Failed to diagnose his cancer soon enough
13. Miss F says the Trust missed several opportunities to perform investigations which may have identified her father’s cancer sooner. She says he first attended A&E on 27 November 2020 and was discharged home the same day with no plan for further investigation. She says the Trust missed several red flag symptoms such as the severity of his pain, signs of jaundice and abnormal blood test results. Miss F says this was the first opportunity the Trust missed to arrange tests for possible cancer.
14. Miss F says following this the Trust missed other opportunities to carry out investigations and delayed the colonoscopy required to diagnose her father’s cancer. She says although an earlier diagnosis may not have prevented her father’s death, it may have enabled him to receive treatment that could have extended his life, relieve his symptoms and improve his quality of life.
15. Mr F attended A&E with a four-day history of abdominal pain. The record of the initial assessment indicates Mr F reported no weight loss or vomiting during the previous few days and no concerns were raised in relation to eating, drinking or shortness of breath. Mr F said he had been constipated for the previous three days but had opened his bowels that day.
16. The records indicate Mr F reported a dull, left upper quadrant abdominal pain that varied in severity but could be rated as high as 8 out of 10 at times. The records indicate the A&E doctor carried out an abdominal examination which did not detect any obvious abnormalities.
17. The records provide no evidence to indicate Mr F was suffering with jaundice and there is no reference to any symptoms consistent with jaundice in the medical or nursing notes from this attendance. The Trust performed a series of blood tests the results of which our A&E adviser said were unremarkable. Our A&E adviser said although some of the blood test results were just outside the normal range, such findings are common in patients with diabetes such as Mr F.
18. The records indicate the Trust discharged Mr F from A&E with a diagnosis of musculoskeletal injury despite him having no recent history of injury or trauma. The records provide no evidence to indicate the Trust referred Mr F back to his GP for any further tests to establish the cause of his abdominal pain.
19. The GMC guidance states doctors must provide a good standard of care and when assessing patients must:
• ‘adequately assess the patient’s conditions, taking account of their history and 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’
20. The NICE guidance on referral for suspected gastrointestinal tract cancer states that patients over the age of 50 years with unexplained abdominal pain should have faecal immunochemical testing (FIT) performed to check for the presence of blood in their stools. If the result of the FIT is positive for the presence of blood, patients should be referred for further investigation for possible bowel cancer.
21. Our A&E adviser said the records support the view Mr F’s unexplained abdominal pain warranted further investigation. In line with GMC guidance and the NICE guidance on referral for suspected gastrointestinal tract cancer, the Trust should have referred him to his GP to arrange for FIT analysis to be carried out. Our A&E adviser said if the FIT analysis identified blood in his stools, this would have led his GP to refer Mr F for further investigation of possible bowel cancer.
22. We found the Trust did not act in line with the GMC guidance and the NICE guidance on referral for suspected gastrointestinal tract cancer when it discharged Mr F on 27 November 2020 without any plans or referrals for further care or investigation. We think this is a failing that resulted in a missed opportunity for the Trust to arrange further tests to investigate Mr F’s unexplained abdominal pain.
23. We cannot say whether further investigations or FIT tests would have identified indications of cancer or resulted in an earlier diagnosis if carried out following the A&E admission of 27 November 2020. However we acknowledge Mr F’s cancer was diagnosed during the weeks that followed and was at an advanced stage when diagnosed. This earlier missed opportunity to investigate his abdominal pain has led to doubt about the impact any possible tests may have had at that time.
24. Mr F attended A&E again on 15 January 2021 due to elevated liver enzymes in his blood tests. During the assessment in A&E Mr F complained again of left-sided upper quadrant abdominal pain for the previous two weeks.
25. Our A&E adviser said the records indicate Mr F’s clinical observations were all within normal range during this attendance. The note of the assessment indicates he reported no recent weight loss or changes in his bowel habit. Mr F described his abdominal pain as 7 out of 10 and he had been managing this by taking co-codamol tablets when required. The records indicate the Trust arranged an urgent ultrasound scan of his liver to take place on 18 January 2021 and discharged him.
26. Our A&E adviser said on this occasion an ultrasound scan of his liver was the appropriate investigation, and it was arranged urgently. Based on the evidence we have seen so far we think the Trust acted in line with the GMC guidance in arranging an urgent ultrasound scan to investigate the cause of Mr F’s abdominal pain.
27. The Trust performed the ultrasound scan on 18 January 2021 and found significant abnormalities in Mr F’s lungs and liver. The Trust also performed a CT scan of his abdomen which showed a mass in his colon. The Trust upgraded Mr F’s care due to suspected cancer and referred him to its colorectal department for urgent investigations the same day. The note in the records indicates the investigations were requested to take place within two weeks. However Mr F was not seen by anyone in the Trust’s colorectal department during the two weeks that followed.
28. The Trust held a telephone review with Mr F on 28 January 2021. The record of the review indicates the Trust informed Mr F of the findings of the CT scan and referred him for an urgent colonoscopy and biopsy. The records indicate these investigations were also requested within two weeks, however the Trust did not arrange the colonoscopy during the two weeks that followed.
29. The records indicate the Trust performed the colonoscopy on 25 February 2021. The Trust made the diagnosis of metastatic cancer of the lungs, liver, chest and abdomen on 2 March 2021.
30. In its response to Miss F’s complaint the Trust said:
‘The 2WW target for first OPA’s (outpatient appointments) is 14 days and the average wait time between January-February 2021 was 10.4 days.
This patient however was an upgrade patient, where the target is four weeks as these are not measured the same as 2WW standard.
Irrespective of this, they had their first appointment within 10 days. Referred 18/01 and seen 28/1.’
31. Our oncology adviser said the ‘2WW target’ referred to by the Trust is a term referring to a set of targets for patients with a suspected cancer. The targets are to see a specialist within 14 days, to receive a diagnosis within 28 days and receive first treatment within 62 days from the date they are referred by their GP or a cancer screening programme. The NHS Long Term Plan was introduced in January 2019 and modified the original 2WW cancer targets.
32. The NHS Long Term Plan says:
‘3.58. We will begin introducing a new faster diagnosis standard from 2020 to ensure most patients receive a definitive diagnosis or ruling out of cancer within 28 days of referral from a GP or from screening.
For people diagnosed with cancer, it will mean they can begin their treatment earlier. For those who aren’t, this will put their minds at rest more quickly at a very stressful time. To support the delivery of the new standard, we will align our Cancer Alliances with STP and ICS footprints and NHS England and NHS Improvement regions. They will implement a new timed diagnostic pathway for specific cancers, building on the timed pathways already being introduced in lung, colorectal and prostate cancer. Data collection for all patients will start in 2019, with full monitoring against the standard beginning in April 2020, and performance ramping up as additional diagnostic capacity comes online.’
33. Within the 28 day period the Trust would be expected to carry out the appropriate tests in order to confirm or rule out a diagnosis of cancer, this would include the colonoscopy and the biopsy. The target date for diagnosis in Mr F’s case would be 15 February 2021 based on the initial referral of 18 January 2021. However the Trust did not diagnose his cancer until 2 March 2021, two weeks and one day outside the 28 day target.
34. Our oncology adviser said the records indicate the main reason for the delay in reaching a diagnosis was the length of time the Trust took to perform the colonoscopy. Despite two referrals for urgent investigations the Trust did not carry out the colonoscopy until 25 February 2021 and by this time the 28 day target for reaching a diagnosis had already passed.
35. If the Trust had performed Mr F’s colonoscopy sooner after the initial referral of 18 January 2021, it is possible his cancer may have been diagnosed sooner and in line with the 28 day target. Our oncology adviser said if diagnosed earlier, plans for his care could have been put in place sooner.
36. The NHS constitution says there should be a maximum 2-month (62 day) wait from urgent referral for suspected cancer to first treatment. The Trust initially referred Mr F for suspected cancer on 18 January 2021 and the first treatment target would be 21 March 2021. However we have not seen any evidence to indicate Mr F was fit enough to withstand chemotherapy at this time and the records state he was too unwell for chemotherapy upon diagnosis on 2 March 2021.
37. Our oncology adviser said there is no evidence in the records to indicate an earlier diagnosis would have enabled treatment which may have changed Mr F’s outcome or extended his life, such as chemotherapy. Sadly by the time his cancer was diagnosed it was very advanced and had spread to several areas of his body. However an earlier diagnosis may have enabled care to be put in place sooner to relieve some of his symptoms and improve his quality of life.
38. We carefully considered Miss F’s complaint and the supporting information she has provided. We also considered the information in the records, guidance and the advice we have received.
39. We found the Trust did not act in line with the GMC guidance or the timescales set out in the NHS Long Term Plan during the diagnostic pathway. We think the delay in carrying out the colonoscopy is a failing and the reason Mrs F’s cancer was diagnosed outside the 28 day target.
40. We acknowledge the NHS Long Term Plan says the 28 day target should be achieved for ‘most patients’. However when reviewing Mr F’s diagnostic pathway we have seen no evidence to explain the lengthy delay in carrying out the colonoscopy. There is no evidence in the records or the Trust’s complaint responses to indicate there were mitigating circumstances which meant the Trust was unable to act on the referrals in a reasonable timeframe or arrange the colonoscopy sooner.
Failed to provide the treatment he needed
41. Miss F says her father endured significant pain during the diagnostic pathway and the Trust did not provide him with pain relief medication at any point.
42. The records indicate during this attendance at A&E on 27 November 2020 Mr F described pain which varied in severity from 2 out of 10 to 8 out of 10 (although it was described as 2 out of 10 at the point of assessment). There is no evidence in the records to indicate the Trust provided Mr F with any pain relief medication during his initial attendance or at the point he was discharged.
43. The RCEM guidance states patients should be asked about their pain and provided with appropriate analgesia. Our A&E adviser said due to his reports of pain it would have been in line with the RCEM guidance for the Trust to provide Mr F with pain relief medication during this attendance and ensure that he had access to it at the point of discharge.
44. We found the Trust did not act in line with the RCEM guidance as it did not provide Mr F with appropriate pain relief medication during this attendance in A&E or when discharging him home. We think this is a failing.
45. The records indicate during his next attendance at A&E on 15 January 2021 Mr F described his abdominal pain as 7 out of 10. Our A&E adviser said reports of such high levels of pain would indicate simple pain relief medication like the co-codamol Mr F said was taking would not be sufficient. The records indicate during the assessment Mr F said the co-codamol was helping with his pain, however there is no indication the Trust explored whether stronger pain relief medication was required due to his high level of pain.
46. There is no evidence in the records to indicate the Trust provided Mr F with any pain relief medication during this attendance or at the point he was discharged. Our A&E adviser said it would have been in keeping with the RCEM guidance to explore whether stronger pain relief medication was required for Mr F’s high level of pain.
47. We found the Trust did not act in line with the RCEM guidance by not exploring Mr F’s pain relief requirements to ensure he was receiving appropriate pain relief medication. We think this is a failing.
48. Mr F next attended the Trust for the ultrasound scan of 18 January 2021. At this point the Trust referred him to its colorectal department for urgent investigations for suspected cancer. The records provide no evidence to indicate the Trust gave Mr F any pain relief medication, or referred him elsewhere to explore pain relief options, during the diagnostic pathway that followed despite his continued reports of pain.
49. We carefully considered Miss F’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We found the Trust did not act in line with the GMC guidance to ensure Mr F received appropriate pain relief medication during the diagnostic pathway. We think this is a failing.
50. Miss F says after his cancer was diagnosed the Trust didn’t provide chemotherapy or refer him to the community palliative care team. She says the Trust did not provide additional support for his nutrition or supplements to try and improve his frailty.
51. Our oncology adviser said there is no evidence in the records to indicate the Trust could have started Mr F on chemotherapy following his diagnosis. Our oncology adviser said once cancer is confirmed, further tests are required to identify the histology (the type and grade of the cancer) and inform the type of chemotherapy required to treat it.
52. The Trust made the initial diagnosis on 2 March 2021 and at this point it is noted in the records that Mr F was not well enough to undergo chemotherapy. The Trust arranged a biopsy to gather a sample for testing. Our oncology adviser said the Trust first attempted a biopsy of the mass in Mr F’s colon however the tissue gathered during the biopsy was unsuitable for testing. The Trust then arranged a second biopsy of Mr F’s liver which was carried out on 24 March 2021.
53. The records indicate the Trust was unable to establish a possible chemotherapy choice from the initial tests of the liver sample and they had to be sent for further tests. These further tests were completed and the histology report produced on 16 April 2021.
54. Our oncology adviser said the records indicate there was no opportunity to start chemotherapy following the histology results. The records indicate Mr F’s condition had not improved since 2 March 2021 and, by 16 April 2021, had deteriorated significantly.
55. We carefully considered Miss F’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We found no evidence to indicate the Trust’s decision not to provide chemotherapy after cancer was diagnosed was inappropriate or not in keeping with the GMC guidance.
56. The records indicate the Trust did not refer Mr F, or ask his GP to refer him, to the community palliative care team despite it being clear he had an advanced cancer until it discharged him from hospital on 22 April 2021. We think this is a failing.
57. We think it would have been in keeping with the GMC guidance to refer Mr F to the community palliative care team following his diagnosis on 2 March 2021. Timely referral to the community palliative care team would have enabled Mr F to receive care and support in his home following his diagnosis and also monitor his condition for any deterioration.
58. Our oncology adviser said there is no evidence in the records to indicate the Trust failed to provide appropriate care to assist Mr F with his nutrition. The records of his attendance on 18 January 2021 and subsequent telephone review on 28 January 2021 specifically state that his weight was stable at this time. Following this the records indicate Mr F was reviewed by the Trust as an outpatient and mostly through telephone reviews.
59. The records do not show that Mr F suffered from significantly reduced appetite or weight loss that required intervention from the Trust until he was admitted to hospital on 16 April 2021. Our oncology adviser said there is no indication in the records prior to this that the Trust needed to provide him with nutritional support.
60. We carefully considered Miss F’s complaint and the supporting information she has provided. We also considered the information in the records and the advice we have received.
61. We acknowledge Mr F became more frail during the diagnostic pathway. We think the lack of support in this regard is more closely linked to the failure of the Trust to refer him to the community palliative care team whilst he was an outpatient rather than a failure of the Trust to provide nutritional support. We think it is likely his increasing frailty may have been identified and acted upon by the community palliative care team if he had been referred by the Trust following his diagnosis on 2 March 2021. We recognise that this was a missed opportunity to provide specialist support for Mr F and his family at what was already a very difficult and distressing time.