9. Mrs A had a medical history of asthma, high blood pressure, osteoarthritis, chronic kidney disease, aortic valve stenosis (narrowing of the aortic valve) and chronic obstructive pulmonary disease (COPD, a lung disease that obstructs airflow). The records indicate she was diagnosed with pre-invasive oesophageal dysplasia in June 2017 which was treated by the Trust with endoscopic mucosal resection (a minimally invasive procedure where irregular tissue is removed by a tube inserted through the mouth).
10. As her comorbidities (her other significant health conditions) posed a risk of her condition deteriorating the Trust decided Mrs A was not suitable to undergo chemotherapy if her condition developed into oesophageal cancer. Due to the length of oesophagus affected by the dysplasia the Trust also decided it was not appropriate to attempt surgery. Instead the Trust decided to provide best supportive care (care that focuses on improving the quality of life for patients with serious illnesses, particularly when curative treatments are not possible or appropriate, by managing symptoms and providing comprehensive support), review her condition and treat her symptoms as and when they arose.
11. The Trust performed biopsies in February 2018 which identified invasive cancer (cancer which has spread beyond the original tissue or cells where they developed) in her oesophagus. The Trust maintained the view Mrs A was not fit enough to withstand chemotherapy or surgery due to her comorbidities and continued to review her condition and treat any symptoms she experienced as and when they arose.
12. The Trust performed biopsies in July 2022 which again showed cancer in her oesophagus, similar to the results of the biopsies in February 2018, indicating her cancer was slow growing. Further scans in August 2022 showed a spread of abnormal cells to local lymph nodes. A barium swallow (a type of x-ray that uses a liquid swallowed by the patient which allows the oesophagus to be viewed) in November 2022 identified a narrowing in her oesophagus and the Trust inserted a stent in January 2023 to reduce the impact of the narrowing.
13. As the Trust deemed it was inappropriate to treat her with chemotherapy or to attempt surgery Mr and Mrs A requested a second opinion from a specialist cancer hospital. In January 2023 the specialist cancer hospital confirmed there were no clinical trials Mrs A would be suitable for due to her comorbidities. The specialist cancer hospital reviewed Mrs A in May 2023 and agreed with the Trust that she was not well enough for either chemotherapy or surgery.
14. Mrs A was admitted to hospital in November 2023 following a collapse and loss of consciousness. She collapsed again whilst in hospital and the Trust identified indications of cardiac syncope (a temporary loss of consciousness caused by heart related issues) which it felt was either due to her pre-existing heart problems or as a result of anaemia (not having enough healthy red blood cells). The Trust provided treatment and discharged Mrs A home in December 2024.
15. She attended again in February 2024 for a CT scan and the Trust diagnosed pelvic deep venous thrombosis (a condition where a blood clot forms in a deep vein) which it treated with anticoagulation medication before discharging her home. Mrs A sadly died in April 2024.
16. In its response to Mr A’s complaint the Trust said:
‘Mrs A had a long segment of abnormal area in her gullet measuring over 11cms with extensive areas of Barrett's oesophagus (where the lower section of the oesophagus is damaged by acid and bile coming back up from the stomach) and cancer. All possible treatment options were considered. she had significant cardiac, renal, and respiratory co-morbidities which meant she was not a suitable candidate to receive surgery or chemotherapy as treatment options. A second opinion was also sought (from the specialist cancer hospital) who reviewed the medical records and agreed any form of surgery or oncological treatment would not be suitable. They agreed best supportive care and treatment of symptoms when they occurred.’
17. The NICE oesophageal cancer guidance says:
‘Consider an open or minimally invasive (including hybrid) oesophagectomy (a surgical procedure to remove all or part of the oesophagus) for surgical treatment of oesophageal cancer.
Offer people with resectable non-metastatic squamous cell carcinoma of the oesophagus the choice of radical chemoradiotherapy or chemoradiotherapy before surgical resection.
Discuss the benefits, risks and treatment consequences of each option with the person and those who are important to them (as appropriate).
Palliative management Non-metastatic oesophageal cancer that is not suitable for surgery
Consider chemoradiotherapy for people with non-metastatic oesophageal cancer that can be encompassed within a radiotherapy field. When the cancer cannot be encompassed within a high-dose radiotherapy field, consider one or more of:
• chemotherapy
• local tumour treatment, including stenting or palliative radiotherapy
• best supportive care (care which focuses on improving the quality of life for patients with serious illnesses by managing symptoms and providing comprehensive support when curative treatments are not an option)
Discuss the benefits, risks and treatment consequences of each option with the person with oesophageal cancer and those who are important to them (as appropriate).’
18. The GMC guidance says:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
• 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
• promptly provide or arrange suitable advice, investigations or treatment where necessary.
In providing clinical care you must:
• prescribe drugs or treatment only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs
• provide effective treatments based on the best available evidence
• respect the patient’s right to seek a second opinion.’
Decision not to provide chemotherapy
19. Mrs A had significant comorbidities and the records indicate the Trust decided not to attempt chemotherapy from the outset due to the risk this treatment would have on her overall condition. The records indicate Mrs A’s cancer was slow growing and the Trust concluded the best option would be to provide best supportive care to prevent her condition from deteriorating and maintain her quality of life for as long as possible. The Trust put in place a plan of care which would act on her symptoms when they arose. This view and approach to care was confirmed by the second opinion from the specialist cancer hospital.
20. Our oncologist adviser said the Trust’s decision to provide best supportive care was appropriate and consistent with the NICE oesophageal cancer guidance and the GMC guidance. The records support the view Mrs A was not well enough to withstand chemotherapy due to her significant comorbidities. Our oncologist adviser said on balance of probabilities it is likely Mrs A would have died sooner if the Trust had provided her with chemotherapy due to the effect this would have had on her other significant comorbidities and her overall condition.
21. There is no evidence in the records to indicate Mrs A’s comorbidities or her overall condition improved during this period to the point where it would have been possible for the Trust to provide her with chemotherapy. The evidence in the records indicates the Trust discussed this with Mrs A and took into account her wish to prioritise her quality of life over invasive or radical treatments.
22. Our oncologist adviser said the records indicate following the Trust’s decision not to provide chemotherapy in favour of best supportive care Mrs A survived the slow growing cancer for 7 years with a reasonably good quality of life. Our oncologist adviser said there is no evidence in the records to indicate the Trust missed an opportunity to provide Mrs A with chemotherapy at any point during this period.
23. We carefully considered Mr A’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we have received. We found the Trust’s decision not to provide Mrs A with chemotherapy can be supported by the evidence in the records.
24. The NICE oesophageal cancer guidance recommends clinicians consider chemotherapy and it is clear from the information in the records that the Trust considered this option. There is no specific guidance that states when chemotherapy should be provided. This is a clinical decision made after full assessment of the patient’s condition, and having considered the possible risks of the treatment against the desired effects. It is a decision made after full consideration of the clinical facts and after discussion with the patient and consideration of their views and wishes.
25. The NICE oesophageal cancer guidance says clinicians should discuss the benefits, risks and consequences of treatment before deciding whether it is appropriate. The GMC guidance says clinicians should provide treatment only if they are satisfied it serves the patient’s needs. We found the Trust considered chemotherapy in line with the guidance and made an appropriate clinical decision, which can be supported by the evidence in the records, not to provide it due to the risk it would lead to a deterioration in her condition or poorer quality of life.
26. We found no evidence to indicate there was a time during this period where Mrs A was fit enough to have chemotherapy or that the Trust missed an opportunity to provide it.
Decision not to attempt surgery
27. The records indicate due to the length of the section of her oesophagus affected by the abnormal cells and due to her significant comorbidities, the Trust decided not to attempt surgery from the outset. This view was confirmed by the second opinion from the specialist cancer hospital.
28. Our surgeon adviser said when deciding whether a patient is suitable for surgery it is important to consider the risk of the surgery and the impact this may have on the patient’s overall condition. The other factor to consider is the possibility the patient may live a good quality of life for a number of years after their diagnosis without treatment whilst also avoiding the pain and stress of surgery.
29. These are involved and difficult discussions and the patient’s wishes should be taken into consideration. The records indicate the Trust discussed the risks of surgery with Mrs A in line with the GMC guidance and took into account her wish to prioritise her quality of life over invasive or radical treatments.
30. Our surgeon adviser said in this instance surgery would have involved removal of the part of the oesophagus containing the cancer. This is major surgery and depending on the size and position of the section of oesophagus being removed, it can have a lasting impact on the patient’s wellbeing and activities of daily living. Our surgeon adviser said as Mrs A wasn’t considered fit enough to have surgery it was appropriate for the Trust to conservatively manage her symptoms when she developed oesophageal cancer.
31. We carefully considered Mr A’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we have received. We found the Trust’s decision not to attempt surgery can be supported by the evidence in the records.
32. The NICE oesophageal cancer guidance recommends clinicians consider surgery and it is clear from the information in the records that the Trust considered this option. There is no specific guidance that states when surgery should be provided. This is a clinical decision made after full assessment of the patient’s condition and having considered the possible risks against the desired effects. It is a decision made after full consideration of the clinical facts and after discussion with the patient and consideration of their views and wishes.
33. The NICE oesophageal cancer guidance says clinicians should consider surgery and discuss the benefits, risks and consequences before deciding whether it is appropriate. The GMC guidance says clinicians should provide treatment only if they are satisfied it serves the patient’s needs. We found the Trust considered surgery in line with the guidance and made an appropriate clinical decision, which can be supported by the evidence in the records, not to attempt it due to the risk it would lead to a deterioration in her condition or a poorer quality of life.
34. We found no evidence to indicate there was a time during this period where Mrs A was fit enough to have surgery or that the Trust missed an opportunity to attempt it.