ED attendances 22. Miss V complains the Trust did not test her mother’s blood and it failed to identify her cancer on two separate attendances in the ED in March 2022. We looked through the records carefully. Whilst Miss V says her mother attended the ED twice before a third time when the lung abnormality was found, we can only see one occasion in March when Mrs Q attended before she was then admitted, and the abnormality found.
23. This is in line with the Trust’s response to Miss V’s complaint, which explained Mrs Q attended on 1 March, before attending again on 22 March when she was admitted. As we explain in our background section, on this second attendance Mrs Q’s blood was tested, she was admitted, and the mass in her lung was identified. We therefore considered Miss V’s complaint about 1 March only.
24. Records show that when Mrs Q attended on 1 March, she walked into the ED independently, reporting a 12-month history of upper left sided back pain. She was triaged by the ED nurse.
25. RCEM guidance explains that triage is a system of sorting patients, according to a combination of their presenting complaint and their measured physiological observations when they arrive in the ED. The Manchester Triage System is used within most EDs nationally and applied here. Records show Mrs Q was triaged appropriately, in line with this.
26. Our nursing adviser says Mrs Q’s presenting complaint suggested she had long-standing, chronic musculoskeletal back pain. The ED nurse took an ECG (electrocardiogram, a scan to test the heart’s electrical rhythm) which was normal and ruled out any cardiac cause for her pain. The triage nurse also measured Mrs Q’s physiological observations, and our nursing adviser confirms these were all within the normal range.
27. Based upon this combination of the presenting complaint and findings on assessment, the ED nurse then streamed Mrs Q to the UCC. RCEM guidance explains that streaming is the process of allocating patients to different services, to ensure the patient is directed to the correct person or service to manage their clinical needs. Records show Mrs Q was streamed appropriately, in line with this.
28. Our nursing adviser explains there was no concerning finding, no ‘red flag’ from Mrs Q’s presentation, her reported history or on observation or ECG to have warranted anything more than a routine, non-urgent response. The decision to stream her into the UCC was reasonable.
29. We know Miss V is concerned her mother’s blood was not tested. We do not find any clinical indication for this on 1 March. Our nursing adviser confirms Mrs Q did have appropriate investigation in the form of assessment of her physiological vital signs and an ECG.
30. Our nursing adviser says Mrs Q’s presentation suggested a long-standing back pain, and blood testing is not an indicated investigation for this. Blood testing could have been considered at the UCC however this was not required nor was it indicated as part of Mrs Q’s triage in the ED.
31. When Mrs Q attended the ED on 22 March, her presentation was completely different. On that occasion she arrived by ambulance with shortness of breath, worsening and more acute pain, her oxygen saturations were low and they remained low despite supplemental oxygen. Alternative actions and investigations were taken because this was a different presentation.
32. We hope to assure Miss V the actions taken by the Trust on 1 March were appropriate and in line with the guidance as cited above. We do not see any evidence of service failure here.
Confirming the diagnosis 33. Miss V complains the Trust delayed confirming whether her mother had lung cancer or sarcoma until June. Records show confirmation of lung cancer was documented at the oncology clinic on 10 June. We recognise this was some time after the first abnormal finding on chest X-ray, after Mrs Q attended the ED on 22 March. We hope to assure Miss V that the time taken was needed due to the complex circumstances, and there is nothing to show any unreasonable delay or service failure occurred.
34. Our clinical adviser confirms that initially, Mrs Q’s care was prompt and in line with NOLCP guidance. She had a CT scan taken just two days after the abnormal chest X-ray findings, a biopsy taken on day nine and review in the chest clinic on day 21. This was all timely.
35. However, Mrs Q’s biopsy sample appeared to look like a sarcoma. Our clinical adviser explains that sarcomas are more common in younger patients, and so considering its appearance and Mrs Q’s age, it was reasonable the Trust sought the advice of the sarcoma MDT. The sarcoma MDT was based at a different hospital trust and the need to gain their input understandably took some time.
36. Even once this MDT concluded it was not a sarcoma, it was unable to definitively conclude that Mrs Q had lung cancer, questioning the possibility of a mesothelioma. Mrs Q underwent further tests. She was reviewed again in the chest clinic on 12 May, referred to the oncology clinic once molecular test results were available on 20 May and had a repeat CT scan three days later. She was seen in the oncology clinic on 10 June when the definitive diagnosis was reached, treatment was decided, and this commenced on 23 June.
37. Our clinical adviser explains that the treatment for confirmed sarcoma is very different compared to the treatment for confirmed lung cancer. This means the additional steps taken in Mrs Q’s case were all appropriate, in ensuring clear identification of the type of her cancer, so the correct treatment pathway could commence.
38. NOLCP guidance recommends starting treatment for lung cancer within 14 days of MDT recommendation. In Mrs Q’s case, it took over 90 days from the initial cancer presentation to her treatment starting. The time taken in Mrs Q’s case may have breached NOLCP guidance, however this was for understandable reasons, as we have explained. We therefore do not see that the time taken was due to any service failure.
39. We understand the reasons why Miss V remains concerned about this. It must have been an incredibly difficult and distressing time to wait without clarity over the diagnosis and the next steps with treatment. We hope to assure Miss V that the time taken in her mother’s case was needed, to rule out sarcoma and to reach an accurate diagnosis for the appropriate treatment plan, and we do not see any evidence of undue delay.
C. diff 40. During her admission in September, Mrs Q tested positive for C. diff. We know Miss V strongly believes this happened because her mother was left laid in her own faeces overnight between 26 and 27 September. We can assure Miss V we do not see any evidence to suggest her mother was left soiled for any lengthy period, with the evidence showing appropriate continence care was given on the night in question.
41. NEWS2 guidance recommends how frequently a person should receive nursing checks. Our nursing adviser says under NEWS2 guidance and considering her clinical circumstances, Mrs Q should have received nursing checks at four to six hourly intervals. In addition, her repositioning schedule notes that she required repositioning every two to four hours.
42. Entries in the various nursing charts and records show that throughout the night in question, Mrs Q received checks in line with NEWS2 guidance and her repositioning schedule. We are assured Mrs Q was not left for any extended unreasonable period.
43. In terms of Miss V’s concern about her mother’s continence care, the records note that at 9.30pm and midnight Mrs Q was dry. At 2am it is noted she was ‘wet or soiled’, and it is documented that she was changed. When checked again at 3.10am and 4am, and on later occasions through to the morning, records note that she was found to be dry. Our nursing adviser confirms that the evidence shows appropriate action was taken when Mrs Q was found to have been incontinent.
44. When we spoke with Miss V, she said when visiting her mother that morning, a patient in the same bay told her that her mother had been soiled and crying out for help that did not come. We are incredibly sorry to hear this was her experience and understand the distress and anger Miss V told us she felt when hearing this. We hope to assure Miss V that the records do not suggest Mrs Q was left laid in her faeces for any extended period, as is Miss V’s concern.
45. We know Miss V is concerned about how her mother developed C. diff. Information on the NHS website explains that people more at risk of developing C. diff are those who are taking antibiotics, those who are staying in hospital for a long time and those who have a weakened immune system from having a long-term condition, for example cancer, or treatment like immunotherapy.
46. All of these listed risk factors applied in Mrs Q’s case. This means that her risk of developing C. diff was already increased, for all of these reasons, any of which could have been the cause.
47. In addition, our nursing adviser explains that anyone can carry the C. diff toxin and be unaware, remaining asymptomatic, and sometimes for many years. Our nursing adviser explains it is only when a person may be more at risk, for example any of the above risk factors apply, that the C. diff toxin can then make them present with symptoms. It is entirely possible this is an explanation for Mrs Q’s testing positive.
48. We cannot know the exact reason why Mrs Q developed C. diff, and we know this will likely be an ongoing upset for Miss V. We can know from clear records, that Mrs Q was not left laid in her faeces for any extended period throughout this night. We also know that sadly, Mrs Q had every listed factor known to increase someone’s risk of developing C. diff, and she could simply have been carrying the toxin without knowledge. Importantly, in terms of Miss V’s concern, we do not see any evidence of service failure here.