15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong. We will explain the reasons for our decision in more detail below.
Failure to carry out a biopsy and delayed diagnosis of cancer
16. Mr R was under regular follow up by the Trust due to his throat narrowing and scarring. Mrs H is concerned her husband’s throat cancer was not detected at any of these appointments until April 2023. She is concerned the Trust dismissed any changes seen as scar tissue, and failed to perform a biopsy.
17. The notes show Mr R was seen by the ENT team regularly between March 2021 and April 2023.
18. In March 2021, he was examined and found to have a narrowing of his throat. In April 2021, Mr R had a camera investigation of his throat with laser treatment of the narrowing. He had this procedure again in October 2021.
19. On examination in March 2022, the notes indicate a definite improvement in the narrowing on flexible nasendoscopy (FNE- a thin camera inserted through the nostril to examine the nose and throat).
20. In June 2022, Mr R had an examination of his throat by ENT, and a camera test of his swallowing and voice by Speech and Language therapists. There was no evidence of cancer documented on this examination.
21. In August 2022, the Trust examined Mr R’s throat and the narrowing had not returned. Staff discussed a further examination, but he was not keen to proceed as his symptoms were not bothering him enough.
22. In December 2022, he was seen again and it was noted his narrowing had returned. He had been discussed in the Multidisciplinary Team Meeting and the outcome was that his symptoms of difficulty swallowing were unlikely to improve. He was given the number for the nurse specialist if things got worse and laser treatment was needed again.
23. On 3 April 2023, he attended the Emergency Department with a sore throat and left sided neck swelling. He was seen by ENT who arranged an urgent MRI of his neck. This suggested cancer.
24. We have seen videos of the FNEs performed on 26 May 2021, 8 June 2022 and 5 April 2023. Our ENT adviser reviewed the videos, photos and written documentation of each of Mr R’s attendances.
25. Our ENT adviser explained the videos of May 2021 and June 2022 show no evidence of a tumour, but it is present on the video of April 2023. From this, it is clear the tumour developed between June 2022 and April 2023.
26. We have reviewed the documentation of examinations between June 2022 and April 2023 and there is nothing to suggest the suspicion of a tumour. The descriptions are that of narrowing, rather than bleeding or a lump that would be expected with a tumour.
27. Our ENT adviser explained there is no specific guidance related to performing a biopsy, but standard practice would be to not perform routine biopsies unless something abnormal was seen.
28. Our ENT adviser explained Mr R had narrowing of his throat. On occasions, lasers were used to stretch the tissues and relieve this narrowing. Nothing was ever identified in his throat as looking abnormal and needing to be removed or biopsied.
29. GMC guidance says at 15b: ‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must promptly provide or arrange suitable advice, investigations or treatment where necessary.’
30. Our ENT adviser’s view, which we share, is that the Trust acted in line with GMC guidance as no further investigations by way of biopsy were deemed necessary for Mr R until April 2023.
31. Mrs H is concerned there are missing videos of her husband’s FNEs as she recalls seeing most his examinations being recorded.
32. We spoke to the Trust regarding this. It explained most of the scopes in the department are for live examination only and do not have a recording facility, but one of them does. Whether the examinations are recorded or not depends on machine availability. For all examinations there is a full written note made on the patient’s records.
33. We checked this with our ENT adviser and they confirmed, although it varies across Trusts, generally all videos are not stored. They confirmed the written documentation in Mr R’s notes was sufficient to establish the findings of each examination.
34. Once the neck lump had been identified on 5 April 2023, the Trust’s plan was to perform an urgent MRI scan and possible biopsy. The MRI took place on 20 April 2023 and the biopsy took place on 23 May 2023.
35. The government pledge of waiting times says there should be a maximum 62 day wait from urgent referral for suspected cancer to first treatment, and that patients waiting for a diagnostic test should be waiting less than six weeks.
36. Mr R’s MRI took place 15 days after cancer was first suspected, well within the guidance for a diagnostic test. His biopsy was carried out as soon as he was fit and well enough to tolerate it. Our adviser commented there was no delay in the biopsy as this required him to be well enough to tolerate the procedure. This was done at the first opportunity it was safe to do so.
37. Our ENT adviser commented that when cancers develop after treatment for a first cancer, these tend to be more aggressive, which explains the quick progression of Mr R’s cancer when it was identified.
38. Overall, we see no indications the Trust could, or should, have diagnosed Mr R’s cancer any earlier than it did. We appreciate Mrs H’s concerns that something may have been missed, but we hope she can be reassured that the Trust acted in line with guidance. There is nothing to indicate it could have made the diagnosis sooner.
Discharge on 28 April 2023
39. Mr R was admitted to the Trust on 19 April 2023 with sudden onset groin pain. He was admitted for a suspected infected hip, but diagnosed with gout after tests showed no infection.
40. On 27 April, he had a chest x-ray showing shadows that could be consistent with infection. On the same day, the Trust stopped his antibiotics. The Trust discharged him home on 28 April. A week later, he was readmitted with pneumonia.
41. Mrs H is concerned her husband should not have been discharged home on 28 April.
42. Our physician adviser told us the government guidance on hospital discharge applies here. Annex D sets out the criteria to consider if a patient can be considered for discharge. If the answer to each question is no, active consideration for discharge must be made.
43. Mr R did not require high dependency care, oxygen therapy, iv fluids or iv medications. His NEWS score was not greater than 3 and he did not have a reduced level of consciousness. He did not have an acute functional impairment or in the last hours of his life. He had no recent invasive procedures.
44. Our physician adviser explained there is often a lag between the clinical picture and x-ray findings. They explained the most important consideration of whether someone can be discharged home is their clinical condition. Mr R’s NEWS score (indication of how unwell someone is from their observations) was 2. His blood markers of infection were improving, and he had completed a course of antibiotics. Therefore, Mr R would not be kept in hospital on the basis of his chest x-ray alone.
45. A physiotherapist assessed Mr R on 26 April and found he was functionally close to his condition prior to admission. They confirmed his family were happy for him to return home, and no additional support was needed. The nursing notes on 28 April indicate Mr R’s discharge was discussed with him and his family, and they raised no concerns at the time.
46. Based on his clinical condition on 28 April, we agreed with our physician adviser’s view that Mr R’s discharge was justified, safe and in line with guidance.
47. We understand Mrs H’s concerns given Mr R’s deterioration a week later. However, we see no indications the Trust acted outside of guidance in discharging him home on this day.
Failure to act on low oxygen on 15 May 2023
48. On 4 May 2023, Mr R was admitted to the Trust with pneumonia. On 14 May 2023, Mr R was moved to a new ward. Overnight, he became unwell and in the early hours of 15 May, he struggled to breathe and required an emergency tracheostomy.
49. Mrs H says she reported her husband’s low oxygen levels on the morning of 15 May, but nursing staff did not act quickly enough in calling the emergency buzzer. We can see how distressing this must have been for Mrs H to witness.
50. On the evening of 14 May, in response to Mr R’s high NEWS score, nurses contacted the doctor or nurse practitioner, at 9pm, 11.35pm, 2.41am and 3.11am. Each of these incidences resulted in Mr R being prescribed medication, fluid or oxygen appropriate to his condition.
51. On the morning of 15 May, Mrs H reports Mr R was shivering and unable to breathe. She reported calling the nurse and asking her to call the doctors. She explained the nurse changed the oxygen mask but did not call a doctor. She said a few minutes later, her husband’s eyes rolled up, his oxygen level fell to 70% and a nurse came in to pull the emergency buzzer.
52. We reviewed Mr R’s medical records. On the morning of 15 May, his NEWS score was 4 at 5.55am. The retrospective nursing notes indicate Mrs H alerted the nurse to Mr R’s breathing at 6.35. The nurse noted his oxygen saturations were 84%, increased the delivery of his oxygen via a different mask, and his oxygen levels improved to 93%. They informed the nurse in charge.
53. Our physician adviser explained the Royal College of Physicians report is relevant in this situation. It says at section 12: ‘We recommend that these triggers should determine the urgency of the clinical response and the clinical competency of the responder(s). A low NEW score (1–4) should prompt assessment by a competent registered nurse or equivalent, who should decide whether a change to frequency of clinical monitoring or an escalation of clinical care is required.’
54. NICE CG50 says at section 1.10 a graded response strategy for patients at risk of deterioration should be used. For the low-score group, the actions are ‘Increased frequency of observations and the nurse in charge alerted.’
55. Our physician adviser confirmed the nurse took appropriate steps to take immediate action. They increased Mr R’s oxygen supply and escalated the matter to the nurse in charge in a timely manner. This was in keeping with the guidance above.
56. When Mr R became more unwell at 7am, the emergency buzzer was pulled and medical staff attended immediately. Again, this was appropriate and in line with the guidance.
57. We recognise this situation was upsetting for Mrs H as her husband became very unwell. We appreciate she is severely impacted by what happened to her husband. We hope she can be reassured by our view, which is that the Trust did not fail to act in a timely manner to Mr R’s oxygen levels.