East Lancashire Hospitals NHS Trust

5. Miss A complained the Trust did not recognise and investigate her red flag symptoms for cancer between March and October 2023.

6. Miss A had a history of cancer. She received a diagnosis of stage four metastatic breast cancer on 2 October 2023 and had a terminal prognosis and life expectancy of between three and 12 months. She considered her medical history should have led clinicians to identify her cancer much sooner.

7. She said the delay in diagnosis means she did not have the option for better treatment and a better prognosis. This impacted both her mental and physical health.

8. Miss A also complained about the way the Trust communicated her diagnosis to her. She said she found out about her diagnosis by reading a discharge summary. She said the Trust should have arranged a sensitive discussion to share her diagnosis with her and that finding out about her diagnosis in this way caused her significant distress.

9. In bringing this complaint to us Miss A wanted the Trust to acknowledge what went wrong and pay her financial compensation.

10. Miss A had cerebral palsy, which is a condition that affects movement and posture. She had breast cancer in 2010 and underwent chemotherapy (treatment using drug therapy), radiotherapy (treatment using radiation) and a double mastectomy (surgery to remove both breasts).

11. In March 2023 Miss A had COVID-19, after which she experienced a lasting cough and weight loss. She had an MRI head (a brain scan) in March and a chest X-ray in April. In May a neurorehabilitation consultant confirmed the scans showed no significant abnormality and that Miss A’s deterioration was related to her cerebral palsy.

First admission

12. On 3 July staff admitted Miss A to hospital. She had been vomiting frequently, experiencing facial numbness and back spasms. She had a CT head scan (a scan that uses computers to take detailed pictures of the brain) and chest X-ray upon admission. Her blood test results led staff to suspect she had biliary sepsis (also known as biliary tract infection, which occurs when bacteria infect bile ducts). Staff prescribed antibiotics, referred her to rheumatology (a team that investigates and treats conditions that affect the muscles or joints) and ordered an abdominal ultrasound (a scan of the abdomen). The results of the ultrasound showed her liver was normal.

13. On 7 July staff began to suspect Miss A may have gallstones, which are small stones that form in the gallbladder, and referred her to gastroenterology. This is a team that investigates and treats conditions that affect the digestive system.

14. The gastroenterology team took over her care on 11 July and ordered an endoscopic retrograde cholangiopancreatography. This is a specialist camera test that checks the liver, gallbladder and pancreas for gallstones. Staff scheduled this for 3 August.

15. Between 11 July and 3 August staff treated Miss A with IV (intravenous) fluids and anti-sickness medication as she continued to experience vomiting. On 3 August staff decided to insert a nasogastric tube (a tube used for feeding) as she had been struggling to eat and vomiting throughout her admission.

16. On 8 August staff ordered an endoscopic ultrasound, which is a procedure that combines a camera test with an ultrasound to diagnose gastrointestinal diseases.

17. On 10 August staff ordered a gastric emptying study, which is a test that measures how quickly food leaves the stomach and enters the small intestine and follow up on the camera test results.

18. Staff received the study report on 15 August. This showed delayed gastric emptying in keeping with gastroparesis. Gastroparesis is a condition where the stomach muscles are unable to move food effectively into the small intestine, leading to delayed gastric emptying. The same day Miss A developed a new cough, and staff ordered a chest X-ray, the results of which showed no lung collapse or fluid.

19. Between 17 and 24 August staff were treating Miss A for gastroparesis, and she was under the care of dieticians.

20. On 28 August staff formally diagnosed Miss A with gastroparesis, meaning she was not getting enough nutrition. Staff discharged her on 31 August and referred her for an outpatient appointment to have a gastric pacemaker fitted. This is a device that helps stimulate and improve movement of food through the stomach.

Second admission

21. On 11 September staff admitted Miss A to hospital as she was coughing up lots of white sputum (phlegm) and very breathless. She had an existing diagnosis of gastroparesis and contracted COVID-19 following her previous discharge. Staff admitted her for IV antibiotics and a chest X-ray.

22. By 13 September Miss A was septic with high National Early Warning Scores (also known as NEWS score, which is a tool clinicians use to assess the clinical status and risk of deterioration of a patient). Staff prescribed co-trimoxazole (an antibiotic) as she was allergic to eight other types of antibiotics.

23. On 15 September staff discussed Miss A’s case in a radiology meeting. They noted a recent chest X-ray suggested either COVID-19 pneumonitis (a severe lung condition caused by COVID-19 which leads to inflammation and fluid accumulation in the lungs) or lymphangitic carcinomatosis (a condition where cancer has spread from the primary area to the lymphatic vessels). A doctor discussed inflammation on her lungs with Miss A but did not mention possible cancer.

24. On 16 September staff decided to treat Miss A for COVID-19 related complications and to continue exploring cancer as a possible diagnosis.

25. On 25 September staff determined Miss A was medically fit for discharge. Staff referred her to the lung fibrosis clinic to rule out lung fibrosis (a condition where the lung tissue becomes scarred and thickened, making it difficult for the lungs to function properly) and cancer.

In between admissions

26. On 26 September Miss A spoke to a respiratory consultant about the discharge summary. Staff had documented her diagnoses as Post-COVID syndrome and ‘lymphangitic carcinomatosis’ (suspected cancer). Post-COVID syndrome is also known as long COVID and referred to when patients experience signs and symptoms that develop during or after COVID-19 and continue for more than 12 weeks, and where they are not explained by an alternative diagnosis.

27. The consultant accepted the summary was poor and that recent scan reports did not mention cancer. They agreed to alter the discharge summary to reflect the correct diagnosis identified at the time of discharge, which was Post-COVID syndrome.

28. On 28 September Miss A had an endobronchial ultrasound (also known as EBUS), which is an ultrasound used to diagnose lung disorders, and a lung biopsy.

Third admission

29. On 30 September staff admitted Miss A to hospital for further investigation as she had been feeling short of breath and experiencing chest pain.

30. On 2 October staff received recent scan reports and noted these showed metastatic adenocarcinoma (a type of cancerous tumour that has spread) secondary to breast cancer. They referred her to the breast team.

31. On 3 October a doctor told Miss A she had cancer. She was clearly deeply distressed by this news, and we were very sorry to hear in her own words how difficult this time was for her.

37. Miss A complained about the way the Trust investigated her for cancer between March and October 2023. She had cancer previously in 2010 and considered this should have led the Trust to identify her new cancer sooner.

38. Miss A was very concerned that she had ‘red flag symptoms’ of cancer during the period of care set out in this complaint which the Trust failed to recognise.

39. In its response to the complaint the Trust acknowledged Miss A had worrying symptoms and spent approximately two and a half months in hospital whilst doctors attempted to diagnose her. It explained doctors found it difficult to confirm a diagnosis, including a diagnosis of cancer, due to alternative possible diagnoses, rather than them missing or ignoring symptoms.

40. We have thought carefully about whether the evidence suggests the Trust failed to act in line with applicable standards in exploring Miss A’s symptoms. We understand from our adviser that there are no specific guidelines on recognising or investigating ‘red flag symptoms’ of cancer. As general information, Cancer Research UK’s webpage on ‘signs and symptoms’ of cancer explains there are over 200 different types of cancer that can cause many different signs and symptoms.

41. In lieu of specific guidelines, we have referred to GMC’s Good Medical Practice in considering the relevant period. Domain 1, section 6, says doctors must provide a good standard of practice and care. If they assess, diagnose, or treat patients they must adequately assess the patient's conditions, take account of their history and, where necessary, examine the patient.

42. Section 7 explains doctors must promptly provide or arrange suitable advice, investigations, or treatment where necessary, and refer to another practitioner when this serves the patient’s needs.

Between March 2023 and April 2023

43. Miss A interacted with the Trust on three occasions between March and April 2023:

• On 28 March she had an MRI head scan as she had been experiencing deterioration in her mobility and new urinary incontinence. The results of this MRI were normal.

• On 24 April she had an appointment with a consultant in neurorehabilitation medicine.

• On 28 April she had a chest X-ray, the results of which were normal. Her GP had arranged this as she had been experiencing a cough since contracting COVID-19 on 18 March.

44. Our adviser confirmed that the investigations the Trust carried out between March and April were clinically appropriate for the symptoms Miss A had been experiencing. This was in line with GMC guidance, which says doctors must promptly provide suitable investigations or treatment where necessary. We understand from our adviser that having a cough is very common after COVID-19 infection, and the normal X-ray result was reassuring. Having reviewed the clinical evidence and our independent advice, we understand there was no need for the Trust to arrange further follow up investigations at this time as neither scan showed any sign of cancer.

45. Miss A was concerned that her medical history and symptoms should have led the Trust to diagnose her cancer sooner. Her history of cancer is well documented in her medical records, and it is clear clinicians were aware of this. The evidence suggests the Trust investigated her symptoms in line with GMC guidance between March and April 2023, and there is nothing to indicate that Miss A’s history should have resulted in the Trust taking different action at that time. The outcome of its investigations showed no sign of abnormality, meaning we cannot say the Trust failed to act in line with applicable standards or that it missed any signs of cancer during this period.

First admission

46. Miss A attended hospital on 3 July as she had been vomiting three times a day for around a week. She had also been experiencing facial numbness and back spasms.

47. As explained above, there are no specific guidelines on the investigation or treatment of the symptoms Miss A was experiencing. We refer again to GMC’s Good Medical Practice.

48. During this admission staff initially treated Miss A for biliary sepsis before referring her to gastroenterology for possible gallstones. She was in hospital for around two months, during which time staff explored the various symptoms she was experiencing and provided a number of tests and treatments. Staff transferred her to gastroenterology on 13 July, who ultimately concluded gastroparesis was the cause of her symptoms.

49. The Trust undertook an initial assessment of Miss A’s needs, carried out tests and provided treatment, and referred her to a specialist team when this was necessary. We understand from our adviser this was all clinically appropriate and in line with the GMC guidance.

50. We recognise that Miss A did not understand why doctors did not identify her cancer during her first admission, given that she was in hospital for such a long time. We are aware this was a significant source of worry and frustration for her.

51. We can see that, as part of the investigations into Miss A’s vomiting, she had a CT scan of her head, lungs, abdomen and pelvis which showed no evidence of cancer. She also had a chest X-ray on 16 August, the result of which was normal.

52. Again, we understand from our adviser that these tests were clinically appropriate for Miss A’s symptoms, and none showed any signs of cancer. The results of those tests did not indicate a need for further cancer-related tests at the time, meaning we cannot say the Trust should have done more. For this reason, we find no failing.

Second admission

53. Miss A returned to hospital on 11 September. She had contracted COVID-19 since her previous admission and was experiencing a cough and breathlessness. Upon admission her NEWS score was high.

54. During this admission staff initially treated Miss A for sepsis. NICE guideline NG51 says clinicians should consider whether a person has sepsis if they present with symptoms or signs that indicate possible infection. The guidance explains clinicians should use NEWS scores to assess people with suspected sepsis in an acute hospital setting.

55. Miss A had a cough, breathlessness and high NEWS scores at the beginning of her admission, which our adviser explained can be signs of infection. They said the clinicians’ decision to suspect sepsis and treat Miss A for this was clinically appropriate. Therefore, we can see the evidence available to us shows the Trust acted in line with NICE guidance 51.

56. On 13 September a chest X-ray suggested Miss A had COVID pneumonitis and clinicians began treating her with dexamethasone (a steroid). This was in line with NICE guideline NG191, which recommends the use of dexamethasone for adults with COVID-19.

57. During a radiology meeting on 15 September clinicians raised the possibility that Miss A may have lymphangitic carcinomatosis. Clinical records suggest this suspicion was based on her recent chest X-ray. Our adviser said it is not clear why doctors considered Miss A may have lymphangitic carcinomatosis as it is not possible to identify this from a chest X-ray.

58. Clinicians sought respiratory team input, who recommended carrying out a CT scan. Our adviser confirmed this was a clinically appropriate investigation, in line with the GMC guidance, as clinicians use CT scanning to rule out lymphangitic carcinomatosis.

59. Miss A underwent a CT scan on 22 September which showed ground glass lung abnormality (hazy grey areas that can show up in CT scans of the lungs). Our adviser explained this type of lung abnormality is not seen in lymphangitic carcinomatosis as it is typically related to lung inflammation or a lung infection such as COVID-19. They noted the CT scan report contained no reference to cancer and clinicians confirmed the diagnosis as COVID pneumonitis.

60. Clinical records show that Miss A began to express a desire to go home after the CT scan. We can see a respiratory consultant said she was fit for discharge and could have the rest of the respiratory investigations she needed as an outpatient.

61. We can see a respiratory consultant arranged a lung biopsy on 27 September and this took place on 28 October. The results of the biopsy led to Miss A receiving a diagnosis of breast cancer on 3 October. It is clear Miss A considered doctors should have reached this diagnosis much sooner, and that this was deeply distressing news.

62. The evidence suggests that the testing Miss A received in her second admission was clinically appropriate for her symptoms, in line with the NICE and GMC guidance above, and results did not show any sign of cancer. This means we cannot say the Trust missed an opportunity to provide a diagnosis of cancer earlier than it did. For this reason, we find no failing in this aspect of the complaint. We hope we have clearly explained how we reached our view staff investigated Miss A’s symptoms in line with the relevant guidelines on this part of the complaint, and that our explanations provide reassurance to her family that there was no missed opportunity here to provide treatment sooner than the Trust did.

Discharge summary

63. We have also considered Miss A’s complaint about the way the Trust communicated her cancer diagnosis to her. She said she found out about this by reading a discharge summary on 25 September and that the Trust should have arranged a discussion to share her diagnosis with her sensitively.

64. In its response to the complaint the Trust accepted the discharge summary was poor and did not accurately capture the correct diagnosis at the point of discharge.

65. The relevant guidance for this aspect of the complaint is the GMC’s Good Medical Practice, Domain 2. Section 28 says doctors must communicate effectively with patients. They must give patients the information they need to know in a way they can understand and include relevant clinical findings on clinical records. Section 23(a) also says good practice means ‘communicating sensitively and considerately, particularly when you’re sharing potentially distressing issues about the patient’s prognosis and care’.

66. Miss A said she found out about her cancer diagnosis by reading the discharge summary on 25 September. We have not seen any evidence that the discharge summary recorded a diagnosis of cancer. Rather, the discharge summary noted ‘suspected lymphangitic carcinomatosis’, meaning Miss A found out that clinicians suspected but had not confirmed the presence of cancer.

67. We recognise Miss A considered staff should have discussed cancer with her prior to discharge. The clinical records show that doctors did not reach a diagnosis of cancer until 2 October. Therefore, we cannot say a doctor should have arranged a sensitive discussion to communicate a diagnosis to her prior to her discharge on 25 September.

68. However, we have identified failings in the Trust’s handling of contents of the discharge letter. GMC’s Good Medical Practice, Domain 3, section 70, makes it clear that doctors must include relevant clinical findings on clinical records. We can see doctors included a possible diagnosis of lymphangitic carcinomatosis on the discharge summary, despite ruling this out via CT scan on 22 September. This meant they entered incorrect clinical findings on Miss A’s records and in turn provided her with an inaccurate discharge summary. This was not in line with Good Medical Practice, and we have found a failing in this aspect of the complaint.

69. Miss A was concerned this inaccuracy meant the Trust missed an opportunity to diagnose her cancer sooner. She considered a delay in diagnosis meant she did not have the option for better treatment and a better prognosis. We have seen no evidence that a delay in diagnosis occurred, meaning we cannot say the Trust’s actions impacted her prognosis or treatment.

70. Miss A said finding out about her diagnosis of suspected lymphangitic carcinomatosis by reading a discharge summary on 25 September caused her significant distress.

71. Miss A contacted a respiratory consultant to query the discharge summary on 26 September. The consultant accepted the summary was poor and said recent scan reports did not mention cancer. They explained her current diagnosis and agreed to alter the discharge summary to reflect this.

72. The consultant also wrote to Miss A on 27 September confirming the correct information, and expedited the outpatient testing she was waiting for, which meant she had a lung biopsy within three days of discharge.

73. It is clear from Miss A’s account of events that she found the incorrect diagnosis distressing. Miss A received the correct information and an apology on 26 September. Our view is that the Trust’s actions caused her distress between receiving the letter on 25 September and speaking to the consultant on 26 September, a period of a day. We have therefore thought about what the Trust has done to put right that distress.

74. When we find a failing led to an impact, we go onto consider what steps the organisation may have already taken to put things right. In considering this, we look at our Principles for Remedy. We also use our Severity of Injustice scale, taken from our Guidance on Financial Remedy.

75. Our scale explains we will consider a case to be level one if we consider the person affected has experienced a low impact injustice such as annoyance, frustration, worry or inconvenience, where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact.  We will usually consider an apology to be an appropriate remedy for these cases.

76. In its response to the complaint dated 5 February 2024 the Trust apologised that staff completed the discharge summary poorly and provided Miss A with incorrect information. It said the doctor who created this had reflected and taken learning from the incident.

77. We consider the failing had an emotional impact on Miss A for around 24 hours. This level of injustice falls on level one of our scale. Given that the Trust has apologised and taken learning, in line with our Principles for Remedy, we consider it has done enough to put right the impact of the failing for Miss A. Therefore, we do not uphold this part of the complaint.

Third admission

78. Miss A returned to hospital for a third time on 30 September. She presented with breathlessness and her oxygen saturations were dropping on exertion.

79. In seeking clinical advice, we understand that there are no specific standards or guidelines on investigating or treating breathlessness. GMC’s Good Medical Practice says doctors must provide a good standard of practice and care. If they assess, diagnose, or treat patients they must adequately assess the patient's conditions, take account of their history and where necessary examine the patient.

80. Miss A’s clinical records show Emergency Department staff assessed her upon arrival. An acute medical unit doctor reviewed the results of that assessment and concluded that Miss A’s symptoms related to the lung problems the respiratory team was already investigating. The doctor planned to continue the steroid treatment she had previously started and refer her back to the respiratory team. Our adviser confirmed this was all clinically appropriate treatment, in line with Good Medical Practice.

81. On 2 October staff received the biopsy report which showed Miss A had cancer, and a doctor explained this diagnosis to Miss A and referred her to the breast cancer oncology team on 3 October. We recognise how deeply upsetting this was for Miss A, who was clearly worried she may have cancer throughout the period of complaint.

82. We understand from our adviser and the evidence available to us that doctors acted promptly on the results of the biopsy and made the appropriate specialist referral, and that no additional cancer tests were indicated during the third admission as Miss A had undergone these and was awaiting results. This was in line with Good Medical Practice, which says doctors must promptly provide or arrange suitable advice, investigations, or treatment where necessary and refer to another practitioner when this serves the patient’s needs. For this reason, we find no failing in this aspect of the complaint.

83. We have not seen any evidence the Trust missed or ignored any signs of cancer during the period of care set out in this complaint. We recognise that Miss A considered the Trust should have diagnosed her cancer much sooner, so we hope these explanations help reassure Miss A’s family we carefully considered all the concerns she raised.

84. With the above in mind, we do not uphold this complaint but hope our independent findings help Miss A’s family to understand what happened.

1. We have carefully considered Miss A’s complaint about East Lancashire Hospitals NHS Trust (the Trust), a complaint which has been continued on her behalf by her father, Mr H. We are very sorry to hear of Miss A’s death on 29 December 2024, and we recognise the significant impact this loss will continue to have for her family.

2. The evidence available to us suggests the Trust investigated Miss A’s symptoms in line with the relevant guidance. We have seen no evidence the Trust’s actions led to a delay in cancer diagnosis. For this reason, we have found no failing in this aspect of the complaint.

3. We have found a failing in the way the Trust generated a discharge summary. The evidence suggests that staff included a diagnosis of suspected lymphangitic carcinomatosis (cancer that has spread to the lungs) despite having ruled this out, meaning Miss A had incorrect information about her diagnosis. The Trust provided Miss A with the correct information within 24 hours of generating the discharge summary.

4. We have not seen anything to indicate this caused a negative clinical impact on Miss A but can see the Trust’s actions caused Miss A distress for around a day. It has apologised and taken learning from this, and so we consider the Trust has already done enough to put right the impact of this failing on Miss A. For this reason, we do not uphold the complaint.