Treatment of prostate cancer
24. Ms T complains Mr R was only offered hormone therapy to treat his prostate cancer. She says other treatment options may have been available and should have been explored.
25. In March 2020, Mr R was diagnosed with grade four prostate cancer, which is the most advanced and aggressive stage of prostate cancer.
26. Mr R was referred to the palliative care team for symptom and pain control whilst his case was discussed by clinicians. On 3 April the urology multi-disciplinary team met and decided to treat the cancer with hormone therapy. The team decided to start with a form of hormone treatment called luteinizing hormone releasing hormone (LHRH).
27. Prostate cancer starts in the male prostate gland and is driven by the male hormone, testosterone. Hormone treatment, such as LHRH works to lower or stop testosterone reaching the prostate cancer cells which can stop or slow the cancer growth.
28. Mr R agreed with the treatment plan and started LHRH treatment at the beginning of April 2020 and was given leuprorelin alongside enzalutamide, which are forms of LHRH treatment and works to lower testosterone levels. Mr R showed intolerance to enzalutamide, so in September 2020, this was changed to abiraterone which is a similar medication used to control testosterone levels.
29. In July and October 2021, Mr R also underwent radiotherapy to specifically treat the cancer that had spread to his bones. During the radiotherapy treatment, the records show Mr R continued with the hormone therapy with the aim of slowing the growth of the cancer in the prostate.
30. The BNF says enzalutamide and abiraterone are recommended options for treatment of prostate cancer in patients who have mild symptoms and before chemotherapy is indicated.
31. NICE guidance on prostate cancer says clinicians should offer androgen deprivation therapy (hormone therapy) to patients with stages 2,3,4 and 5 of prostate cancer for up to six months before, during or after radiation therapy.
32. The same NICE guidance also says clinicians can offer chemotherapy in the form of docetaxel to patients. It says whilst there are benefits to this chemotherapy treatment, the risks should be considered.
33. During an appointment on 23 March 2020, we can see the Trust initially recommended hormone replacement therapy over chemotherapy because of the risks involved of commencing chemotherapy during the Covid-19 pandemic.
34. Our oncology adviser explained at the time clinicians had prioritise treatments which posed the least risk to patients. We note that chemotherapy weakens someone’s immune system leaving them more vulnerable to disease and infection and this needed to be taken into consideration by clinical staff when offering treatment at the start of the pandemic when the effects of Covid-19 was still unknown.
35. Our adviser explained hormone therapy was an appropriate choice of treatment when considering the risk of chemotherapy to Mr R. They also added hormone treatment usually has a positive effect on controlling prostate cancer.
36. We have found the Trust weighed up the benefits and risks of offering hormone therapy and deciding not to offer chemotherapy in March 2020 because of the risks to Mr R’s overall health and immune system. In addition, this is in line with NICE guidance on the treatment of prostate cancer and reflects the difficult situation at the time. We therefore think the Trust appropriately offered LHRH as the first line treatment for the prostate cancer.
37. We have thought about other options to treat Mr R’s prostate cancer, having taken into account that he later fell and broke his left leg. We can see he underwent LHRH and later radiotherapy once the cancer had spread to his bones.
38. Our oncologist adviser explained zoledronic acid is commonly used as a treatment alongside other medications for prostate cancer. Zoledronic acid is a form of bisphosphonate, which are a group of medicines used to help strengthen bones and reduce the risks of breaks and fractures.
39. The BNF says zoledronic acid can be used in patients with cancer in the bones.
40. NICE guidance on prostate cancer says clinicians should consider bisphosphonates to prevent or reduce skeletal events. It also says bisphosphonates can be considered to help with pain relief.
41. In addition, the EAU says patients should be offered bone protective agents in cases where prostate cancer has progressed after initial hormone treatment and there are metastases in the bones.
42. We have seen evidence that shows Mr R was prescribed alendronic acid, calcium and vitamin D in May 2021 and he continued this until September 2021.
43. The Trust prescribed zoledronic acid on 18 October 2021, following Mr R’s fall where he suffered a fracture.
44. Alendronic acid and zoledronic acid are both bisphosphonate medications.
45. Our oncology adviser explained that the use of these medications are important as they may have reduced the risk of complications of the bone metastases, such as fractures. They told us bisphosphonates are used as a complementary medication alongside other cancer treatment to reduce the risk of pain and weak bones.
46. The Trust also told us since this complaint, it now also offers scans to assess the presence of osteoporosis (a disease that causes weak bones) in all patients receiving long term hormone treatment.
47. We are sorry Mr R went onto suffer a fall resulting in a fracture, we hope to reassure Ms T appropriate treatment was given to reduce the chances of this.
Communication about cancer spreading to the brain
48. Ms T says Mr R was told cancer had spread to his brain whilst alone in November 2021. She says the family had specifically asked for news of this nature not to be given directly to Mr R on his own because of the effect on his mental health and his ability to retain and process important information.
49. On 8 November 2021, Mr R was noted to be suffering with headaches, fever and vomiting. Staff recorded he had deteriorated and considered whether Mr R was suffering with an infection or that the cancer had spread to his brain.
50. The Trust carried out a CT scan on the same day to investigate the causes of Mr R’s new neurological symptoms. The records show Ms T had specifically told staff Mr R was struggling to retain information and asked for them to update her on the results of the CT scan, which Mr R consented to.
51. Mr R was transferred to the Emergency Assessment Unit (EAU) on 8 November where the CT scan took place and was reported at 20:32pm. The results showed meningeal metastases, which means cancer cells had spread to the thin tissue layers covering the brain.
52. We can see Mr R was seen by a registrar at around midnight on 9 November and the Trust decided to move him from the EAU back to the orthopaedic centre for further assessment and discussion.
53. The records do not show whether Mr R was given specific information about the findings of the CT scan during the conversation at around midnight. However, he told staff in the morning of 9 November that he had still not ‘taken in the news of the scan’. This indicates Mr R knew about the results when he was seen during the transfer to between wards after the results of the scan.
54. We can see various entries in the notes prior to the scan that state Mr R was struggling to retain information and was confused. We have also seen evidence Mr R had specifically asked for Ms T to be present when ‘news was broken’. We have also seen clear evidence Mr R had heavily emphasised his wishes to be given important information with Ms T present before the CT scan took place.
55. GMC guidance says doctors should communicate sensitively and considerately, especially when sharing potentially distressing information about prognosis and care. It also says doctors should listen to patients and their wishes and recognise when someone may be vulnerable.
56. The same GMC guidance says doctors should clearly and accurately record information shared with patients and any preferences about communication and support preferences.
57. In its complaint response, the Trust has acknowledged there is no clear record of what was said to Mr R during the early hours of 9 November following the CT scan. We have not been able to see a record of what was discussed with Mr R.
58. We have therefore considered what Mr R told staff early the next day about ‘the news’ and that staff recorded he was feeling anxious and unsettled. We think it is more likely than not he was told about the results whilst alone in the early hours.
59. We have considered that there may be some circumstances where staff need to tell a patient about an immediate change in their condition, such as in an emergency. In this case, we have not seen evidence that there was an emergency situation where Mr R needed to be told the information about his prognosis immediately. In the event staff felt they should override Mr R’s wishes and needed to tell him the information straight after the results of the CT scan, for example to explain why he was being transferred to a different ward, we would expect to see a clear record of the conversation and reasoning for this.
60. We recognise the need for communicating important information with patients in a timely manner however, in this case, we have seen clear preferences noted about how Mr R wanted news to be communicated with him.
61. We have not seen evidence that the Trust took Mr R’s wishes into account when giving information about the spread of the cancer to him alone, in the early hours of 9 November and we found a failing in the way the Trust communicated this information. We have seen evidence the Trust had thorough and detailed conversations with Mr R and his family after the initial conversation, which we hope reassures Ms T. As there are limited records regarding the conversation in the early hours on 9 November, we also find a failing in the Trust’s record keeping in relation to this conversation.
62. We understand Mr R would have been distressed to hear the significant news that the cancer had spread and we acknowledge the further distress this has caused to Ms T. We can see the Trust has already acknowledged and apologised for this failing. However, we have not seen it has recognised the significant impact on Mr R, which we think was exacerbated by the fact the news was given in the early hours. We also cannot see any rationale for why the news was given in this way. We have gone on to explain the recommendations we have made at the end of this report.
Physiotherapy
63. Ms T is concerned Mr R did not receive appropriate physiotherapy following surgery to replace his hip on 14 October 2021.
64. Mr R was already in hospital when he reported worsening pain in his spine and left hip and leg on 5 October. He told staff he had an increase in pain in the same areas on 6 October and could no longer stand. An MRI scan was carried out and showed a fracture in his left femur (thigh bone). Mr R underwent surgery on 14 October to replace his hip.
65. The records show Mr R was seen by occupational therapists on 15 October following the operation. The records show he was seen several times following this by occupational therapists and their focus was on ‘function’, with an aim to getting back to carrying out normal day to day activities.
66. The records also show several mobility assessments were carried out following the operation and discharge planning was documented throughout the records.
67. Mr R was discharged on 3 November and the following day attempted to move from a chair where he dislocated his hip. Mr R was admitted to the Nuffield Orthopaedic Centre (NOC), which is part of this Trust and he had further surgery.
68. On 10 November Mr R was transferred from the NOC to Sobell House, which is also part of Trust. He was discharged on 6 December.
69. The records show whilst Mr R was at the NOC he was seen by physiotherapists who assessed his mobility. When Mr R was transferred to Sobell House, he was seen by occupational therapists, and the records show they contacted physiotherapists at the NOC for input on Mr R’s ongoing care.
70. The Trust told us at the time it did not have physiotherapists available at Sobell House.
71. We can also see evidence Mr R was given clear information following the operation in October to follow ‘hip precautions’ and it was noted he responded well to the therapy sessions whilst in hospital.
72. We can see the Trust also arranged for a physiotherapist from Macmillan to see Mr R at home once he was discharged.
73. NICE guidance on hip replacement surgery says patients should be seen by a physiotherapist or occupational therapist on the day of surgery, or no more than 24 hours after surgery to discuss daily activities, home exercise programmes and mobilisation.
74. The HCPC says physiotherapy and occupational therapists should seek advice and refer to other professionals when providing care.
75. Mr R was seen by occupational therapists within 24 hours of his surgery in October and we can see evidence of continued support by the team. In addition he was seen by occupational therapists during his admission to Sobell House and whilst he was not seen by a physiotherapist, the records show the team did have input into his care.
76. Our physiotherapist adviser explained occupational therapists are qualified to care for patients in these types of situations. They added the records show a good level of communication between physiotherapists and occupational therapists during both admissions.
77. We think it is important to note that Mr R also had other comorbidities, including stage four cancer and bone metastases, which may have weakened his bones. Our physiotherapist adviser explained any ongoing cancer treatment and other illnesses can have an impact on someone’s overall mobility after a significant operation.
78. We are sorry to see that Mr R’s mobility declined after the operation and that he did not regain his preoperative mobility. However, we found the Trust provided appropriate physiotherapy care during both admissions and hope this provides some reassurance to Ms T.