Great Western Hospitals NHS Foundation Trust

9. Miss A complains about care provided to her mother, Mrs A, by the Trust. She says the Trust delayed performing a CT scan from 20 August to 12 September 2023.

10. Miss A says as a result of the delay she and the family were denied the opportunity to be properly informed about the progression of Mrs A’s cancer and understand her prognosis sooner.

11. She says they had to watch Mrs A go through unnecessary chemotherapy which caused her mother to be very poorly, and she missed out on earlier palliative care to relieve symptoms and suffering. She says this resulted in a poorer quality of life in her mother’s final months, and knowing this has added to the family’s distress and frustration.

12. Miss A is seeking service improvements and financial remedy.

13. This background is only intended to place the key events related to this complaint in context, not to provide a full, chronological account of everything that happened.

14. Mrs A was a 62-year-old woman who suffered from breast cancer. Since 2022, Mrs A had been receiving cancer treatment at the Trust.

15. On 21 August 2023, Mrs A presented to the Trust with excessive vomiting and nausea. On 24 August, Mrs A was discharged.

16. On 31 August, Mrs A presented to the Trust with nausea and vomiting. On 1 September, Mrs A was discharged.

17. On 6 September, Mrs A presented to the Trust with nausea and fatigue. On 9 September, Mrs A was discharged.

18. On 11 September, Mrs A presented to the Trust with excessive vomiting and nausea.

19. On 12 September, the Trust performed a CT scan on Mrs A. The scan revealed Mrs A’s cancer had progressed.

20. On 14 September, Mrs A’s family were informed of her prognosis and that she had around six weeks left to live.

21. On 15 September, Mrs A left hospital and very sadly died on 19 September.

26. We will now consider whether the Trust delayed performing a CT scan on Mrs A from 20 August to 12 September 2023.

27. Our adviser said there are no specific guidelines on when a scan should be performed in Mrs A’s circumstances. The relevant standard is therefore the GMC’s ‘Good Medical Practice’, which sets out the principles and standards expected of all clinicians.

28. Section 15 of ‘Good Medical Practice’ says clinicians should ‘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’.

29. From Mrs A’s medical records, we can see she presented to the Trust on 21 August with excessive nausea and vomiting. Our adviser said Mrs A had coffee-ground vomiting (blood in vomit) due to a potential tear in the stomach muscle.

30. Our adviser said Mrs A also suffered from peritoneal disease which can cause intermittent obstruction in the bowel and nausea. Mrs A had also started to accumulate fluid around her abdomen (ascites) and her liver function tests had started to deteriorate.

31. Our adviser said given Mrs A’s condition and symptoms, in line with section 15 of ‘Good Medical Practice’, it would have been good clinical judgement to perform a CT scan during this admission.

32. From the records, we can she was not referred for a CT scan during this admission and was discharged on 24 August. We therefore found the Trust has not followed section 15 of the GMC’s ‘Good Medical Practice’.

33. From the records, we can see Mrs A was readmitted on 31 August with nausea and vomiting. Our adviser said Mrs A had fluid in the abdomen which was drained on 1 September.

34. Our adviser said given Mrs A’s condition and symptoms, in line with section 15 of ‘Good Medical Practice’, it would have again been good clinical judgement to perform a CT scan during this admission too.

35. However, regrettably Mrs A was not referred for a CT scan during this admission and was discharged on 1 September. We have therefore found Trust has not followed section 15 of the GMC’s ‘Good Medical Practice’.

36. From the records, we can see Mrs A was readmitted on 6 September with symptoms of fatigue and nausea. Our adviser said given Mrs A’s condition and symptoms, in line with section 15 of ‘Good Medical Practice’, it would have been good clinical judgement to perform a CT scan during this admission.

37. From the records, we can see Mrs A was not referred for a CT scan during this admission and was discharged on 9 September. We therefore again found the Trust has not followed section 15 of the GMC’s ‘Good Medical Practice’.

38. From the records, we can see Mrs A was readmitted on 11 September with nausea, vomiting, and abdominal distention (swollen abdomen). On 12 September, the Trust performed a CT scan, which unfortunately revealed her cancer had spready significantly.

39. Sadly, Mrs A was given weeks to live. We can only imagine how shocking and upsetting this news was to Miss A and her family. We are truly sorry to hear of their experience.

40. Mrs A was discharged on 15 September and very sadly died on 19 September.

41. In summary, we have found the Trust should have performed a CT scan during the admissions from 21 to 24 August, 31 August to 1 September, and 6 to 9 September. However, the Trust did not perform a CT scan until 12 September. We have therefore found the Trust delayed performing a CT scan by approximately three weeks between 20 August to 12 September.

Impact

42. We will now consider the impact of the failing identified and whether we can link it to the injustices claimed. We will consider what would have likely happened if a CT scan had been performed during the three admissions between 21 August to 9 September.

43. Miss A says her and her family had to watch Mrs A go through unnecessary chemotherapy, which caused her mother to be very poorly. From Mrs A’s medical records, we can see her last chemotherapy session was on 17 August, and she did not receive any more chemotherapy after this point.

44. Our adviser said Mrs A’s symptoms during the three admissions between 21 August to 9 September, were likely due to the rapid progression of her cancer rather than the effects of chemotherapy. We therefore cannot link this injustice to the failing found.

45. Our adviser said if a CT scan had been performed during the three earlier admissions, it could have revealed the progression and prognosis of Mrs A’s cancer earlier. It is therefore likely Mrs A’s family could have been better informed of Mrs A’s prognosis and could have prepared better for the end of her life.

46. Our adviser said if a CT scan had been performed during the three earlier admissions, it could have confirmed the progression of Mrs A’s cancer and palliative care could have been started earlier, which could have improved Mrs A’s quality of life in her final weeks to a degree and removed the need for further hospital admissions.

47. We understand Mrs A’s wish was to pass away in a hospice. We also consider if the CT scan was performed earlier, this may have provided the opportunity for Mrs A to explore the possibility of a hospice.

48. We can see it was very distressing for Miss A and her family seeing how poorly Mrs A became, and we understand her sudden decline came as such a dreadful shock.

49. We consider the injustices we have identified would have added significant emotional distress, upset, and frustration to Miss A and her family, adding to their bereavement. We also consider the family have been left with unanswered questions about whether she could have received different care and treatment.

1. We were very sorry to learn the reasons for Miss A’s complaint and about her mother’s tragic passing. We would like to express our heartfelt condolences to Miss A and her family.

2. Following our careful consideration of the comments received, we have decided we are partly upholding Miss A’s complaint.

3. We have found the Trust delayed performance of a CT scan on Mrs A between 20 August to 12 September 2023.

4. We cannot say the Trust’s delayed performance of a CT scan led to unnecessary chemotherapy.

5. However we have found if the Trust had performed a CT on scan on Mrs A during her three admissions prior to 12 September, Miss A and her family could have been better informed of Mrs A’s prognosis and the progression of her cancer, which could have helped them prepare for the end of her life better.

6. We have found Mrs A missed out on approximately two to three weeks of palliative care which would have improved her quality of life during her final weeks to a degree. Mrs A could have been cared for at home or may have been able to explore admission to a hospice and avoided further hospital admissions.

7. We consider these injustices would have caused added emotional distress and frustration to Miss A and her family adding to their bereavement. We also consider the family were left with unanswered questions about whether Mrs A could have received different care and treatment.

8. We can see the Trust has already gone some way in its handling of Miss A’s complaint to address its failing. However, we have made an additional recommendation it pays Miss A £1000 in recognition of the distress caused.

50. We will now consider what Miss A is seeking and what action the Trust has taken to remedy Miss A’s complaint. The ‘Principles for Remedy’ is guidance for organisations to handle complaints properly.

51. We make recommendations in line with our ‘Principles for Remedy’ which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

52. Our principles are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

53. In its final response the Trust acknowledged it should have performed a CT scan on Mrs A earlier. It has also acknowledged the impact of this and apologised.

54. It has also taken learning that it would be unusual for the dose of docetaxel to cause the level of vomiting Mrs A had, which will inform future patients’ care so that other causes of vomiting can be investigated quicker.

55. It also said the learning it has taken from Miss A’s complaint has been shared with the Breast Cancer Clinical Nurse Specialists and the Acute Oncology Clinical Nurse Specialists.

56. We are reassured the Trust has taken learning from Miss A’s complaint in line with our ‘Principles for Remedy’ and we are not proposing to make any further recommendations to the Trust in this regard.

57. However, we do not feel the Trust’s actions have gone far enough in recognising the impact these issues have had on Miss A and her family.

58. We cannot change what happened, however we consider the Trust should pay Miss A a financial remedy in recognition of the distress the failing caused.

59. To decide on a level of financial remedy, we review similar cases where the person has experienced similar injustice, along with our severity of injustice scale.

60. Following this review, we consider the Trust should pay ​Miss A​ £1000 in recognition of the distress of the failure to refer Mrs A for a CT scan caused her. The Trust should make this payment within 30 days of the date of the final report.

61. We would again like to express our heartfelt condolences to Miss A and the rest of her family. We cannot imagine how difficult it has been for her to raise her concerns with us, and we would like to thank her for giving us the opportunity to investigate her complaint.