Care and treatment before the MDM
17. Mrs M said her husband was extremely poorly over several weeks. She believes there were opportunities for him to be given treatment to either extend his life or make him more comfortable. She notes he attended the emergency department twice in December 2021, but doctors did not treat him appropriately. She is particularly concerned that no consultants reviewed her husband until January 2022. She believes clinicians at the Trust did not appreciate how unwell he was because they did not see him. She questions whether doctors could have discussed him at an earlier MDM.
18. The Suspected Cancer Guideline outlines how healthcare professionals should identify and respond to symptoms that could be caused by cancer. It includes a series of recommendations based on the site of the suspected cancer. For suspected pancreatic cancer it says clinicians should arrange for a CT scan to be carried out within two weeks. The criteria for this include being aged over 60, having weight loss, abdominal pain and nausea.
19. Good Medical Practice says doctors must provide a good standard of care. This includes carrying out adequate assessments, taking account of the patient’s history and examining them if necessary. Doctors should also arrange effective, and timely, treatment and appropriate investigations or referrals if needed.
20. The RCEM Standard says a consultant in emergency medicine should review certain groups of patients before they are sent home from the department. This includes patients making an unscheduled return to the department with the same condition within 72 hours.
21. The Surgical Adviser told us the surgeon who Mr M spoke to on 10 December 2021 was right to arrange an urgent CT scan. This was done in a timely manner, as was the next appointment on 21 December to discuss the results. We consider this was an excellent level of care in terms of decision making and in obtaining the scan then discussing the results with Mr M. This was in line with the Suspected Cancer Guideline.
22. The Surgical Adviser told us it must be noted that Mrs M’s episode of care happened around the time of the COVID-19 pandemic. This needs to be taken into consideration. The first two outpatient appointments Mr M had were by phone when under normal circumstances they would have been face-to-face appointments.
23. At the complaint meeting the Trust’s representatives said Mr M should have been offered a face-to-face meeting with a clinician at an earlier stage. They were sorry this did not happen. Our view is that there was no requirement in December 2021 for face-to-face appointments to take place. Doctors took appropriate action during the phone appointments, and we cannot see they would have acted differently if they had seen Mr M in person.
24. Mrs M understood her husband was initially supposed to be included in an MDM that took place on 29 December 2021. The Trust explained that this was incorrect because that list had already been closed. It was not possible to include Mr M because time was needed for an independent review of the CT scan from 15 December 2021 to take place. The Trust apologised to Mrs M that she was led to believe her husband would be discussed on 29 December.
25. The Surgical Adviser told us that in planning for an MDM there is a deadline for the submission of cases after which new submissions are not routinely accepted. The reason for this is that the teams involved in the MDM need time to prepare. For example, radiologists need to review scans and pathologists needs to review test results. This allows a detailed discussion of each case so that the clinicians can formulate the best treatment options.
26. In Mr M’s case it is clear the MDM for 29 December 2021 was already full by the time he was advised, in error, that his case would be discussed. He was added to the next MDM list for discussion. We cannot say this amounted to an unnecessary delay. From the evidence we have seen the clinicians appear to have provided timely care and treatment in this respect. They followed Good Medical Practice by adding Mr M to the next available MDM.
27. The clinical records show Mr M attended the Emergency Department at Hospital B on 26 December 2021. He had spoken with an acute oncology nurse beforehand because he had been generally feeling weak and unwell for a few days. On arrival in the emergency department a junior doctors took Mr M’s history and acknowledged there were ongoing investigations for pancreatic cancer.
28. An acute oncology nurse reviewed Mr M in the emergency department. They noted Mr M was satisfied his GP was managing his pain well by changing medication. There was also a discussion with an emergency medicine consultant. The team treated Mr M by giving him intravenous fluids, anti-sickness medication and dexamethasone (a steroid to improve appetite and help with lethargy), which the oncology nurse recommended. The Emergency Medicine Adviser told us this management was appropriate.
29. We consider the clinicians in the emergency department on 26 December 2021 provided appropriate treatment for Mr M. They arranged blood tests and involved relevant specialists. They also documented plans for follow-up and were aware that an MDM was scheduled. They adequately assessed Mr M and arranged the treatment that was necessary. There was a sensible plan and advice to reattend if the symptoms worsened. They followed Good Medical Practice.
30. Mr M next attended the Emergency Department on 29 December 2021. This was almost 72 hours since he left the department on 26 December. Again, an acute oncology nurse advised him to attend. Mr M had no appetite, abdominal discomfort, nausea and vomiting. Clinicians gave him fluids, anti-sickness medication and pain relief.
31. The Emergency Medicine Adviser told us a specialist should have reviewed Mr M in the emergency department. There is no evidence they did so, even though an acute oncology nurse had recommended Mr M’s attendance. There is also no evidence clinicians formulated a management plan to address Mr M concerns on 29 December 2021.
32. Mr M had been unable to eat for three days and was losing weight because of the effects of the pancreatic cancer. The Surgical Adviser told us doctors should have considered admitting him to the hospital as an emergency under the care of the oncology team. This was particularly relevant given Mr M had attended the department with similar concerns three days earlier. It was wrong to send him home without any change to the plan. The Emergency Medicine Adviser agreed and suggested at the very least there should have been a consultant review. Doctors did not follow the RCEM Standard when they did not arrange this review.
33. We find the Trust did not arrange effective and timely treatment for Mr M on 29 December 2021. It should have ensured there was a consultant review within 72 hours. They did not follow Good Medical Practice or the RCEM Standard.
34. The Surgical Adviser said it was likely that a consultant review would have led to a recognition that Mr M was seriously unwell and needed to be admitted. He would then have been seen by the specialist team. The Emergency Medicine Adviser told us steps could have been taken to manage Mr M’s cachexia (this is a condition when there is significant weight loss or muscle wastage).
35. The Surgical Adviser told us that, when patients cannot tolerate oral food or fluids there are a number of options to control symptoms. While the stomach was not obstructed it was not functioning correctly because of pressure from the advanced cancer. The Surgical Adviser said it could have been an option to carry out a gastroscopy and place a naso-jejunal feeding tube (where a tube passes through the nose into the bowels to provide nutrition). This would have bypassed the stomach and allowed Mr M to maintain his nutrition and hydration.
36. Sadly, Mr M had an aggressive cancer. Even with improved management it is likely he would have died within a short timeframe. But, in hospital, healthcare professionals would have attempted to control his symptoms and had discussions with him and his family. It is likely his pain would have been better managed and there would have been a package of supportive care that would have allowed the family to have more time together and given him a more dignified death.
37. The Surgical Adviser also told us that, if Mr M had been admitted to hospital, it is likely the treating team would have recognised he would never have been fit enough for palliative chemotherapy. There would have been no need for him to have a gastroscopy to try and obtain a tissue biopsy, which is what happened at Hospital A on 7 January 2022. It is possible Mr M’s life could have been extended if the gastroscopy had been avoided. But we also recognise it is likely Mr M would have died soon afterwards given the aggressive nature of the cancer.
38. In summary, we find clinicians followed the relevant standards for Mr M up to his second attendance at Hospital B’s emergency department on 29 December 2021. At that point care fell below the relevant standards. Had clinicians followed the standards it is likely they would have admitted Mr M to hospital. There is a possibility this could have extended his life, but only by a short period. But his pain and discomfort would likely have been better controlled. He would not have had to travel to the appointment at Hospital A. Mr M would also have been able to spend more quality time with his family and his death may have been more dignified.
Gastroscopy
39. Mrs M questions whether the gastroscopy was appropriate given how unwell her husband was by that stage. She believes, if the procedure had not gone ahead, she would have been able to spend more time with her husband and that he may have lived longer.
40. There were no specific guidelines about clinical decisions relating to a gastroscopy. Doctors would be expected to follow Good Medical Practice to provide a good standard of care as detailed above. It says doctors must provide effective treatments based on the best available evidence. They should only provide treatment when they are satisfied it serves the patient’s needs.
41. We can see that clinicians at the MDM on 4 January 2022 decided that a gastroscopy was needed to help with diagnosis. They noted the cancer was inoperable. They do not appear to have been aware of Mr M’s attendances at the emergency department. This suggests they were unaware of the deterioration in Mr M’s condition. They made the booking for the gastroscopy before Mr M moved to the hospice.
42. The Trust explained in its complaint response that clinicians at the MDM decided to recommend a gastroscopy because they wanted to confirm the type of Mr M’s tumour. It said oncologists would not have been able to treat the cancer without a biopsy sample.
43. Dr L recalled that he explained to Mr M on the day of the procedure that he was not happy to continue because of the risks attached. He said Mr M wanted to go ahead because he was under the impression that treatment would be available for him. Dr L said he went ahead because of the decision from the MDM and in line with Mr M’s wishes. At the complaint meeting the Trust’s representatives said there was ‘no question that if the procedure had not gone ahead [Mr M] would have lived longer.’
44. Dr L said, in future, he would ensure decisions are made by the team carrying out the gastroscopy and not the patient. He said he would refuse to perform a procedure if he had similar concerns.
45. The Surgical Adviser said if clinicians had known Mr M had moved into the hospice the sensible decision would have been to cancel the gastroscopy and focus instead on controlling symptoms without invasive tests. On the day of the procedure, Mr M was keen to proceed with the gastroscopy but does not appear to have been fully informed of the poor prognosis of the cancer. The Trust argued that a physician at the hospice attempted to discourage Mr M from going ahead with the procedure.
46. Records from the hospice show Mr M had a face-to-face consultation with a physician who was employed there. Mr M asked questions about the prognosis and the physician told him that at best he would live for a number of months and at worst it would be weeks. The physician noted the plan was for him to have the gastroscopy and Mr M said he appreciated this was ‘just to double check the diagnosis.’ Based on the hospice records we cannot see any evidence to suggest the physician discouraged Mr M from having the gastroscopy.
47. Mr M was clearly hoping that chemotherapy would delay the progression of the disease, and this could only have happened with a biopsy. He had also travelled a significant distance to attend the appointment. We can appreciate that Dr L was in a difficult position.
48. Dr L could have contacted the treating team to raise concerns about the planned procedure. Dr L told us this would not have been possible. The Surgical Adviser said If Dr L could not contact the team, he should have delayed the gastroscopy because Mr M was too unwell, and the risks of serious injury or death were too high.
49. The Surgical Adviser explained how, during the gastroscopy, the stomach needs to be inflated with air. In Mr M’s case this led to the tumour becoming separated from the stomach wall, leading to perforation and sepsis. With such an aggressive tumour this perforation could have happened spontaneously at a later date. The tumour might also have eroded into the surrounding blood vessels leading to an acute bleed. There is no way of predicting whether a biopsy will lead to a perforation. But we can say that the decision to carry out the gastroscopy accelerated Mr M’s death.
50. We find the Trust did not provide effective treatment to Mr M as the gastroscopy did not meet his needs. This meant the clinician did not follow Good Medical Practice. This failing meant Mr M died the day after the gastroscopy. Had the gastroscopy not gone ahead the likelihood is that Mr M would have lived a short time longer. It is not possible to say exactly how long.
51. We can also see how, if the procedure had not gone ahead, the focus of the treating team would have been on trying to ensure Mr M was comfortable towards the end of his life. Mrs M and her family would also have been able to spend more time with him.
Travel for the procedure
52. Mrs M says her husband moved into a hospice that was virtually next door to Hospital B. She understands Hospital B has the facilities to carry out a gastroscopy. Despite this she says staff from the Trust made him travel 36 miles to Hospital A for the gastroscopy. By this stage her husband was seriously unwell, and the journey was traumatic for him.
53. There are no specific standards or guidelines that apply to this part of Mrs M’s complaint. As we have explained above, Good Medical Practice says doctors must provide a good standard of care. The MDM was led by a doctor.
54. The representatives at the complaint meeting agreed that Mr M could have had the gastroscopy at the Hospital B. They said he should not have had to travel to Hospital A and apologised to Mrs M.
55. We can see the clinicians at the MDM on 4 January 2022 had already planned for Mr M to attend the gastroscopy appointment before he moved to the hospice. At that point they were unaware of the recent deterioration in his health. They could not have anticipated how distressing the journey would have been for Mr M.
56. The Surgical Adviser told us that patients awaiting a gastroscopy are always offered the first available appointment. If they cannot attend that appointment, they would then be offered the hospital they would prefer. Mr M agreed to attend the appointment at Hospital A, which was the earliest available appointment.
57. We cannot be critical of the clinicians at the MDM who offered Mr M the first available appointment for a gastroscopy, based on the information that was available to them at that time. We can appreciate how distressing the journey was for Mr M and how this was worrying for his family. We find the clinicians followed Good Medical Practice.
Communication
58. Mrs M says poor communication meant it was not possible for her and her sons to say goodbye properly. She says the records suggest the cancer was inoperable but says this was never explained at the time to her husband or his family.
59. Good Medical Practice says doctors must give patients the information they want or need to know. It also says they must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
60. We can see little evidence of communication from clinicians to Mr M and his family. Clearly, Mr M’s condition progressed rapidly from the time he received his diagnosis. This meant there were limited opportunities for conversations with a doctor.
61. On 21 December 2021 there was appropriate communication from the doctor. They explained to Mr M that the recent scan showed a concern ‘that could potentially be cancer.’ They said the prognosis would depend on test results.
62. We can see Mr M had discussions with an oncology nurse specialist around the time of his attendances at the emergency department. But records from those attendances clearly say Mr M ‘is not fully aware of the outcome or prognosis.’
63. At the MDM on 4 January 2022 one of the actions was for a cancer nurse specialist to update Mr M. At that stage the clinical team knew Mr M’s cancer was inoperable and, at best, he could have been offered palliative chemotherapy. There is no evidence to suggest this conversation happened. Evidence from the hospice suggests Mr M was still unaware of the prognosis when the physician there reviewed him the day before the gastroscopy.
64. The Surgical Adviser told us the plan was likely to have been to discuss treatment options once the biopsy results became available. This is normally a sensible approach. But the team was unaware of how unwell Mr M was and so did not appreciate the urgency of communicating with him and his family. Had Mr M been admitted to hospital, as should have happened by 29 December 2022, it is likely that clinicians would have been able to have a direct conversation with the family.
65. We agree with Mrs M that there was poor communication from doctors at the Trust. This fell below Good Medical Practice. They should have ensured they gave Mr M, or his family, an explanation about the likely outcome for Mr M following the MDM on 4 January 2022. Had they known the cancer was inoperable the family would have been able to prepare themselves for Mr M’s death and ensure they were able to spend more time with him towards the end of his life. We can see how this continues to be a source of distress for Mrs M and her family.