19. 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 there were delays in referrals or diagnosis.
20. We did see an indication there was a delay in the pathology report and lack of communication between the Trust and Mrs O. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have found the Trust has already done enough to put right the impact of these events.
21. Our adviser explained that Mrs O’s condition was rare and there are no specific guidelines which are relevant. Our adviser did refer us to NHS England guidance, delivering cancer waiting times, a good practice guide, 2015. This sets out the two-week window to see a specialist where cancer is suspected.
22. GMC good medical practice says a doctor must promptly provide or arrange suitable advice, investigations or treatment where necessary. It also says to consult colleagues where appropriate.
23. From review of the medical records, we can see that Mrs O was seen at the Yorkshire clinic on 12 May 2022. A history of nasal congestion was noted and an endoscopy showed a mass (lump). An MRI scan was requested. The MRI was carried out on 1 June 2022 and Mrs O was seen back in the clinic on 16 June 2022. The MRI showed an abnormal mass (lump). The doctor recommended a review by a head and neck specialist and a biopsy. Mrs O was referred to the ear, nose and throat team (ENT) at the Trust.
24. Mrs O attended the Trust for an appointment on 8 July 2022. An initial diagnosis of lobulated white vascular mass (lump) seen in postnasal space (space at the back of the nose which connects to the throat) was noted. Mrs O was listed for an urgent endoscopic biopsy.
25. Mrs O underwent the biopsy on 17 July 2022. It was noted benign neoplasm (abnormal growth of tissue) of anterior wall of nasopharynx (top part of the throat). The biopsy took place nine days after referral into the NHS. We have seen no evidence of delay. This was in line with GMC guidance. The timeframe between being seen in the Yorkshire clinic and ENT at the Trust were as expected because there was no suspicion about a malignant lesion at this point, therefore a more urgent referral was not needed in line with NHS England guidance.
26. On 4 August 2022, Mrs O raised concerns of timeliness in ENT. She was waiting for histology results and was anxious and upset the results were not back yet. This was chased and a follow up was recorded for 12 August 2022. It was noted that the pathologist was on annual leave.
27. Within its complaint response letter, the Trust said that the initial biopsy taken in July 2022 was sent to a pathologist who was away on leave and this led to a delay in reporting. The department have reviewed their processes when consultants are on annual leave to prevent cases being delayed in the future. It apologises for the delay and acknowledges how incredibly difficult the wait must have been.
28. We have seen a letter dated 8 August 2022. This was following a telephone conversation between the doctor and Mrs O. It explained the doctor wanted to provide a better understanding for Mrs O following their conversation. The doctor explained that during the procedure the mass (lump) mainly comprised of cartilages and therefore he debulked it as much as possible so there was enough of a specimen for histology but also good symptomatic relief. The specimen was sent as a fast track to the laboratory and was subsequently reviewed by two histopathologist. Both of them provisionally reported ‘atypical (irregular) chondromatous lesions (benign tumours made of cartilage) without definite evidence of malignancy’. There were areas of atypical changes in the specimen which need further clarification from a specialist care centre in Birmingham. The centre had more experience in pathologies and would be able to tell if these were atypical or degenerative changes. It was explained these are extremely uncommon and given rarity of these, it is best to give it more time for better understanding and diagnosis. Once the doctor had an update, they explained then would let her know.
29. Mrs O’s condition was discussed at a head and neck cancer multidisciplinary team meeting (MDT) on 24 August 2022. The discussion was arranged because of the CT scan in May 2022 and biopsies from 17 July 2022. The MDT noted that Mrs O had previous breast cancer. It was noted that the biopsies had been reviewed by the team in Birmingham, who recommended a referral to Birmingham for an MRI scan of the neck. The MDT said it would discuss Mrs O’s care again in three weeks.
30. Mrs O was updated with the outcome of the MDT. The Trust provided an update about the pathology report and the referral to the Birmingham MDT. The Trust noted she sounded anxious. It said a further discussion and update would take place in three weeks. The referral was dictated to Birmingham MDT and the letters were sent the same day, on 24 August 2022. We have seen no indication of a delay with this referral because it was sent the same day as the MDT. This was in line with GMC guidance, there was no suspicion of malignancy at this point.
31. We cannot comment on the care taken over by Birmingham, because this is not part of the complaint brought to us.
32. On 30 September 2022, Birmingham MDT chased the Trust for copy of the MRI scan. It is noted in the medical records that Mrs O was also upset at delays and uncertainty. The Trust apologised to her for this. On 12 October 2022, a further MDT advised that Mrs O was now under the care of Birmingham.
33. On 7 October 2022 Mrs O telephoned the Trust to chase for an update. A telephone call was made to Mrs O, she advised she will be seen by an ENT surgeon at Birmingham. It was noted that she understood the uncertainty of the histological diagnosis (examination of the tissue which was removed) and that her case was rare in head and neck medical practice.
34. Mrs O had concerns about the distance between her home and Birmingham and why she could not be referred somewhere closer. Our adviser explained that rare tumours need to be dealt with in a centre that has enough clinical data to ensure they are managed appropriately. It is noted within the medical records that Mrs O understood the uncertainty of the histological diagnosis and that her case is rare in head and neck medical practice.
35. Within its complaint response letter, the Trust apologised if the need for her care to be transferred to Birmingham was not clearly explained to Mrs O at the time. We understand this caused Mrs O anxiety, we appreciate she would have been worried at the time about the diagnosis she was waiting for. We understand that it must have been frustrating being told she would need to travel to a hospital, not close to her home.
36. The medical records tell us that the nature of the lesion was a rare cartilaginous tumour and the pathology took longer to process. The initial doctors who saw Mrs O felt that input was needed from a specialist centre to reach the diagnosis, following this there would be a discussion with the head and neck cancer multidisciplinary team meeting (MDT). Rare tumours can take time to achieve a diagnosis, and the action taken to reach a diagnosis was in line with GMC guidance when seeking advice from colleagues.
37. We do accept that there are indications of a delay in the pathology report. Mrs O attended for biopsy on 17 July 2022. These were sent to a pathologist who was on annual leave and this caused a delay until 8 August 2022. This resulted in Mrs O chasing the results and feeling anxious.
38. Within its complaint response letter, the Trust said that the initial biopsy taken in July 2022 was sent to a pathologist who was away on leave and this led to a delay in reporting. The department have reviewed their processes when consultants are on annual leave to prevent cases being delayed in the future. It apologises for the delay and acknowledges how incredibly difficult the wait must have been.
39. We contacted the Trust to ask if it had taken any further learning from this. The Trust has confirmed that the senior general manager was involved in the issue regarding the pathology result. They have informed us that going forward the Trust aims to identify early if the pathology department does not have the capacity to report on a biopsy result. It uses an outsourcing company at times of annual leave, excess demand or sickness. This is normal practice within most histopathology departments where there is a shortage of consultants and large workload. We have seen a copy of the Trust’s standard operating procedure for this and are satisfied that there is a process in place to prevent delays from occurring when pathologists are on annual leave. We are of the view that the Trust has already done enough to put right the impact of these events.
40. We are of the view that the communication around the care provided could have been better. Within its complaint response, the Trust accepts that its lines of communication could have been better and its coordination of updating Mrs O with results. It accepted that the service manager in the ENT department recalled a number of telephone calls with Mrs O which does suggest she was struggling to get answers to her enquiries. It acknowledged this is unacceptable and apologised for this. From review of the medical records Mrs O appears to have been kept up to date about what was happening and what the Trust was waiting for. We have not seen any evidence of referrals being lost in the system, the evidence does show that Mrs O had to contact the Trust on occasions for updates rather than the Trust updating her.
41. We appreciate this would have added distress at a time when Mrs O was already feeling anxious about her diagnosis and treatment. We contacted the Trust to ask if it had taken any further learning from this. The Trust’s service manager for the area has informed us that now all conversations with patients are documented on the electronic patient records system. This creates a detailed record of all patient communication, pathways (plans of care) are validated. Clinicians have been asked to provide next steps without delay from both the service admin team and the cancer tracking teams. We are of the view that the Trust has already done enough to put right the impact of these events.
Summary
42. We have decided not to consider this complaint further at detailed investigation. We have not found any indications that there were delays in referrals or diagnosis. We did see an indication that there was a delay in the pathology report and lack of communication with the Trust and Mrs O. We are of the view that the Trust has already done enough to put right the impact of these events. It has taken learning from this complaint in relation to the pathology reporting and communication. There is nothing further we can add to this complaint at detailed investigation.
43. Our decision is not made without recognition of the distressing events. We understand the events have caused severe stress and anxiety. We appreciate it must have been a very stressful time for Mrs O whilst she was waiting for extremely important results.
44. We do log all the complaints we receive. This means, if we receive a similar complaint about the same organisation or see a pattern from a number of complaints, we may raise this with the organisation in future. We will log this complaint, so we have a record of it if we do receive any similar complaints. We hope this reassures Mrs O that she did the right thing by bringing her complaint to us.