The Practice
Appointments on 15 June and 5 July
26. Mr A complains his wife suddenly developed severe breathing problems but the GP at the Practice did not consider this was serious and did not act promptly to make sure she received the treatment she needed.
27. The GMC’s Good Medical Practice says doctors must ‘adequately assess the patient’s conditions, taking account of their history’ and examine them where necessary. It says doctors must ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’.
28. The NICE CKS for breathlessness says doctors should ‘assess the person's blood pressure, pulse rate, respiratory rate, temperature, level of consciousness, and oxygen saturation. They should consider the need for an emergency admission.
29. On 15 June, Mrs A initially had a telephone conversation with a GP. The records say Mrs A had shortness of breath that had been worsening over the past two weeks. She had no chest pain and her breathing was ok when sitting.
30. The GP decided to arrange a face-to-face appointment so they could examine her and saw her later that day. The record says Mrs A’s chest was clear, indicating the GP had listened to her chest with a stethoscope. There is record of her being breathless when walking upstairs.
31. To assess Mrs A, the GP checked her blood pressure in-line with the NICE CKS guideline. Our GP adviser has said a blood pressure machine also displays a person’s pulse rate and so it is likely the GP checked this, even if they did not document it.
32. There is no reference to Mrs A’s respiratory rate, temperature, level of consciousness, or oxygen saturation, in-line with the NICE CKS guidelines. Our adviser has commented checking Mrs A’s oxygen saturation level would have been particularly important. This is because this test would show the extent her breathlessness was affecting the levels of oxygen in her blood.
33. We consider the evidence shows the GP did not fully assess Mrs A in-line with the NICE CKS on breathlessness. This was a failing in care and we have considered the impact linked to this from paragraph REF _Ref181610030 \r \h 52 of this report.
34. The outcome of this appointment was the GP suspected Mrs A’s blood pressure medication could be affecting her breathing. They arranged blood tests, an ECG (a test to check the heart) and chest X-ray to further investigate the cause. Our GP adviser has said that overall, these were appropriate tests to request to check for underlying issues.
35. On 5 July, Mrs A attended the Practice again because she had been away on holiday and was continuing to suffer with breathlessness. The GP documented they looked at the results of her chest X-ray and this was clear. The blood tests results showed abnormal liver results and so they requested repeat blood tests and ordered a liver ultrasound scan. Our GP adviser has said these were appropriate tests for the GP to request.
36. The GP also took Mrs A’s blood pressure (and therefore checked her pulse rate), and this was normal. The GP thought Mrs A may have asthma and so took a peak flow reading. This was 170 l/min.
37. A peak flow test measures the amount of air moving in and out of the lungs, the acceptable reading is determined on the person’s height, gender and weight. The records do not document the GP’s consideration of whether the peak flow reading was in the expected range for Mrs A.
38. The chart, ‘Normal values for peak expiratory flow’ suggests a woman of Mrs A’s height and age should have been reaching a value of over 350 l/min. Our adviser has said Mrs A’s reading appears low. The GP prescribed Mrs A an inhaler and gave her advice on when to use this.
39. There is no record the GP checked Mrs A’s respiratory rate, temperature, level of consciousness or oxygen saturation level, in-line with the NICE CKS guidance. This means the assessment was incomplete to fully understand what was causing Mrs A’s breathlessness. We consider this was a failing in assessing Mrs A and we have considered the impact linked to this below.
40. In terms of whether the GP should have referred Mrs A for urgent treatment on either of these dates, we have referred to the NICE CKS on breathlessness which sets out when doctors should arrange an emergency admission. This includes if the doctor suspects a pulmonary embolism (a blockage in a blood vessel in the lung) or severe or life-threatening asthma where the patient has an oxygen saturation level of less than 92%.
41. The guidance also says if the cause of breathlessness is unclear, the doctor should use their ‘clinical judgement’ and ‘a low threshold for admission may be required in order to rule out serious causes’.
42. We have considered what a full assessment would have likely shown on 15 June and 5 July. To do this, we have referred to the hospital records.
43. Before attending the GP appointment on 5 July, Mrs A had a pre-operative assessment at hospital. The nurse documented Mrs A’s heart rate was 97 beats per minute (a normal heart rate is between 60 and 100 beats per minute).
44. The nurse also measured Mrs A’s oxygen saturation level as 91%. Had the GP measured Mrs A’s oxygen saturation level when she later attended the Practice, we consider it likely the result would have been the same, or very similar.
45. Mrs A told the nurse she was experiencing shortness of breath and was seeing her GP about this. She described being able to walk a mile while away on holiday.
46. When Mrs A attended the emergency department on 7 July, her oxygen saturation level was 87%.
47. Our GP adviser has commented the results from 5 and 7 July indicate Mrs A’s oxygen saturation levels were declining over time. They have also noted that while Mrs A was experiencing breathlessness in June, she had been able to travel abroad and while she was having symptoms, she did not report serious difficulties.
48. Based on the trend seen in these results, we think on balance it is more likely than not Mrs A had higher oxygen saturation levels on 15 June than on 5 or 7 July. Our GP adviser has said an oxygen saturation level higher than 91% would not have indicated Mrs A needed an emergency admission.
49. In terms of what should have happened on 5 July, our GP adviser has commented the cause of Mrs A’s breathlessness remained unclear. In this circumstance, our adviser has said the GP should have considered the possibility of Mrs A having a pulmonary embolism. This is because people with breast cancer are at a higher risk of blood clots.
50. Our GP adviser has said this consideration, along with oxygen saturation of 91%, should have led to the GP arranging for Mrs A to go to hospital to rule out a more serious underlying cause for her symptoms.
51. Following careful consideration of the NICE CKS and the advice we have received, we find it a failing that the GP did not refer Mrs A to hospital on 5 July. We have considered the impact linked to this below.
Impact
52. Mr A says if the GP had carried out all the relevant tests, they would have led to his wife attending hospital and to having an earlier diagnosis of liver cancer. He says this could have led to earlier treatment that could have given her more time to live, and time for him and his family to say goodbye.
53. We are sorry for the significant distress and upset Mr A has suffered considering how things could have been different for his wife with an earlier diagnosis. We have carefully considered the impact we can link to the failings.
54. As set out above, while we do not know what all the assessment results would have been on 15 June, we consider it is likely Mrs A did not need emergency hospital care on this date. Based on the available evidence, if the GP had done all the tests, we do not think the results would have significantly changed the management of her care. We therefore do not think the failings we have found in the GP’s assessment on 15 June had a clinical impact.
55. On 5 July, the GP should have referred Mrs A to hospital for further tests. This would be two days earlier than she attended, and we have considered the difference this would have made.
56. Mrs A’s blood tests on admission to hospital showed she had abnormal liver test results, as the GP blood tests results had also shown. This prompted the medical team to arrange an urgent ultrasound scan. The NICE guidance for suspected cancer [NG12] says this should happen within two weeks.
57. When Mrs A admitted on 7 July, she was supposed to have a liver ultrasound scan on 11 July but this did not happen. She instead had a CT scan the following day and this showed her liver was abnormal. Our physician adviser explained it was not possible to diagnose Mrs A from this scan and we have covered this in more detail later on in our report.
58. Our physician adviser has explained that to reach a diagnosis, doctors would next have arranged a biopsy of Mrs A’s liver to take samples of tissue. A histopathologist would then need to complete a report of the findings. This process would take a few days.
59. A multidisciplinary team (MDT) would then review the results of all the tests to determine the diagnosis and what kind of treatment would be suitable. The overall time this process would take would be more than the two additional days Mrs A could have had in hospital.
60. In consideration of the advice we have received, an earlier admission on 5 July would not have been enough time for the clinical team to have diagnosed Mrs A with liver cancer. We therefore do not consider this would have changed the treatment she could have had.
61. With an earlier admission, our GP adviser has said this would have given the family more time to understand the seriousness of Mrs A’s condition. We also consider Mr A has suffered upset and distress in feeling the Practice did not take his wife’s symptoms seriously and did not assess her correctly. This is an on-going injustice and we recognise how strongly Mr A and his family feel about this.
62. We partly uphold the complaint about the Practice. We have set out our recommendations to address the impact Mr A has suffered as a result of the failings at the end of this report.
ICHT
Breast cancer diagnosis
63. Mr A complains ICHT diagnosed his wife with breast cancer, but her post mortem report from July 2022 says there was no tumour present in her breast. Mr A is very concerned ICHT scheduled for her to have surgery and considers that had she lived to see this date, it is unlikely she would have survived this.
64. Guidance from the Royal College of Radiologists says: ‘diagnostic assessment of patients with breast symptoms is based on ‘triple assessment’ (clinical assessment, imaging and needle biopsy). The tests used in each case are determined by the symptoms, clinical findings and age of the patient’.
65. Mrs A had a mammogram in May 2022 and the results showed an area of density in her right breast. This prompted the breast cancer team to arrange further tests. On 1 June, Mrs A had an ultrasound and had a biopsy taken.
66. The histopathology report from the biopsy has descriptions of the tissue samples from both a macroscopic and microscopic level (observations made by eye, and by using a microscope).
67. The histopathologist diagnosed invasive ductal carcinoma in the right breast. This is when cancer cells in the milk ducts have invaded the breast tissue. It was a high-grade intraductal carcinoma, this is a type of cancer that grows quickly and is more like to come back after treatment.
68. The scans showed the cancer was 6mm in diameter and the volume of cancer that had invaded into the breast tissue was 1mm.
69. Our breast cancer surgeon adviser reviewed the evidence in Mrs A’s records and says the imaging and the biopsy results showed she had breast cancer. The results of the tests were all reviewed and discussed by a multidisciplinary team which included a surgeon, radiologist and pathologist. All the specialists agreed on her diagnosis.
70. Our adviser has explained Mrs A’s breast cancer was very small. The scans allow a specialist breast cancer team to find small cancers and they use these to take targeted and precise biopsies of affected tissue. A pathologist completing a post mortem is not guided by imaging and this may explain why a very small cancer would not be picked up.
71. We can understand why Mr A has questioned his wife’s diagnosis after reading the post mortem report, and this has led to him disagreeing she had breast cancer.
72. Following careful consideration of the available evidence, it is our view the breast cancer team at ICHT diagnosed Mrs A in-line with the guidelines from the Royal College of Radiologists. We have seen no indication the diagnosis was incorrect, and so we find no failing here.
73. In terms of the team arranging for Mrs A to have treatment, a consultant discussed this with her on 15 June 2022. They shared the results of her tests and explained the plan for her to have surgery to remove the cancer. The consultant referred her to CWFT for surgery but Mrs A sadly died before this could take place.
74. NICE guidance for the diagnosis and management of early and locally advanced breast cancer says, ‘studies have demonstrated that for invasive breast cancer, breast conservation (surgical wide excision of tumour combined with radiotherapy to the breast) produces equivalent survival to mastectomy’.
75. Mrs A had invasive breast cancer and the guidance recommends surgery to remove this. Our breast cancer surgeon adviser has confirmed the plan for surgery was appropriate.
76. In terms of whether Mrs A would have been well enough for the surgery, as noted above, she attended a pre-operative assessment on 5 July. The nurse documented she was due to see her GP about her breathlessness. Under whether Mrs A was ‘fit for surgery’, the report says, ‘awaiting anaesthesia review’.
77. Our breast cancer surgeon adviser has said that on the day of surgery, an anaesthetist would have reviewed Mrs A to check she was well enough to go through this. They, and the surgeon, would not just rely on a pre-operative assessment and would not proceed if they considered a patient was too unwell to survive surgery.
78. In consideration of the advice we received and with reference to the NICE guidelines for managing breast cancer quoted above, we find no concerns with the plan for Mrs A to have surgery.
79. We are sorry to hear of Mr A’s concerns around ICHT’s management of his wife’s care. We hope we have been able to clearly explain how we have reached our decision on this.
Appointment on 15 June
80. Mr A has told us that when his wife attended the appointment with the consultant on 15 June, she told him she had shortness of breath. He complains the consultant did not arrange any tests to find out what was causing this and told her she did not need to change her plans to travel abroad.
81. The GMC’s Good Medical Practice says doctors must ‘adequately assess’ a patient’s condition, and ‘refer a patient to another practitioner when this serves the patient’s needs’.
82. The record of this consultation has no reference to Mrs A telling the consultant she was short of breath, or of any discussion about this.
83. Where we have contradictory accounts about what happened, we consider the available evidence to reach a view on this.
84. ICHT shared comments with us that the consultant does not recall having specific concern with Mrs A’s breathing that day. If a patient is visibly breathless and they need emergency care, the consultant said they would refer them to A&E. If urgent care was not indicated, they would refer them to their GP for further assessment.
85. Mr A was present at the appointment and he has told us that without question, his wife told the consultant she was short of breath, and she also told a nurse.
86. We recognise this was the same day Mrs A attended the Practice to see a GP about her breathing difficulties. This shows Mrs A had concern with her shortness of breath on the same date she saw the consultant.
87. We have considered the evidence and comments from both parties. On balance, we think it more likely than not that Mrs A told the consultant she had been experiencing shortness of breath.
88. We can reasonably determine Mrs A’s level of breathlessness that day by referring to the GP Practice records to see a description of this: she was short of breath on exertion, she was ok sitting and felt worse going upstairs.
89. Our breast cancer surgeon adviser has said checking a person’s breathing is one of the basic principles of medical care. A medical professional should not ignore a report of breathlessness. It would be clear if a patient was seriously struggling for breath, for example, preventing them from being able to finish their sentences.
90. Our breast cancer surgeon adviser has further explained breathlessness is however a common symptom and there can be several causes for this, some serious and some not. A doctor will therefore use their judgement to decide it this is something they need to act on, such as by arranging tests or referring them for emergency care, or if it is something their GP can manage.
91. Mrs A’s records indicate she had milder breathlessness in June but this started to worsen in July, leading to her feeling so unwell she went to A&E on 7 July.
92. Mr A questions why the consultant did not consider his wife’s breathlessness was a red flag for something more serious. Our breast cancer surgeon adviser has explained that while shortness of breath can be a symptom of metastatic breast cancer, there is a threshold for when doctors would decide to further investigate a symptom.
93. The Royal College of Radiologists guidelines on screening and symptomatic breast imaging say, ‘metastatic disease at presentation occurs in only 4–6% of patients’.
94. Our breast cancer surgeon adviser has said a doctor will assess the risk, and severity of symptoms to decide if they need to act. In Mrs A’s case, she had a 1mm invasive tumour in her breast. A cancer this small would be considered relatively low risk and without any further red flags, it would not be unreasonable for a doctor to consider a report of breathlessness was unrelated to the breast cancer and would therefore not need further action. She was also seeing her GP about the issue.
95. Mrs A’s post mortem shows she sadly died from liver cancer which led to multi-organ failure. She had two types of cancer, and the breast cancer had not spread.
96. We consider the consultant likely did not have significant concern with Mrs A’s breathing on 15 June. This could account for why they did not document this.
97. On review of the records which show the progression of Mrs A’s symptoms, and the advice we have received, we do not consider the consultant acted outside of GMC guidelines on 15 June. We have therefore not found failing in the consultant not referring Mrs A for emergency treatment on this date.
98. We recognise Mr A considers this should have been an earlier opportunity to identify what was wrong with his wife. We hope we have been able to explain why we do not think this was the case. Our decision is we do not uphold the complaint about ICHT.
CWFT
Diagnosis and treatment
99. Mr A complains doctors considered multiple causes for his wife’s condition but did not find she had liver cancer which meant she was not able to have relevant treatment before she sadly died.
100. When Mrs A attended the ED, she reported worsening breathlessness on exertion for the past two weeks. A doctor reviewed her, noted her medical history of breast cancer, that she had a high heart rate and oxygen saturation levels of 89%. They planned for her to have blood tests, an ECG, ABG (arterial blood gas analysis, this measures how much oxygen and carbon dioxide are in the blood) and a chest X-ray.
101. The chest X-ray and the ECG were both normal. The ABG results indicated Mrs A’s lungs were not getting enough oxygen into her blood and were not removing enough carbon dioxide. The team gave her oxygen.
102. Mrs A’s blood test results showed abnormal liver results and the team booked for her to have a liver ultrasound. The blood test also showed she had a very elevated D-dimer of 8800ng/ml. For an adult, a normal result is under 500ng/ml. A D-dimer test detects the presence of protein fragments in the blood from broken down blood clots.
103. The ED team suspected Mrs A may have a pulmonary embolism. This can cause symptoms of breathlessness and as noted earlier in our report, people with breast cancer are at a higher risk of blood clots. The team arranged for Mrs A to have a CT pulmonary angiogram (CTPA), this is a scan that looks for blood clots in the lungs.
104. The CTPA carried out on the afternoon of 7 July did not show Mrs A had a blood clot, but showed changes to the top of her lungs that could have been an infection. The radiologist commented the scan was not of good quality and so if there were on-going concerns, the team should request a repeat scan. A doctor requested a repeat CTPA and Mrs A was transferred to a ward.
105. Despite the initial findings of the CTPA, doctors still had a high clinical suspicion Mrs A may have a pulmonary embolism and treated her with blood thinning medication (anticoagulant).
106. NICE guidance on venous thromboembolic diseases says that for people who present with the signs or symptoms of a pulmonary embolism, including shortness of breath, doctors should examine them and offer a chest X-ray to exclude other causes.
107. The chest X-ray did not show anything abnormal and so doctors then requested the CTPA. The NICE guidance on venous thromboembolic diseases says when doctors consider a pulmonary embolism is likely, they should offer a CTPA.
108. The NICE guidance says if the CTPA does not identify a pulmonary embolism and doctors do not suspect deep vein thrombosis, the person should still be given a long-term anticoagulant, and doctors should think about alternative diagnoses.
109. In Mrs A’s case, although the CTPA did not show a pulmonary embolism, it was not a good quality scan. Doctors requested a repeat scan because they considered Mrs A’s symptoms and test results indicated this. However, we can also see they were carrying out a range of tests to rule out other possible causes, including an infection.
110. Our physician adviser has reviewed the initial assessment of Mrs A and has said the medical team arranged the relevant tests for Mrs A. Her symptoms and the results of the blood tests indicated she may have a pulmonary embolism, this was an appropriate consideration to rule out. We consider this management met with the NICE guidelines referred to above.
111. On 8 July, Mrs A still needed oxygen to help her breathe. A urine test showed she may have an infection and so doctors prescribed antibiotics.
112. The following day, the records say Mrs A told a doctor her breathlessness had improved. When doctors tried taking her off oxygen however, her oxygen saturation levels dropped. A doctor prescribed steroids that can help reduce inflammation in the lungs and thereby help with breathing.
113. On 10 July, Mrs A still needed oxygen, but a doctor noted she was comfortable and not short of breath. The plan was to wean her from the oxygen, but attempts were unsuccessful. The team changed her antibiotics to a type that can treat pneumonia. It was still unclear to the medical team what was causing her breathlessness.
114. On 11 July, Mrs A was more unwell. She had nausea and was feeling weak. A doctor reviewed her and decided to seek advice from an oncology consultant. The consultant reviewed the CTPA report from 7 July and did not think her issues were breast cancer related but recommended a respiratory opinion.
115. Mrs A was supposed to have a liver ultrasound scan on 11 July, but this did not take place. We have considered this in detail from paragraph REF _Ref182380745 \r \h 127. Mrs A was moved to the respiratory ward. A respiratory doctor reviewed her and considered her low blood oxygen levels were ‘out of proportion’ to the CTPA scan findings. They requested further tests. She was now being treated for pneumonia.
116. Mrs A deteriorated on 12 July with lower blood oxygen saturation levels despite oxygen support. There were two emergency calls and doctors attended to treat her. Doctors requested further tests including blood tests, a chest X-ray, a CPTA of her abdomen and pelvis, and an urgent echocardiogram to check her heart.
117. At around 1.45pm, Mrs A went into peri-arrest. This is the period just before a cardiac arrest when a patient is very unstable and needs urgent care. The intensive care team attended and put Mrs A on a ventilator, this pumps air into the lungs. She was given medications and fluids and was transferred to intensive care.
118. The repeat CTPA showed Mrs A had nodules in her lungs, these are growths that can be cancerous. She also had enlarged lymph nodes and an enlarged liver with an irregular appearance. The scan did not show a pulmonary embolism, and no clear evidence of a lung infection.
119. The intensive care team reviewed the results of Mrs A’s tests and considered she had an ischemic liver injury, this is when the liver is damaged due to a lack of oxygen or blood. She also had sepsis, this is when the body’s reaction to an infection causes injury to its own tissues and organs. Mrs A was critically unwell and their plan was to give her treatment to keep her organs functioning.
120. Despite the extensive treatment, Mrs A’s condition continued to deteriorate and she very sadly died early on 13 July. We understand this was unexpected and a huge shock to Mr A and his family.
121. Our physician adviser has reviewed the considerations made by the medical teams, and the investigations they carried out. They have said the plan for Mrs A’s care was appropriate based on her symptoms and test results. The team initially wanted to rule out a pulmonary embolism and treated her for this in the meantime.
122. The team also considered Mrs A had an infection and treated her for this while continuing to run tests to try and understand any other underlying cause for her symptoms. Several specialists reviewed her to provide advice and had input in her care.
123. On review of the post mortem, our physician adviser has explained the cause of Mrs A’s breathlessness was likely the embolisation of the liver cancer, not a blood clot. This is when tumour deposits travel through the blood to the lungs creating similar symptoms to a blood clot. This process would account for her high D-dimer results, and likely for why she was breathless and had a high heart rate.
124. We can see that by 12 July, doctors were aware something serious was wrong with Mrs A’s liver, and the next steps to diagnose cancer would have been a biopsy and for an MDT to review all her results and decide what treatment could be suitable. Sadly, Mrs A died before these steps were possible. Our physician adviser has explained Mrs A had extensive liver cancer that had spread to her lungs and lymph nodes, she was very unwell.
125. We understand Mr A’s concern doctors did not diagnose his wife with liver cancer before she died. We hope we have been able to explain why we consider the medical team’s initial suspicion of a pulmonary embolism was reasonable based on her risk for this, and her symptoms. We also consider the team were arranging the relevant tests to try to find out if anything else was causing her symptoms. We are very sorry to hear how difficult this time was for Mr A and his family.
126. We consider the overall management of Mrs A’s care and treatment met with the GMC’s Good Medical Practice by doctors adequately assessing and examining Mrs A, arranging and providing suitable investigations and treatment, and making referrals to other practitioners. We have therefore not seen failings here.
Liver ultrasound
127. Mr A complains doctors knew within hours of his wife’s attendance to hospital on 7 July that she had abnormal liver test results and yet they did not investigate this with any urgency.
128. As referred to above, NICE guidance for suspected cancer [NG12] says that when doctors suspect liver cancer, they should ‘consider an urgent, direct access ultrasound scan (to be done within two weeks) to assess for liver cancer in people with an upper abdominal mass consistent with an enlarged liver’.
129. Doctors examined Mrs A and there is no reference to her having an upper abdominal mass, but her abnormal liver blood test results indicated a problem. In this scenario, our physician adviser has confirmed it was appropriate for the clinical team to arrange an ultrasound scan to take place within two weeks.
130. The records from 7 July show the clinical team planned for Mrs A to have a liver ultrasound scan and scheduled this for 11 July.
131. On 11 July, Mrs A was not supposed to eat prior to the scan because this can affect the quality of the scan images. Staff mistakenly gave Mrs A some toast that morning and she had a bite to eat. The medical team spoke to the radiology team and they agreed to go ahead and do the scan despite this.
132. By the afternoon, Mrs A had still not had the scan and so a doctor chased this. The radiology team said she had not been added to the list and now no staff were available to carry out the scan. The doctor advised Mrs A to be nil by mouth the following morning in preparation for a scan.
133. The following day, as set out above, Mrs A’s condition worsened and she had a CTPA scan of her abdomen and pelvis. Our physician adviser has said this scan did not lead to a clear diagnosis for Mrs A because while it showed her liver was abnormal, it did not show a mass or tumour. It showed enlarged lymph nodes which suggest a type of cancer, but it was not possible to reach a diagnosis from this scan alone.
134. Our physician adviser has explained if Mrs A had an ultrasound scan on 11 July as planned, this would have shown a similar result of an abnormal looking liver and would not have resulted in a diagnosis.
135. A CT scan shows more detail than an ultrasound scan. If Mrs A had the ultrasound scan on 11 July, it is likely doctors would have requested a CT scan as the next step to further investigate the findings. Having the CT scan instead of the ultrasound scan essentially bypassed Mrs A needing to have this.
136. We hope it offers some reassurance to Mr A that despite the ultrasound scan not taking place as planned, his wife instead had a CT scan which highlighted the medical team needed to further investigate what was wrong with her liver. We are very sorry Mrs A sadly deteriorated quickly from 12 July and recognise why this has led to Mr A having serious questions about what happened.
137. It was not ideal Mrs A did not have the ultrasound scan on 11 July. Doctors had arranged this but it did not happen as it was supposed to. We recognise the medical team tried to fix this but could not. With reference to the NICE guidance for liver cancer however, the timescale for an urgent ultrasound scan is two weeks. We therefore do not consider it a failing this did not happen on this date as this was still within timescales.
Communication
138. Mr A complains hospital staff did not contact him or his family about his wife’s condition from 8pm on 11 July until 1.10pm on 12 July. Mr A’s daughter says they were made to feel as if they were being a nuisance for wanting to know what was happening.
139. The GMC’s Good Medical Practice says doctors, ‘must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’. There is no specific guideline to say how quickly families should be updated about loved ones.
140. Nursing records from 11 July say that just before midnight, some of Mrs A’s observations declined, however they were ‘fairly stable’ and she looked ‘comfortable’. Nurses asked for a doctor to review her, the doctor asked nurses to continue to observe her. Mrs A remained stable overnight and so we consider it reasonable staff did not call her family during this time.
141. At 9.15am on 12 July, a nurse documented Mrs A’s oxygen saturation levels were worsening and they initiated an emergency call for doctors to attend. Nurses made a further emergency call at around 12pm. Doctors then moved Mrs A to intensive care after she went into peri-arrest.
142. Mr A has told us his daughter attended the hospital at 1.10pm and found her mother in a corridor just after having the repeat CT scan. She was in distress and was struggling to breathe. Mr A says his daughter was the one to tell the rest of the family to come immediately.
143. On review of the records, an intensive care note from 3.12pm says the medical team had updated Mrs A’s family. A doctor from the medical team said they spoke with Mrs A’s daughter and daughter-in-law explaining her condition. They expressed concern at how quickly she had become so unwell.
144. There is a detailed note from around 9.30pm by the consultant who spoke with Mrs A’s son, daughter, husband and daughter-in-law. They had explained how unwell Mrs A had become, that they were supporting her organs but if she did not improve over the next few hours, ‘there is high chance that she will not survive this admission’. The consultant said they could stay, or the team would call if there was any further deterioration.
145. A note at 3.23am on 13 July says the consultant had informed the family Mrs A had sadly died. The family were shocked by how quickly this happened and asked if the consultant knew the cause of her acute liver failure. They explained they did not have a definitive diagnosis.
146. Our physician adviser has reviewed the records and explained a medical team’s priority is to first provide the appropriate care and treatment for the patient, and to update family afterwards.
147. In terms of the later update with the consultant at around 9.30pm, our physician adviser has commented the discussion with the consultant was around six hours after the first update, and in a busy clinical environment, this seems reasonable. Mr A has told us he was satisfied the intensive care team updated them as they were able to.
148. Mr A does not however consider it was good enough staff had not contacted him and his family on the morning of 12 July. We are sorry for how upsetting it is for him to feel he missed out on time being able to see Mrs A. We recognise it was a shock for his daughter to attend the hospital and to see Mrs A so unwell and being taken to intensive care.
149. On careful review of the records, we can see the medical and nursing teams were attending to Mrs A on the morning of 12 July as her condition suddenly started to fluctuate and worsen. Initially, the teams focussed on addressing her symptoms and finding out what was happening. Mrs A’s condition significantly deteriorated following the CT scan which is when her daughter visited.
150. We recognise how strongly Mr A feels about this matter and have carefully considered what he has told us, along with the records and the advice we received. In consideration of the nursing and medical teams focussing on caring for Mrs A that morning, we do not find staff not contacting Mr A during this time a failing. We consider staff updated Mr A and his family appropriately after providing the emergency care Mrs A required, and this was in-line with the GMC guidance on communication.
151. In summary, we have not seen failings in the complaint about CWFT and so we do not uphold this. We are sorry for any distress our decision causes Mr A and we hope the information we have shared in this report will go in some way to answering his questions about his wife’s care.