Nottingham University Hospitals NHS Trust

4. Mr F complains the Trust failed to quickly diagnose the return of his wife’s cancer. He says despite Mrs F being admitted to the Trust five times in 2021 for breathing problems and reporting chest pain and weight loss, the Trust repeatedly and wrongly thought she had ongoing chest infections. Mr F says the Trust should have done more, different and quicker investigations and if it had, it would have found the cancer had come back.

5. Mrs F’s cancer was diagnosed in October 2021. Mr F says if his wife’s cancer had been diagnosed sooner, she may have lived longer and could even still be alive today. Mr F misses his wife every day and he says what has happened has left him very upset, angry and confused.

6. Mr F would like the Trust to acknowledge its failings and to apologise for the impact. He would like lessons to be learned and for improvements to be made to make sure this does not happen to anyone else. Mr F also wants a financial payment to recognise the impact on him.

7. Mrs F was in her seventies at the time. She had a long-standing diagnosis of chronic obstructive pulmonary disorder (COPD is a progressive lung disease) and had been treated for squamous cell carcinoma (a type of cancer) of the lung in 2017. Mrs F also had a chronic infection called aspergillosis (a fungal infection caused by a common mould) in one of her lungs. She had a 12-month treatment course for this from April 2019 to April 2020, with treatment restarting in July 2020.

8. Before any of Mrs F’s admissions to the Trust in 2021, she was seen in a respiratory clinic. A clinic letter noted some shortness of breath (SOB) with recent weight loss, but an otherwise good appetite. A second clinic letter noted Mrs F had regained 5kg she had lost before and that she often had breathlessness and a productive cough (one producing phlegm).

9. The first admission was from 7 to 12 June 2021. Records note Mrs F was admitted with increased SOB and a cough. A chest X-ray showed patchy consolidative changes in her right upper lung. Consolidation is a term used to describe an area on X-ray that seems dense and white and is often the sign of fluid or inflammation (swelling) from infection. Mrs F had raised inflammatory markers (blood test results that show inflammation) in the blood and was treated with antibiotics for pneumonia (inflammation of the lungs usually caused by an infection). A letter after her discharge home says Mrs F was underweight and the aim was to increase her eating to help with weight maintenance.

10. The second admission was from 5 to 9 July. Records say Mrs F was admitted with a two to three-week history of worsening SOB, reduced exercise tolerance and chest pain. Her main diagnosis was pneumonia. A CT scan (a scan to show detailed images of inside the body) showed superadded acute infection (a secondary infection developing in a person who already has another infection). The Trust gave Mrs F intravenous antibiotics (through the veins) and because she was still underweight, a referral was made to improve her nutrition.

11. The third admission was from 3 to 12 August. Records note Mrs F was admitted with a two-week history of SOB and with a main diagnosis of superadded cavity fungal infection. Clinicians noted a plan for Mrs F to have a bronchoscopy if her sputum (phlegm) sample came back negative and if they saw no improvement to antibiotic treatment. A bronchoscopy is a procedure where a tube with a light and camera on the end is inserted through the nose or mouth, to let clinicians look at the lungs and air passages. The next day, clinicians noted that a chest X-ray was taken. As this showed improvement, the bronchoscopy did not go ahead.

12. The fourth admission was from 23 August to 10 September. Records note Mrs F was admitted with hallucinations after starting a different type of antibiotic. Her unresolved aspergillosis with superadded infection is noted. A bronchoscopy was done on 2 September that found an obstruction in part of the right lung. A chest X-ray was taken on 3 September and compared with the chest X-ray images taken in August, that showed no changes to this part of the lung and no new lesions.

13. The lung cancer multidisciplinary team (MDT is when a group of clinicians from different areas of medicine meet to discuss a patient) discussed Mrs F’s case on 17 September. They noted that bronchoscopy results found no malignant (cancerous) cells. The MDT recommended continuing Mrs F on her medication, to repeat aspergillus investigations and a CT scan and to take a ‘watch and wait’ approach.

14. The fifth admission was from 26 September to 19 October. Ambulance records note Mrs F’s extensive COPD and chest history and that she felt worse that day, collapsing to the floor when Mr F helped her out of the bath. Admission records note Mrs F had reported significant weight loss since her last discharge on 10 September, overall 6kg in four years. Mrs F reported chest pains and the plan included another CT scan, sputum sampling and continuing antibiotics.

15. On 29 September a consultant radiologist noted some erosion of the rib seen in the repeated CT scan images. Another chest X-ray was taken on 7 October and a consultant noted it was likely Mrs F’s cancer had come back. Oncology (cancer) advice was taken, leading to another referral to the lung cancer MDT, where cancer was confirmed. The diagnosis was explained to Mrs F on 14 October and a palliative care referral was made and fast-tracked. Very sadly, Mrs F died in November.

19. Mr F’s main concern is that the Trust kept saying Mrs F was suffering from repeat chest infections.

20. Looking through each admission in 2021, Mrs F typically had a combination of breathlessness and a cough, and at times with chest pain and weight loss. We think it was reasonable for the Trust to put these symptoms down to the three conditions Mrs F was known to have. This conclusion was in line with BMJ guidance on COPD that explains:

‘Patients with COPD may also present with acute, severe shortness of breath, fever, and chest pain during acute infectious exacerbation.’

‘Weight loss, muscle loss, and anorexia are common in patients with severe and very severe COPD.’

21. The BMJ guidance says this about pneumonia:

‘Pneumonia is inflammation of the lungs...Typical symptoms might include fever, cough, dyspnoea, and chest pain.’

22. The BMJ guidance says this about aspergillosis:

‘Invasive pulmonary aspergillosis presents with fever, mild to moderate non -productive cough, and pleuritic chest pain.’

‘Occasionally, weight loss, chronic cough, and malaise may occur.’

23. From what we have seen, the Trust considered Mrs F’s symptoms fully, taking into account her overall health. We appreciate the symptoms can suggest cancer. As seen in the guidance above, these are also symptoms of the three conditions Mrs F was known to have.

24. Mr F says the Trust should have done more to investigate. Our adviser confirms the Trust did appropriate investigations throughout each admission. This included observations of vital signs, physical examinations and clinical ward round reviews, blood tests, CT and X-ray scans. This was in line with GMC guidance that says:

‘You must provide a good standard of practice and care.

If you assess, diagnose or treat patients, you must: a) adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient b) promptly provide or arrange suitable advice, investigations or treatment where necessary’.

25. Records show on each admission Mrs F had blood samples taken and tested. These showed raised white blood cells and C-reactive protein levels, which are both markers of inflammation in the blood. These markers are raised when a person has an inflammatory condition like an infection. Considering this, our adviser says the Trust appropriately diagnosed Mrs F with a superadded bacterial infection.

26. The different scans showed Mrs F had a cavity in the lung and in this she had aspergillus fungus, that had developed into aspergillosis. Our adviser explains this conclusion is supported by evidence at the August admission where Mrs F’s case was discussed with the consultant microbiologist, who reviewed all her CT scans and X-rays. They found the results in keeping with the conclusion of a superadded bacterial infection.

27. Our adviser says Mrs F’s chest pain and weight loss symptoms did not suggest any need for further investigation, when considering other results including blood testing and imaging, which were all in keeping with her diagnosed conditions.

28. We know Mr F is also concerned that the bronchoscopy was not done sooner. Our adviser explains this was done to explore the infection by taking samples, to better help clinicians prescribe the most effective medication to treat Mrs F’s infection. The bronchoscopy was not done to specifically look for cancer and there was no need for this. At the time it was taken, there was no clinical evidence to suggest possible cancer.

29. Bronchoscopy results did not find any visible evidence of cancer within the airways and the samples taken did not report any malignant cells. This together with all the scans taken during 2021, did not show any sign of any cancer. We see nothing to suggest an earlier bronchoscopy would have proved anything different.

30. The MDT in mid-September reviewed all scans and had the bronchoscopy results. It found that Mrs F’s most recent CT scan showed a large thick-walled cavity, which had been there since 2019. This was when her aspergillosis was first diagnosed and so again, this finding was in keeping with the diagnoses Mrs F already had.

31. On 29 September, the consultant radiologist reviewed the most recent CT scan, noting some erosion of the rib. This was the first clear sign of something that did not relate to the diagnoses Mrs F had and showed a possibility of cancer. Our adviser explains rib erosion can be quite subtle on a CT scan. There is nothing in the recorded evidence to show any clear sign that the cancer had come back, but the Trust missed this. Records show as soon as this first sign was found (erosion of the rib), the Trust acted quickly and Mrs F’s cancer was found soon after.

32. We understand why Mr F has concerns. Our adviser says it is well known that people with lung conditions including COPD, pneumonia and aspergillosis, experience repeated chest infections.

33. We have not seen anything to suggest any failure by the Trust. Our adviser says there was nothing to clinically suggest the need for any more investigations to be done until the rib erosion was found. This was the first sign of something more serious. We hope this information assures Mr F.

1. Mr F complains Nottingham University Hospitals NHS Trust (the Trust) failed to quickly diagnose the return of his wife’s cancer in 2021. Mrs F sadly died in November 2021. We are very sorry to hear this.

2. From the evidence we have carefully considered, we do not think the Trust did anything wrong when Mrs F was admitted in 2021. We have seen evidence that her symptoms were all reviewed and reasonably put down to the three lung conditions she was known to have. We have not seen anything to suggest the Trust should have done more or that it missed an opportunity to find the cancer earlier.

3. For these reasons, we are not investigating further. We know how important this complaint is to Mr F and how much this experience has had an impact on him. We are very sorry to hear about his distress and we appreciate the details he kindly shared with us.