, at this stage, staff did not refer Mrs A to the other Trust for an urgent bilateral nephrostomy. We identify this as a failing.
73. Instead, the Trust scheduled for Mrs A to undergo the bilateral nephrostomy on Monday 30 January at the Trust. This does not work in line with the Trust’s explanation that interventional radiologists were only available on Tuesdays and Fridays.
74. Sadly, on Monday 30 January, the radiologist was unexpectedly off work so Mrs A could not undergo the procedure. Her medical records show us that staff then placed Mrs A on the list to get a bilateral nephrostomy on Wednesday 1 February. Again, this does not work in line with the Trust’s explanation that the interventional radiologists were only available on a Tuesday and a Friday.
75. We can see there were several delays in providing Mrs A with a bilateral nephrostomy. These delays meant Mrs A did not receive a bilateral nephrostomy promptly, outside of the 12 hours stipulated by NICE guidelines on AKI.
76. We have carefully considered the Trust’s reasons for this delay and recognise some of the delays were outside of its control. But, because Mrs A’s cancer had reoccurred and spread, and as she was at an increased risk of her developing a life-threatening infection, staff should have done more to expedite her treatment. This is a failing.
77. As we have identified several failings, we have gone onto consider the possible impact this had on Mrs A’s clinical condition in our ‘impact of failings on clinical care’ section.
Impact of failings
78. Our oncology and urology adviser both explain Mrs A’s low back pain post-surgery was likely caused by her recurrent cancer blocking her ureters. Her very low eGFR and high CA125 levels during this time are evidence of this.
79. If the oncologist at the Trust had acted on Mrs A’s blood test results and carried out a CT scan in early January, staff would have known Mrs A’s cancer had reoccurred and blocked her ureters sooner than 25 January. Mrs A would have received treatment sooner, and likely before her admission.
80. However, our urology adviser explained this does not necessarily mean Mrs A would have recovered from her kidney failure. As the NCBI study on ureteric obstruction explains, 40% of patients who receive treatment in a similar situation to Mrs A sadly die within the next 90 days.
81. Further to this, whilst waiting for a bilateral nephrostomy, staff had to delay Mrs A’s chemotherapy treatment. This is because her kidneys would not be able to remove the chemotherapy treatment from her body, causing her more harm.
82. Our oncology adviser explained that even if staff had carried out a bilateral nephrostomy sooner, Mrs A may still not have recovered enough to restart chemotherapy in a timely manner.
83. As we can see in the NCBI study on malignant ureteric obstruction, only 57% of patients who receive treatment to relive obstructive uropathy were well enough to undergo further chemotherapy treatment.
84. Even if staff were able to begin chemotherapy treatment, the BJC study shows us Mrs A’s prognosis before surgery was only 12 months. NCBI study on PCN in malignancy associated ureteric obstruction also shows that where cancer has caused ureteric obstruction, and patients receive treatment for this, on average their prognosis is less than 6 months.
85. Our oncology advisor explained even if staff had carried out a bilateral nephrostomy sooner, and Mrs A’s condition improved enough to receive chemotherapy promptly, this would not have cured her cancer. Mrs A would have received palliative chemotherapy, to help manage her symptoms, rather than prolong her life.
86. The BJC study shows that only 42% of patients with Mrs A’s cancer respond well to chemotherapy. Our oncology adviser explained that Mrs A’s cancer had reoccurred promptly after surgery which shows it was highly progressive and aggressive. Therefore, it is unlikely her cancer would have responded to chemotherapy and would have continued to grow even with treatment.
87. Overall, having considered our urology and oncology adviser’s advice, on balance of probabilities, Mrs A would have likely died within three months of her cancer reoccurring and spreading to her ureters. Treatment is unlikely to have prolonged her life significantly.
88. Sadly, Mrs A and her family did not have this additional time to understand what was happening and explore the option of moving to palliative care. Had the failings we have identified not occurred, Miss A and her family would have had additional time to understand Mrs A’s prognosis and spend more quality time with her before her passing.
89. We know Mrs A was suffering from significant discomfort and pain in the final days of her life. Had staff provided her with treatment sooner, and explored the options of palliative care with her, this could have been prevented. Seeing Mrs A in pain and discomfort would have also been very traumatic for Miss A and her family. The impact of this will be long lasting.
90. Miss A has also unfortunately suffered from anxiety and depression as a result of the events surrounding her mother’s very sad death. She has lost faith in the Trust. We are very sorry to hear about Miss A’s pain and recognise the impact of this is significant.
91. To work towards helping put matters right for Miss A, we have asked the Trust to take specific actions. We also feel the Trust should take steps to ensure the failings we have identified do not reoccur. We have commented on this further in ‘our recommendations’ section.
Nurses at the Trust did not deliver the fundamentals of care effectively
92. The British Journal of Nursing explains all patients should have a nursing assessment upon their admission to help assess their needs and plan their care. An assessment should include a conversation between the nurse and the patient to discuss what they need that will help promote their wellbeing.
93. From this assessment, the nurse should formulate a care plan identifying the needs of the patient and what interventions staff will implement to help resolve those needs.
Nutrition, fluids and hydration 94. NICE guidelines on nutrition explain patients should be screened for risk of malnutrition on admission to hospital, using a validated screening tool such as a malnutrition risk assessment (MUST). This measures unintentional weight loss and provides the patient with a score, which helps clinicians assess if they are low, medium or high risk of malnutrition.
95. It also explains clinicians must consider the total intake a patient receives, including any food, oral fluid, oral nutritional supplements and intravenous (IV) fluids.
96. Nursing staff carried out a MUST assessment which showed Mrs A scored 0. This shows her risk of malnutrition was low and staff did not need to carry out any further action to prevent malnutrition. Also, prior to Mrs A’s admission, she was independent with her dietary needs and could verbalise her own needs. This continued during her admission.
97. Although there was no risk of malnutrition, nursing staff did plan to carry out the following actions to ensure this remained low. The plan was to:
• Repeat MUST score and weigh weekly • Ask the medical team to review for IV fluid • Commence food and fluid charts • Offer two nutritional supplements daily • Encourage high protein/high calorie choices from the menu • Offer snacks between meals • Provide patient with ‘Making the most of your food & drink’ leaflet • Consider finger food options from menu for appropriate patients
98. Our nursing adviser explained that Mrs A’s MUST score showed she had a low risk of malnutrition. Because Mrs A could verbalise her own needs, this plan was not necessary.
99. However, as Mrs A was severely nauseous and unable to tolerate fluids orally, nursing staff discussed this with the medical team and ensured she received sufficient IV fluids. This was in line with NICE guidelines on malnutrition.
100. We recognise that on some occasions Mrs A did not consent to having a cannula inserted. The Trust explain that in some cases, this was not resolved in a timely manner. This meant she remained without IV fluids for very short periods of time.
101. However, we can see Mrs A did not go without IV fluids for a significant amount of time and staff offered Mrs A drinks regularly. They ensured her fluid input and output was balanced. For this reason, we have not identified these shortfalls as failings.
Physical handling/mobilisation
102. NICE guidelines on pressure ulcers explain patients with limited mobility are at an increased risk of developing pressure ulcers. Staff should carry out an assessment using a validated scale, such as the Waterlow score, to help assess a patient’s risk.
103. If a patient is high risk, then staff should check their skin every two hours and reposition them every four hours. If a patient already has a pressure ulcer, staff should also provide patients with barrier creams and pressure relieving equipment.
104. Staff initially carried out a manual handling risk assessment upon Mrs A’s admission. Although she could move herself around her bed independently, she was too weak and unwell to mobilise independently outside of her bed. She always required nursing support with this.
105. Staff also carried out a Waterlow risk assessment to assess her risk of developing pressure ulcers. Mrs A scored 16 which indicated she was at high risk of developing pressure ulcers. She already had a grade 2 pressure ulcer to her lower back.
106. We can see staff provided her with appropriate barrier cream for her pressure ulcer and replaced the dressing appropriately throughout her admission. They also used pressure relieving equipment to help reduce the risk of her developing pressure ulcers.
107. The records show the Trust did not do what it should have done. On 27 January staff only checked her skin twice and then only once on 28 January. On 30 January staff did not check her skin at all. This suggests staff did not support her with mobilising every four hours.
108. Our nursing adviser explained this could be because Mrs A was mobilising independently within her bed, and nursing staff were aware of this. However, in line with NICE guidelines on pressure ulcers, staff should have checked her skin every two hours and should have helped her mobilise every four hours. That this did not happen is a failing.
109. Having carefully considered Mrs A’s medical records, we can see she did not develop any other pressure sores as a result of not being checked or helped with mobilisation on these days. Although we recognise this would not have been comfortable for Mrs A, and distressing for her family, we cannot see this affected the care she received.
110. For the distress this caused Miss A, we consider the Trust should take steps to help put matters right. We also feel the Trust should take steps to ensure the failings we have identified do not reoccur. We have commented on this further in ‘our recommendations’ section.
Hygiene, bladder and bowel care 111. NICE guidelines on patient experience explains nursing staff should ensure a patient’s personal needs (continence, personal hygiene and comfort) are regularly addressed. Nursing staff should obtain consent from patients with capacity for support with this.
112. Upon admission, nursing staff carried out an assessment which showed Mrs A was not self-caring and would need assistance from a nurse for her personal needs. Mrs A’s medical records show that on some occasions, Mrs A was attempting to self-care, but nursing staff were there to support her if needed.
113. Mrs A’s medical records also show us that on two different occasions Mrs A had complained about her call bell not being answered overnight so she was unable to use the toilet. On another occasion Miss A had spoken to staff about the delay in bringing Mrs A a commode.
114. We recognise this would have been very uncomfortable for Mrs A and it did allow her to maintain her dignity. It would have also been very distressing for Miss A to see her mother like this and to help support her mother with hygiene needs, as Trust staff were not meeting these.
115. Our nursing adviser explained the poor hygiene, bladder and bowel care would not have affected Mrs A’s clinical condition at the time. However it would have added unnecessary upset and stress to both Mrs A and Miss A, at an already difficult time.
116. For the distress this caused Miss A, we feel the Trust could take steps to help put matters right. We also feel the Trust should take steps to ensure the failings we have identified do not reoccur. We have commented on this further in ‘our recommendations’ section.