3. Mrs K complains staff at the Trust failed to find her father’s (Mr J) cancer from early May 2023 to late November 2023.
4. Mrs K says the delay diagnosing his cancer meant staff only found it at an advanced stage. This meant he lost the chance to have earlier life-saving treatment, and he died in May 2024.
5. Mrs K wants the Trust to make service improvements, to apologise about the impact of its failings, and a financial remedy.
6. Mr J saw his GP on 2 May 2023. This followed a visit to his local urgent care centre three days earlier because he began to vomit after eating. His GP referred him to the Trust’s urology department on 5 May for investigations into prostate cancer. The Trust’s urologists did scans later in the month.
7. On 2 June, Mr J attended the Trust’s Emergency Department (ED) with abdominal pain. In a CT scan staff did to investigate his pain, radiologists reported seeing a lesion in the neck of his pancreas. They had suspicion this may be cancer.
8. Hospital staff referred him to the Trust’s hepatobiliary multi-disciplinary team (the MDT) to do further investigations. This is a group of healthcare professionals from different clinical specialisms who work to diagnose, treat, and manage hepatobiliary cancers, which includes pancreatic cancer.
9. One of the Trust’s surgeons within the MDT began coordinating Mr J’s care. From 6 June, Mr J had more tests and scans at the Trust to investigate his condition. From the results, the MDT did not conclude Mr J’s lesion was cancerous.
10. In October, the surgeon referred Mr J to have an endoscopic ultrasound (EUS) with EUSguided tissue sampling in a specialised unit at a different NHS hospital trust.
11. This is a procedure where staff insert a thin flexible tube with a camera and ultrasound probe attached through the patient’s mouth, down the oesophagus, and into the stomach and nearby organs. This equipment shows images of the area. Staff also attach a needle to the endoscope. The needle can take tissue samples from the area. Staff can later perform laboratory tests on these samples.
12. The tests the other hospital’s histologists did on Mr J’s tissue samples indicated pancreatic cancer. They shared the results of these tests with the Trust in November.
13. The Trust’s MDT considered these results during their meeting on 14 November, alongside all the other investigations they had done. They diagnosed Mr J with pancreatic cancer. They noted his cancer had not spread to other parts of his body or nearby lymph nodes. However, the lesion was compressing nearby veins and arteries.
14. This meant staff could not operate and give Mr J curative treatment. On this basis, they offered Mr J palliative chemotherapy on 20 November.
19. In her complaint to the Trust and to us, Mrs K said Mr J’s GP started arranging investigations into the cause of his illness from the start of May 2023. This involved referrals to the Trust to do investigations. She considered the Trust’s staff then missed a series of opportunities to find Mr J’s pancreatic cancer. This included:
• staff not spotting it in X-rays Mr J had on 4 May • staff not spotting it in blood tests his GP did on 5 May, which they sent to the Trust • staff not spotting it in a pelvic MRI scan the Trust’s urologists arranged which he had on 16 May, or in an abdominal ultrasound he had on 25 May • surgical staff wrongly considering a lump they saw on his pancreas in a CT scan on 2 June indicated pancreatitis • surgical staff not spotting changes and considering cancer in a further CT scan he had on 24 July.
20. Mrs K said the Trust’s staff then sent him for investigations at another hospital. We described these investigations in paragraphs 10 to 12. She said staff at the other hospital considered Mr J had cancer and they shared this finding with the Trust. She said it then took until 20 November for the Trust’s staff to diagnose pancreatic cancer.
21. In its complaint process, the Trust said, prior to June 2023, Mr J’s GP had been arranging investigations to determine why he was unwell. The tests he had before June would not have detected pancreatic lesions.
22. The tests he had specifically on his pancreas began from June. Further to his 2 June CT scan, this included blood tests (looking for tumour markers) and an MRI scan of his pancreas on 6 June. The Trust said its MDT reviewed all these results and they indicated pancreatitis was the likely cause of his symptoms. However, the MDT planned a further scan for him in eight weeks.
23. The MDT brought this forward and did another CT scan on 24 July. The Trust said this scan showed improvement in the inflammation around Mr J’s pancreas, but widening of the tube draining his pancreatic enzymes. Given the remaining inflammation, the Trust said it was difficult to diagnose cancer, especially in the absence of symptoms like jaundice. The MDT planned a repeat scan to take place in three months.
24. Jaundice is when someone’s skin or the whites of their eyes turn yellow. It can be an indication of a serious illness like liver disease.
25. As Mr J’s symptoms persisted and he experienced pain, staff reviewed his scans again and the MDT arranged the referral we described in paragraphs 10 to 12. The Trust said his EUS needed to happen at a specialist unit at another NHS organisation. It added it had no control on the waiting times and when this unit would do his EUS.
26. We saw the Trust’s staff acted in line with guidelines.
27. NICE Guideline 85 explains what staff should do in respect to diagnosing pancreatic cancer. Section 1.1 says, in people without jaundice, which our surgeon said applied to Mr J, who have pancreatic abnormalities on imaging, staff should:
• offer a pancreatic protocol scan • if the diagnosis is still unclear, offer a fluorodeoxyglucose positron emission tomography CT scan and/or EUS with EUS-guided tissue sampling • if cytological or histological samples are needed, offer EUS with EUS-guided tissue sampling.
28. Our surgeon explained pancreatic cancer is often difficult to diagnose. It relies heavily on the right radiological tests to first highlight a mass or lesion within the pancreas that may raise suspicion. They said there are dedicated pancreatic protocol CT scans and MRI scans which focus on the pancreas. These are the best scans to show abnormalities.
29. They added diagnosing pancreatic cancer is reliant on the correct reporting of radiological tests. On this basis, we asked our radiologist to review all Mr J’s scans. Our radiologist said staff accurately reported his scans and they saw no omissions in the information they included based on what his imaging showed.
30. This means we saw the Trust’s staff went on to make decisions based on the best available evidence at each stage they reviewed a scan and decided what to do. Section 16 in Good Medical Practice says staff should provide care based on the best available evidence.
31. Mr J’s care records show his GP started arranging tests from early May 2023 in response to the symptoms he started having. This included blood tests and his 4 May X-ray. Based on the results, his GP referred him to the Trust’s urology department to investigate their suspicion about prostate cancer. Mr J’s GP noted his blood tests showed elevated prostatespecific antigen (PSA) levels.
32. PSA is a protein produced by both normal and cancerous prostate cells. Assessing PSA can help staff in diagnosing prostate cancer. High PSA levels can be a sign of prostate cancer. However, there are other reasons these levels can be high.
33. Our surgeon said these tests would not provide any information about pancreatic abnormalities. Therefore, we did not see the Trust’s staff missed an opportunity to diagnose pancreatic cancer, or they missed evidence of pancreatic abnormalities at this stage that they should have investigated further.
34. The Trust’s urology staff did an MRI scan on Mr J’s prostate and pelvis on 16 May. They also did an abdominal ultrasound on 25 May. Our surgeon said the evidence available at the time on Mr J’s condition supported staff doing these tests to investigate the suspicion around prostate cancer.
35. That said, our surgeon added his MRI scan would not show the pancreas. The type of ultrasound scan he had would not be able to detect pancreatic cancer unless it was at an advanced stage. For example, if there was a large mass pressing on other organs in the area.
36. Mr J’s ultrasound showed nothing like this. Rather, radiologists reported the presence of bowel gas around the pancreas which obscured it. Our surgeon said this is a common finding in such scans. For this reason, ultrasounds are not a good test for identifying pancreatic abnormalities.
37. Therefore, while we saw these were suitable scans to do at the time, staff would not be able to assess and diagnose pancreatic abnormalities through reviewing them.
38. Soon after his abdominal ultrasound, Mr J attended the Trust’s ED reporting abdominal pain. This resulted in him having a scan our surgeon said can detect pancreatic abnormalities. That was, his abdominal CT scan on 2 June.
39. The Trust’s radiologists reported they saw an ill-defined lesion in the neck of his pancreas. As this raised suspicion of possible pancreatic cancer, staff referred Mr J to have an urgent review with the MDT. The MDT then arranged for him to have an MRI scan using contrast dye on his pancreas, which he had on 6 June.
40. Our surgeon said the MRI scan was a dedicated pancreatic scan which would complement the CT scan Mr J had. They said the MRI scan would provide the best results to inform any decision on next steps in Mr J’s management. They also said staff arranged it in a timely way given they did it urgently on 6 June.
41. Having considered what happened in early June, we saw staff promptly offered Mr J the type of pancreatic protocol scan NICE Guideline 85 recommends after they came across evidence indicating pancreatic abnormalities.
42. MDT staff reviewed the results of Mr J’s scans on 13 June and saw him in the surgical clinic on 16 June. They noted his MRI scan indicated the lesion was inflammatory in nature. They saw his alpha-fetoprotein (AFP) tumour marker test (a blood test assessing levels of AFP which staff can use to assess for pancreatic cancer) did not indicate pancreatic cancer. In the clinic, Mr J reported he was feeling better than he did earlier in the month.
43. On this basis, staff considered pancreatitis caused his pain and ED attendance. However, they planned a follow up CT scan to assess him again in six to eight weeks.
44. Our surgeon said the available evidence supported the diagnosis staff made and their plan to reassess this with the next scan they scheduled.
45. Therefore, having arranged the pancreatic protocol scans recommended by NICE Guideline 85, we saw staff decided what to do based on the evidence from these tests. This means we saw no fault in the diagnosis they made at the time and the next steps they planned and when they would take them.
46. Staff did Mr J’s follow up CT scan on 24 July. Radiologists again reported the scan indicated a benign lesion which was inflammatory in nature.
47. Given the continued evidence about the lesion being benign, our surgeon said this supported staff deciding not to take further action other than to arrange a follow up scan which they planned to do in three months. Again, we saw staff made this decision based on evidence which came from the type of scan NICE Guideline 85 recommends.
48. In a telephone consultation Mr J had with a surgeon on 5 September, he explained his abdominal pain persisted. The MDT then brought forward his planned follow up scan, and they did a CT scan on the area on 23 September. Radiologists reported they saw little change in his pancreas compared to his scan on 24 July.
49. When the MDT reviewed the results, our surgeon said this evidence supported staff continuing to manage Mr J on the basis his condition was likely to be benign. However, given his symptoms persisted, this was a valid reason to refer him for his EUS with EUS-guided tissue sampling on 12 October. He then had this procedure at the unit the MDT referred him to on 23 October.
50. Our surgeon said if his pancreatic swelling was purely inflammatory in nature, they would normally expect to see the area of inflammation lessen. However, Mr J’s scans, including the one on 23 September, did not show this. This was a reason to do further investigations at this stage to challenge the existing evidence indicating his condition was benign.
51. This means we saw, when there was evidence emerging there may be an alternative cause to Mr J’s symptoms, and a potentially unclear diagnosis, staff arranged one of the tests they should have in this situation. That is, the EUS with EUS-guided tissue sampling recommended by NICE Guideline 85.
52. Staff at the other hospital who performed the EUS reported the images from this scan indicated Mr J’s lesion appeared to be inflammatory rather than cancerous.
53. However, the hospital’s histologists later completed tests on the tissue samples obtained during the procedure, and these tests indicated pancreatic cancer. They shared these results with the Trust’s MDT on 6 November. Considering this new evidence, the MDT then diagnosed Mr J with pancreatic cancer during their meeting on 14 November.
54. Our surgeon said the new evidence supported this diagnosis and the offer staff then made for Mr J to have palliative chemotherapy. This was because staff could not operate on the tumour (for the reasons we described in paragraph 13 and 14). Our surgeon said they would expect to see staff review such results and make this diagnosis within the timescales they did after receiving the results from the EUS-guided tissue sampling.
55. Having considered all the above information and advice, we saw staff arranged the tests NICE Guideline 85 recommends when evidence emerged about Mr J’s pancreatic abnormalities. They did so within the timescales our surgeon expected to see.
56. The evidence from these tests informed the next actions staff took. This included arranging specialised tests when later medical evidence suggested reasons to question the existing diagnosis (pancreatitis). On this basis, we saw no delay in staff diagnosing Mr J’s cancer.
57. Our surgeon said, sadly, Mr J’s cancer was difficult for staff to diagnose. Even the images from his EUS, which is a specialised test, indicated his lesion was benign.
58. We recognise all this is likely to be difficult for Mrs K to reconcile. Especially as earlier scans identified the lesion that turned out to be cancerous.
59. We hope we have clearly explained why the Trust’s staff acted in line with guidelines. We hope our explanations help in bringing Mrs K closure about whether staff could and should have diagnosed Mr J’s cancer earlier.
1. We recognise Mrs K and her family have been through a difficult time. We appreciate Mrs K considers Mr J’s death and the bereavement her family went through was avoidable.
2. We have carefully considered her concerns about how long it took the Trust to diagnose Mr J’s pancreatic cancer. Having done so, we saw staff acted in line with guidelines and we found no avoidable delay in diagnosing Mr J. This means we have decided not to consider Mrs K’s complaint further.