Consent and treatment
16. Mr A complains the Trust rushed his wife into agreeing to an operation to remove part of her lung, instead of offering or considering radium treatment for her cancer. He felt the operation was too much for his wife to cope with.
17. Within the Trust’s complaint response dated 19 June 2024, it said the consultant thoracic surgeon confirmed that during Mrs A’s consultation on 7 March, he described the proposed surgery. This was supported by using a 3D model representation of the chest to make clear the extent of the planned operation and indicated to Mr and Mrs A where the tumour [lung] was on the 3D model.
18. It said the consultant explained the volume of the lung that was planned to be removed accounted for 30% of her right lung. He discussed the risks of the operation and said the assessment of Mrs A’s preoperative parameters were very good, including her breathing tests and performance status.
19. The Trust said Mrs A did not have any obvious underlying serious conditions which might increase the risk of the operation. It was the opinion of the entire team that her risk of serious complications after surgery was low. Unfortunately, there still exists a risk that patients can die because of the complications that occur. The risk of death from such surgery is around 1-2% which it said it communicated to Mrs A during the clinic consultation and documented in the clinic letter.
20. The relevant guidelines are:
• RCS: Consent: Supported Decision Making of England guidance.
21. These guidelines explain that clinicians should give patients the information they need to make a decision about the treatment, including risks of the treatment. If agreed, consent should be written and recorded.
• BTS: Guidelines on the Radical Management of Patients with Lung Cancer.
22. This document provides guidance to clinicians on possible treatments, which include surgery, radiotherapy, chemotherapy. This is dependent on the stage of the cancer.
• NICE [NG122]: Lung cancer: diagnosis and management.
23. This guidance aims to improve outcomes for patients by ensuring the most effective tests and treatments are used.
24. Our surgeon adviser said there is no evidence within the medical notes that show the Trust rushed Mrs A into agreeing to an operation to remove part of her lung. The Trust’s investigation into her lung nodules began in June 2023 – nine months before her operation. The records show the Trust discussed with Mrs A her diagnosis, treatment, risks and benefits in line with RCS guidance.
25. The clinic letter of the consultation on 7 March 2024 shows the Trust’s Surgeon explained the treatment and the risks and benefits, in line with the RCS guidance. It recorded that Mrs A was happy with the explanation and was keen to proceed to surgery as soon as possible.
26. A consent form was also signed by Mrs A agreeing to the treatment on 7 March – five days before her surgery. A clinician also checked with Mrs A on the day of the surgery (12 March) that she had no further questions and recorded that she ‘wishes the procedure to go ahead.’ Our surgeon adviser said the records show the Trust gave her plenty of time to decide what treatment she wanted.
27. The records show the clinicians considered her medical history and her health condition at the time when considering surgery, including her lung function which was satisfactory. There is nothing within the records which indicate she was unfit for surgery during her pre-operative assessment. Our surgeon adviser said she was medically fit for the operation, in line with the BTS and NICE Guidance.
28. Mr A questions whether radium treatment should have been offered to his wife.
29. Our surgeon adviser said radium treatment (radiotherapy) would not be an effective treatment for the pathological stage of Mrs A’s tumour. This would have a worse potential long term survival rate based on the pathological stage of her tumour, compared to surgery. The clinicians assessed how advanced her tumour was before surgery and correctly advised that surgery to remove part of her lung was the most appropriate and best course of treatment to offer Mrs A, in line with BTS guidelines and NICE Guidance (NG122).
30. We are sorry to learn of Mr A’s concerns about the Trust’s care and treatment of his wife and the impact he says this caused. We have carefully considered his and the Trust’s account, Mrs A’s medical records and clinical advice.
31. This shows the Trust explained the treatment and the risks and benefits to Mrs A in line with relevant guidance. There is no evidence within the medical records to show the Trust rushed Mrs A into agreeing to an operation to remove part of her lung. Her medical history indicates she was medically fit for the operation and that surgery to remove part of her lung was the most appropriate course of treatment.
Discharge
32. Mr A complains the Trust discharged his wife on 21 March 2024 when she was not well enough. He says it discharged her too early.
33. Mr A explains the staff said they had witnessed his wife walking up a flight of stairs on her own and that she could walk 20 metres unaided. However, Mr A said that on the afternoon before her discharge, his wife had to be helped out of bed and assisted to the bathroom, which was only five metres away.
34. Mr A says his wife was still receiving treatment for very low oxygen levels immediately before her discharge. He says his wife needed three people to get her out of the taxi on her discharge and three people to assist her to the bathroom once she was at home.
35. The Trust said it considered Mrs A fit to be discharged on 21 March by both the physiotherapist (PT) and the medical team.
36. It explained Mrs A had been assessed regularly by the PT team during her stay on ward J84 and they saw her on the day of her discharge to check she was well enough to go home.
37. The PT documented they observed Mrs A was able to independently mobilise (both with, and without her stick) approximately 20 metres without any shortness of breath and witnessed her walking up and down a flight of stairs safely. She was keen to go home, she was given advice about gently increasing her mobility with the expectation this would progress in her home environment without the need for any input from the community team.
38. It apologised Mrs A was waiting such a long time on the day of discharge and that as the hospital transport did not arrive, a taxi was requested to allow her to discharge that day. It apologised Mr A struggled to assist his wife out of the taxi when she arrived home.
39. Although Mrs A had been assessed as able to walk a reasonable distance and climb stairs, the team should have anticipated that later in the day, she would have been more fatigued and less able to mobilise independently.
40. Our surgeon adviser says there are no specific guidelines on fitness for discharge after thoracic surgery to refer to. It is a clinical decision made by the team based on the patient’s physical status, X-rays and blood tests and for Mrs A, these were all satisfactory. Fitness to discharge – based on Mrs A’s situation – would be down to clinical experience.
41. Our surgeon adviser said based on the medical records Mrs A was medically fit to be discharged, in line with clinical experience.
42. According to the medical records, Mrs A had overcome her medical complications following surgery. From 18 and 19 March, there was improvement in her condition, there is no record she was confused, she was eating and drinking well. Her observations were all satisfactory. The chest X-ray and blood tests were reported as satisfactory, and the notes indicate she was keen to go home.
43. A registrar and senior consultant assessed Mrs A prior to her discharge, as well as an advanced health practitioner and PT. All suggested she was fit to be discharged. There is no evidence within the records to indicate she was unfit to be discharged.
44. The Trust signposted Mrs A to further services following her discharge. It arranged an outpatient appointment for post operation review four to six weeks after her discharge. It arranged an outpatient appointment for a nurse led clinic a week after, for blood tests and a chest X-ray. It provided details in the discharge report of who to contact if she experienced any symptoms that she felt may relate to her recent admission.
45. We acknowledge Mr A’s concerns on whether the Trust discharged his wife when she was not well enough. We have carefully considered all the relevant evidence. This shows from a medical perspective, Mrs A was fit to be discharged. A registrar and senior consultant assessed her prior to her discharge, as well as an advanced health practitioner and PT. This showed Mrs A’s physical status was assessed and suggested she was fit to be discharged. There is nothing to suggest the Trust did anything wrong here.
Care package
46. Mr A complains the Trust did not consider his wife’s home conditions, offer or put in place a care package to support her at home prior to her discharge.
47. He says he is unwell and has to care for his 53-year-old son who suffers from severe epilepsy and stroke dementia, both facts the hospital was aware of, so he cannot understand why there was no care package offered or put in place.
48. The medical records show the Trust’s PT team assessed and treated Mrs A following her surgery. This was to improve her mobility and breathing (due to lung surgery).
49. The records show the PT assessed Mrs A on the day of her discharge. This records she was independently mobile. She could walk with or without a stick for 20 metres and walk up and down stairs. It is documented she independently washed and could change her clothes.
50. As a result of the PT assessments during her admission, and particularly the day of discharge, our PT adviser said there was no requirement for the Trust to consider or put in place a package of care for her, in line with good clinical practice. This is because Mrs A was independently mobile at time of discharge.
51. There is a reference in the medical notes that Mrs A’s husband and her son had their own health issues and that she supported them. Our PT adviser said this would not have a bearing on whether a care package should have been considered or offered. This is because any care package would be for the patient only. As Mrs A was recorded as being independently mobile, including independent in washing and getting dressed, there was no requirement for a care package to be considered or offered at time of discharge.
52. The Trust could have considered referring Mrs A to see an occupational therapist (OT) prior to or after discharge, but there are no guidelines or standards to say it should have done so.
53. Even if the Trust did refer Mrs A to see an OT, it is impossible to know whether they would have agreed to see her - bearing in mind she was independently mobile - or whether they would have considered a care package was required.
54. We acknowledge Mr A questioning whether the Trust should have considered his wife’s home conditions, offer or put in place a care package to support her at home prior to her discharge.
55. We recognise Mr A disputes how independently mobile his wife was on the day of discharge. Based on the weight of the evidence, which includes the PT assessments during admission and on the day of discharge, as well as our clinical advice, we cannot say the Trust failed to offer a package of care.
56. We are sorry to learn of Mr A’s complaint and the death of his wife. Our primary investigation decision is not made without recognition of the impact this has had on Mr A. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it.