Delays 20. NHS England sets cancer waiting time standards to speed up diagnosis and treatment for patients. In January 2023 the cancer wait time standards were:
• maximum of two weeks from receipt of an urgent 2WW referral to first outpatient appointment in 93% of cases • maximum of 28 days from 2WW referral to informing the patient of the diagnosis in 75% of cases • maximum of 31 days from decision to treat to first definitive treatment in 96% of cases • maximum of 62 days from urgent 2WW referral to first treatment in 85% of cases.
21. Mrs R’s referral was received by the Trust on 31 January and her first outpatient appointment was on 14 February. This was in line with NHS England’s cancer wait time standards.
22. She had a CT scan on 16 February which showed the presence of cancer; however, the Trust could not know what type of cancer it was until it undertook a biopsy. The biopsy took place on 15 March and her diagnosis was confirmed on 21 March. This was seven weeks after the initial 2WW referral, which fell short of the cancer wait time standard of 28 days from referral to diagnosis.
23. An oncology review took place on 30 March and chemotherapy was planned to commence on 21 April. This met the target of 31 days from the decision to treat to the date of first treatment. However, because of the delays in diagnosing Mrs R’s cancer, it had taken 81 days from her 2WW referral to treatment commencing. This fell short of the national cancer wait time standard of 62 days.
24. Within the national cancer wait time standards there is a recognition that some patients will not meet this standard. This is because there can be good reasons for delay in some cases. For example, a minority of cases may be very complex and may require a number of tests that could not reasonably be undertaken within the target timeframe.
25. Given the standards allow for a minority of cases to miss the time targets, we have considered whether the Trust met its cancer targets overall and whether Mrs R, sadly, fell within the minority of cases that the standards accept may not meet these targets.
26. The Trust’s Integrated Performance Report for March 2023 reveals a worrying failure to meet all of the NHS England cancer wait time standards. For the 62-day referral to treatment standard, the Trust achieved this in just 47.6% of patients compared to the national target of 85%. This falls far short of the national target.
27. On balance, given the Trust was significantly failing to meet its targets for diagnosing and treating cancer and Mrs R’s diagnostic journey was relatively simple, we have found this delay amounts to service failure.
28. Our Oncology Adviser explained that, sadly, Mrs R’s cancer was terminal, and the delays had no impact on this. However, our Oncology Adviser also said that the delays meant Mrs R was unfit for palliative treatment by the time it had been arranged.
29. Had the Trust met the national cancer standard for referral to treatment, her palliative care should have commenced on or before 3 April. The chemotherapy referral happened on 31 March, and the consultant was satisfied she was fit for treatment. Further, her medical records dated 5 April indicate she was still fit for treatment and awaiting palliative chemotherapy.
30. Our Oncology Adviser explained we cannot know how Mrs R would have responded to palliative chemotherapy treatment. Chemotherapy takes a number of days or weeks to make a difference. Some patients will respond positively and experience symptomatic relief and an extension of their life. Others experience serious side effects and no improvement in quality or length of their life.
31. What we can say, however, is that Mrs R lost the opportunity to engage in chemotherapy, and her family will never know whether or not this could have improved her quality of life and/or extended her life to give her more time with her family. This is a serious injustice to them.
32. The Trust has acknowledged some of the delays in diagnosing and treating Mrs R’s cancer. However, the response lacked sufficient detail to acknowledge the full extent of the failings. It also reassured Mr R it had improved its performance on cancer wait times, but did not explain how it had done this or whether it was now meeting the national cancer wait time standards.
33. We have reviewed the Trust’s latest data on its cancer wait time standards. The standards have changed slightly since October 2023; however, the 62-day referral to treatment target remains in place. As of March 2025, the Trust achieved the 62-day target for just 46.8% of patients, which represents a further decline in its performance. We are not satisfied the Trust has done enough to improve its service and we have outlined recommendations for improving its service at the end of this report.
34. With regards to the delays in treating Mrs R’s ascites in between February and April 2023, the GMC’s Good Medical Practice guidelines (section 15b) states that doctors must promptly provide suitable treatment.
35. Our Oncology Adviser explained there was a missed opportunity to drain Mrs R’s ascites in February 2023, when she was admitted to hospital via the emergency department. Given how significant the ascites was, this should have been drained on 16 February; however, this did not happen until 1 March.
36. Following the initial delay, Mrs R had her ascites drained promptly on each presentation to the ED. Our Oncology Adviser explained that, sadly, because her cancer was progressing, so was the severity of her ascites. This deterioration was not due to further delays in draining the ascitic fluid but, rather, was due to the progression of her cancer.
37. We have found the Trust delayed in draining Mrs R’s ascites between 16 February and 1 March 2023 and that this amounts to service failure. Our Oncology Adviser explained this would likely have been very uncomfortable for her. We consider it more likely than not that this failing caused her avoidable distress for that two-week period.
38. In its response to Mr R’s complaint, dated 12 February 2024, the Trust acknowledged the delay in draining his mother’s ascites and apologised. It did not acknowledge and apologise for the impact this had.
39. Our NHS Complaint Standards say that organisations should ‘give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned’. For this reason, we are not satisfied the Trust’s apology aligned with these service standards and we have outlined recommendations at the end of this report.
Discharge 40. NICE guideline NG27 (transition between inpatient hospital settings and community) says that as soon as a person is admitted to hospital, staff should form an hospital-based MDT that will support them. This should include discharge planning, which should commence on admission to hospital.
41. In line with these guidelines, the Trust should have developed a discharge plan that took account of the following:
• details of Mrs R’s health condition • information about her medications • contact information after discharge • arrangements for continuing health and social care support • the details of any useful community or voluntary services.
42. The Trust should have given this plan to Mrs R and all those involved in her ongoing care and support, including any family members who were supporting her.
43. The Trust should also have allocated a discharge co-ordinator to be responsible for arranging follow-up care in the community and identifying any family members who would provide support. If the discharge plan involved support from family members, the hospital-based MDT should have taken account of their ability to provide support.
44. There is very little evidence of any discharge planning in Mrs R’s medical records for her admission between 9 and 18 April. There is no evidence that any of her social care needs were assessed prior to discharge, nor any multidisciplinary discharge planning.
45. Her medical records show that a ‘Patient Discharge Planning Log’ was left blank and the ‘Day of Discharge’ checklist was also not completed. In addition, the palliative care team’s assessments of Mrs R on 13 and 14 April record no details relating to discharge planning. The nursing notes during this admission also do not reference any details regarding discharge planning or support that would align with NICE guideline NG27.
46. Without an assessment of her social care needs and multidisciplinary engagement to plan Mrs R’s discharge, we cannot conclude her discharge was safe. This is because, whilst she may have been medically fit for discharge there was no assessment of her needs or plan to ensure these would be appropriately met in the community.
47. The Trust appears to have been relying on Mrs R’s son to manage her care, but there is no evidence it considered his ability to do so nor any evidence the Trust provided any of the information required by NICE guideline NG27.
48. We have found the Trust’s discharge planning for Mrs R fell so far short of the national guidelines that Mrs R’s discharge was unsafe. This amounts to service failure.
49. We have considered the impact this had on Mr R. He explains that this was the most traumatic aspect of his mother’s end-of-life care. He says his mother suffered unnecessarily due to the lack of support and he was very distressed when witnessing this. He adds that this discharge was more distressing than her terminal diagnosis, and that he still has nightmares and replays memories from those final weeks.
50. This is a very serious injustice to Mrs R and her son, and it stemmed directly from the failings we have identified. Whilst navigating Mrs R’s end-of-life care would be distressing in and of itself, the Trust’s failure to appropriately and safely plan her discharge in April significantly exacerbated this distress and has caused a lasting emotional impact to her son.
51. The Trust has not acknowledged the failings identified, nor has it taken appropriate steps to put things right. We have outlined recommendations at the end of this report.
Palliative care 52. There are no national guidelines outlining a specific timeframe within which palliative care should be arranged, nor how this should be prioritised or followed up if there are delays.
53. However, NICE guideline NG142 (end of life care for adults) outlines the steps that should be taken to plan end-of-life care, and we have considered whether these were completed in a timely manner. We have also considered whether any departure from these guidelines may have delayed Mrs R accessing the palliative care she needed.
54. In line with NICE guideline NG142, the Trust should have:
• undertaken an initial holistic needs assessment • provided a repeat assessment of Mrs R’s holistic needs at key transition points, such as discharge from hospital or when her preferences/goals had changed • ensured good communication between community-based and hospital-based care providers • developed systems to ensure ‘smooth and rapid’ transfer between care settings, ensuring care packages and equipment are available.
55. On 30 March an oncologist documented they had explained to Mrs R that her cancer was not survivable. At this point, the Trust should have considered commencing a palliative care pathway because it knew Mrs R may have less than 12 months to live. We have seen no evidence this happened.
56. Mrs R attended the Trust’s ED on 9 April and was admitted to hospital. A CT scan on 11 April revealed significant disease progression. On 12 April the consultant documented a plan to refer Mrs R to the community palliative care team and she agreed to a do not attempt resuscitation order. At this point there was a clear need for palliative care planning and ensuring this was in place if and when Mrs R was discharged into the community.
57. An holistic needs assessment was undertaken by the hospital-based palliative care team on 13 and 14 April. The assessment of 13 April considered her physical, social and emotional needs. It documented a plan for pain relief whilst in hospital. This was in line with NICE guideline NG142.
58. The Trust referred Mrs R to a local hospice on 12 April, advising that she was due to be discharged the following day. However, the ward round notes made by the consultant indicate there was no plan to discharge Mrs R at that time. Furthermore, this referral was made prior to the holistic needs assessment from the hospital palliative care team. This means the referral was inaccurate and her care needs could not be outlined in appropriate detail.
59. Because Mrs R was not ready for discharge on the date provided by the referral, the hospice contacted Mr R to advise it could not provide further support until she was discharged. The Trust says it alerted the hospice to Mrs R’s discharge from hospital on 18 April, but we have not seen evidence that this happened.
60. We have found the Trust failed to ensure ‘smooth and rapid’ transfer between care settings and ensure good communication between itself and community-based care providers. Whilst the Trust referred Mrs R to a hospice on 12 April, this referral contained inaccurate information and happened prior to the consideration of her community care needs.
61. We have found the Trust failed to effectively co-ordinated Mrs R’s palliative care between the hospital and the hospice, delaying her access to this care. This fell short of NICE guideline NG27.
62. In addition, we have not seen any evidence the Trust reviewed Mrs R’s palliative care needs when she was discharged from hospital on 18 April. This meant there was no plan to transfer her palliative care to the community and ensure she had the support she needed as she approached the end of her life. This was not in line with NICE guideline NG27.
63. We have found the Trust failed to plan Mrs R’s community palliative care in line with national guidelines. This delayed her care, and the Trust should have taken steps to prioritise and progress her access to this support. This departure from national guidelines amounts to service failure.
Communication 64. When communicating with patients, different clinicians have different responsibilities in terms of the nature and frequency of communication. Broadly speaking, doctors are responsible for communicating diagnosis, prognosis, and treatment options. Nurses are responsible for liaising between the doctors and the patient and providing day-to-day updates and advice on the care being provided. This is not definitive, however, and there may be overlap in communication from these different roles.
65. NICE guideline NG142 states that patients approaching the end of their life should have regular discussions with a member of their care team. This guidance also recommends that NHS service providers should clarify whether and how they would like their family members involved in key decisions, and review this regularly. With the patient’s consent, they should share information with family members.
66. NICE guideline CG138 (patient experience in adult NHS services) also outlines that patients should be given the information and support they need in a way they can understand. Those supporting the patient should explore what information they want and, based on this, give the patient clear, consistent, tailored information throughout all stages of care. This should include, but is not limited to:
• their condition and treatment options • where they will be seen and who will undertake their care • expected waiting times for consultations, investigations, and treatment.
67. The communication from Mrs R’s oncologist, on 30 March, regarding her diagnosis, prognosis and treatment options was to a good standard. There was also good communication from the physicians during a family meeting on 12 April, and with regards to the do not attempt resuscitation order. The evidence shows the doctors communicated the diagnosis, prognosis and treatment options in line with NICE guideline CG138.
68. Unfortunately, there is little documented by the nursing team in relation to communication with Mrs R and her family. We have seen no evidence the nursing team explored what information she wanted or needed, nor that they clarified the family members she would like included in key decisions about her care prior to 24 March.
69. On 24 March a nurse documented a conversation with Mrs R where they explained her diagnosis and the next steps. This communication was to a good standard; however, there were no further documented instances of communication between the nursing team and Mrs R or her family until 13 April, when the palliative care team assessed her needs.
70. On 21 April a specialist oncology nurse documented a plan to update Mrs R’s family; however, there is no documented evidence this happened. A palliative care plan completed on 22 April indicates the nurse discussed the plan with Mrs R’s son; however, they left the items discussed blank which means we cannot know what was communicated to him.
71. We have found the communication from the doctors aligned with national guidelines. We have also found the communication documented by the nursing team fell far short of NICE guidelines CG138 and NG142. On balance, we have found the Trust’s overall communication amounts to service failure.
72. We can understand why the lack of communication from the nursing team was so distressing for Mr R and his mother. Receiving a terminal diagnosis that is rapidly deteriorating is an incredibly distressing time for any family, and good communication is important in supporting families to navigate this difficult time.
73. Whilst the Trust has acknowledged and apologised for some shortcomings in its communication, we are not satisfied it has acknowledged the extent of what went wrong. We are also not satisfied it has done enough to explain how it will improve communication in the areas where it acknowledged its service fell short. Therefore, we have outlined recommendations below.