OGD 27 September 2021
29. Mr A says the Trust failed to correctly diagnose Mr R’s oesophageal cancer after his OGD on 27 September 2021. He feels Trust staff missed the signs of cancer on the OGD test which meant his cousin went without the timely care he needed.
30. It must have been incredibly distressing for Mr R and his family, when they found out he had terminal cancer in January 2022. We are very sorry to hear Mr A has been left with long lasting worry the trust could have diagnosed this sooner. We recognise this complaint is very important to him.
31. Barrett’s oesophagus is a condition where the lining of the patient’s food pipe is damaged by acid and bile from the stomach. The BSG guidelines explain clinicians should diagnose a patient with this disease, in cases where ‘any portion of the normal distal squamous epithelial lining’ has been replaced with ‘metaplastic columnar epithelium’ and is ‘clearly visible.’
32. What this means is, when a patient has Barrett’s oesophagus, the normal cells in the lining of the oesophagus are replaced by ‘mature cells’ due to prolonged irritation from stomach acid and bile. This change can be seen on an OGD image.
33. The BSG guidelines continue to explain if a clinician performs an OGD and finds ‘visible lesions’ in the oesophagus, they should be considered ‘malignant’ (cancerous) ‘until proven otherwise’.
34. The BSG guidelines recommends clinicians should carry out a ‘high-resolution endoscopy’ to diagnose a patient with Barrett’s oesophagus as this is the ‘gold standard diagnostic tool’.
35. Further, BMJ guidelines explain if a clinician performs an OGD and does not identify any visible lesions (signs of cancer), they should ‘carry out a biopsy’ in the ‘Barrett’s segment’ (area of the lining showing Barrett’s oesophagus) to fully investigate the patient’s symptoms.
36. Mr R’s medical notes indicate the Trust carried out a biopsy on 27 September 2021. There were no issues noted. The notes say the biopsy showed inflammation of his upper stomach but no signs of cancer or pre-cancerous changes.
37. We first asked our gastroenterology adviser to review Mr R’s OGD images and report of 27 September 2021. We asked them to tell us whether the OGD was performed correctly, and if it showed any indications Mr R had signs of cancer at the time of the procedure.
38. Our gastroenterology adviser confirmed the images from the OGD were of ‘high quality’. This indicates the test was performed in line with BSG guidelines, as it recommends using a ‘high resolution endoscopy’ to investigate the patient’s symptoms.
39. Our gastroenterology adviser explained the notes from the procedure show the endoscopist used appropriate techniques to look in detail at the impacted areas of the oesophagus. This included taking four biopsies at the ‘gastro-oesophageal junction’ which is the area where the oesophagus meets the stomach. Mr R’s records note the upper part of his stomach had an appearance of Barrett’s oesophagus.
40. Our gastroenterology adviser went on to say the images did not show any ‘visible lesions’ which would indicate Mr R had potential cancer. Instead, the images showed Mr R had ‘severe oesophageal inflammation and ulceration’ (open sores in the tissue lining). Our gastroenterology adviser confirmed these symptoms fit a diagnosis of Barrett’s oesophagus. This is because the appearance of the oesophagus lining showed ‘prolonged irritation’ in line with BSG guidelines.
41. Our advisers’ comments are also in line with the Trust response which says that no cancer was seen, only Barretts oesophagus, the Trust says it did not consider cancer at this time, as the biopsy did not indicate this.
42. Our advisor tells us it does not appear that the Trust were thinking Mr R had cancer at that time as the recent gastroscopy had shown severe ulceration that can also cause pain and swallowing difficulties.
43. Our adviser also says there was no suspected cancer, the Trust were looking to exclude dysplasia and to check mucosal healing to determine the treatment plan for the future.
44. Our adviser asked to see clearer images from the OGD including colour images and the OGD report. We obtained these and our adviser says they were of high quality, and no cancer was visible.
45. In summary, we hope to reassure Mr A that both the OGD images and biopsies taken on 27 September, do not indicate Mr R had signs of oesophageal cancer. We are satisfied the Trust performed the OGD as it should have done, and in line with BSG guidelines.
46. The endoscopist appears to have taken high quality images of Mr R’s oesophagus and correctly taken biopsies to sample his damaged tissue. Neither of these test results indicate there were cancerous lesions present in his oesophagus.
47. We sincerely hope this will give Mr A some much needed closure for this part of his complaint.
Follow up (OGD) procedure
48. Mr A tells us the Trust initially scheduled a repeat OGD for Mr R on 29 November 2021 to monitor his symptoms and diagnosis of Barrett’s oesophagus. He says Trust staff incorrectly cancelled his OGD which goes against guidelines. This has left Mr A feeling the Trust missed a further opportunity to potentially diagnose his cancer earlier.
49. British Medical Journal (BMJ) guidelines explain in cases where a patient has severe oesophageal ulcers, (as was the case with Mr R) clinicians should ‘carry out a follow up gastroscopy’ (OGD) within eight weeks, to check for ‘ulcer healing’ unless there is a ‘contraindication’ to do so.
50. Contraindication means when a medical procedure or treatment is inadvisable, due to the potential harm it could cause the patient.
51. Mr R’s discharge notes of 7 December 2021 explain Trust staff did not agree to carry out the repeat OGD because he was too frail and ‘unfit for surveillance’. It is clear Mr R appeared very unwell at this stage. This would have been immensely difficult for Mr A to witness. We are sorry to hear he feels Trust staff did not do enough at this time, to support him and monitor his symptoms.
52. Our gastroenterology adviser reviewed Mr R’s medical records from this admission. Mr R had been diagnosed after his first OGD with Barrett’s oesophagus. The scan images showed he had severe ulceration, caused by this condition, along the lining of his oesophagus. As such, Trust staff initially made an appropriate decision to book a repeat OGD to check if his ulcers were healing.
53. Sadly, during his second admission, the records indicate Mr R was frail and unwell. On this basis, our gastroenterology adviser said Trust staff made an appropriate decision to cancel his repeat OGD. This is because, there is a significant risk attached to carrying out an OGD when the patient has severe frailty. They advised when a patient is frail and has multiple comorbidities (as was the case for Mr R) the procedure can compromise their respiratory system (breathing).
54. This is a significant ‘excessive’ risk to the patient’s safety, compared to the benefits of carrying out the OGD. Therefore, in line with BMJ guidelines, it was clinically appropriate not to go ahead with the OGD as this was a significant ‘contraindication’.
55. Our gastroenterology adviser continued to explain the initial OGD results, and his biopsies did not indicate Mr R had cancer. Therefore, this was unlikely to be the cause of his swallowing difficulties. This strengthens the clinical rationale that the trust did not carry out a repeat OGD. It was not a high priority to reassess Mr R for cancer as there was no visible cancer symptoms following the first test results. Our gastroenterology adviser concluded it was reasonable to delay the OGD test, until Mr R was more stable and able to tolerate the procedure.
56. The Trust guidance for Barrett’s oesophagus says:
“What if my results do not show pre-cancerous cells?
“Even if no precancerous cells are found, there is still a risk of this developing in the future. The aim of Barrett’s surveillance is to identify these precancerous cells early, therefore you will still be invited to have regular endoscopy tests. The interval of which this will occur will be decided after your biopsy results have been reviewed along with how much of the lining of the oesophagus has been affected with Barrett’s oesophagus.
Although the aim of the endoscopy surveillance is to find abnormal areas of Barrett’s early on, there is no guarantee that having regular endoscopy surveillance will detect all cancers at an early stage.
Rarely, cancers can develop between one surveillance endoscopy and the next one. Current guidelines do not recommend surveillance for patients with short segments of Barrett’s (<3 cm) if the cell type is not concerning. In these cases, you may be discharged back to your GP with advice.”
57. The Trust guidance also says “Although endoscopy is a safe procedure, there can be some serious complications. As a result, surveillance endoscopy is not recommended for some patients with severe heart or chest problems, or increased frailty in the elderly.”
58. Based on the evidence we have seen, we did not see any failings for this part of the complaint. We consider the Trust staff made an appropriate decision to cancel Mr R’s repeat OGD, given the significant risks associated with the procedure. We found the Trust made this decision in line with the relevant BMJ guidelines.
59. We hope this reassures Mr A, Trust staff did not miss an earlier opportunity, to carry out tests to diagnose Mr R’s cancer.
Malnutrition and swallowing difficulties
60. Mr R complains Trust staff did not manage his cousin’s nutritional needs appropriately. He feels they did not do enough, to support him with his swallowing difficulties or offer alternative treatments, such as a nasogastric tube (NG) or peripherally inserted central catheter (PICC) line.
61. Mr R says this resulted in his cousin suffering rapid and significant weight loss. He says that when the trust diagnosed Mr A with cancer, he was too frail to receive active treatment. Mr R is concerned this outcome could have been different, had the Trust managed Mr A’s nutritional care correctly.
62. Records show Mr A reported he used to weigh 70kg, but records document he weighed 46.3kg on 4 December 21. His records note is height 1.75m, which means his BMI would be calculated as 15.1.
63. The Trust have said, the Doctor explained that as Mr R was able to manage fluids, it would not be normal practice to insert feeding tubes. The Trust also say that Mr R’s weight was stabilising prior to discharge.
64. The Trust also explained that the Speech and Language Therapy team (SALT) reviewed Mr R on 23 September 2021 for a swallowing assessment. The Trust say the assessment found that Mr R’s swallowing was largely within functional levels.
65. The SALT team documented that there was no indication for ongoing input and no evidence of oropharyngeal dysphagia (swallowing disorder).
66. The Trust also say that the SALT team had regular reviews: 29th and 30th November 2nd, 3rd, 6th, 16th, and 20 December 2021. Their initial impression was that Mr R’s swallowing problems were likely due to past medical history of a hiatus hernia and gastro-oesophageal reflux disease (GORD).
67. The Trust say it is documented that the SALT team made some recommendations:
• Thin Fluids • Soft and Bite sized diet • Red Tray – assistance for feeding • Alert and sitting fully upright for oral intake • Keep upright for at least 20 minutes after meals • Slow pace – small, single bites/sips • Small meals and snacks throughout the day • If sensation of residue, wait for this to clear before taking another bite/sip • Please contact SALT and consider making patient Nill by Mouth if coughing/wet voice with oral intake.
68. The Trust tell us a dietician carried out a review on 1 December 2021 and it is noted that Mr R was malnourished and recommended a build-up regime.
69. NICE nutrition guidelines recommend all inpatients should undergo a Malnutrition Universal Screening Tool (MUST) assessment. This assessment considers the patient’s Body Mass Index (BMI), recent unplanned weight loss, and acute disease score, which looks at any medical reason why the patient might struggle with eating.
70. Further, NICE nutrition guidelines recommend carrying out weekly MUST screening for patients who are ‘at risk’ of malnutrition. Nutrition support should be considered for patients who:
• have a BMI of less than 18.5 kg/m2 • unintentional weight loss greater than 10% within the last 3 to 6 months • a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3 to 6 months.
71. Finally, NICE nutrition guidelines explain healthcare professionals should consider any swallowing issues a patient has when deciding on their nutrition care plan. It says they should also use ‘oral, enteral or parenteral nutrition support, alone or in combination, for people who are either malnourished or at risk of malnutrition’ as outlined above.
72. Our specialist dietician adviser tells us in line with NICE nutritional guidance, Mr R should have had his weight recorded on admission. As he was an inpatient this weight should have been recorded and monitored weekly as a baseline. When there is a clinical concern, this can be done even more frequently. This is considered ‘screening for malnutrition’, it should also include calculating a person’s BMI to consider what risks a patient may face as a result of their weight or nutritional score.
73. The medical records document Mr R’s struggle to eat and drink, worsening vomiting and nausea and weight loss. Our adviser says the Trust should have completed strict food charts, but these were not done.
74. The adviser says the records appear to demonstrate that the Trust did not adequately monitor Mr R’s weight, as per national guidance.
75. We can see no evidence of regular weight monitoring, and until dietetics request this, no clear plan as to how the Trust should facilitate this. It would also appear that Mr R’s BMI was never completed until a dietetics review in December.
76. In line with guidance the Trust should have reviewed Mr R’s weight weekly, along with BMI and weight changes, and noted that he had difficulty in eating and drinking. This would have likely highlighted his ongoing weight loss and high nutritional risk sooner, to trigger a dietetic referral.
77. Our adviser says the nutritional score is often calculated using the MUST (malnutrition universal screening tool), that is what we would expect to be used. The MUST tool asks clinicians and other medical professionals to consider, weight, BMI, and other things such as refeeding risk. This tool will provide a risk score that will give clinicians a treatment plan.
78. We have reviewed all the documentation from the Trust. This shows the Trust has not followed the national guidance when monitoring/documenting Mr R’s weight and malnutrition.
79. Our adviser tells us the Trust staff should have been documenting Mr R’s weight loss, if they had, they would have picked up on his weight loss and could have potentially prevented the malnutrition he faced. We have found a failing with this issue.
80. Records show dietetics have requested on many occasions for strict weight/food monitoring, and we cannot see this was actioned. It appears from the records that ward/nursing staff were not adequately managing Mr R’s health issues, and many concerns were missed.
81. Our adviser commented that they would also have liked to see accurate and well filled out food record charts available, detailing what Mr R was managing to eat and drink, including the volume and texture of the food, to effectively monitor his oral intake.
82. Our adviser cannot comment that Mr R’s death was avoidable. That said, we can clearly see what his suffering was, and the lack of nutritional screening may have prolonged his suffering and contributed to an undignified death.
83. Mr A says the impact of this is that Mr R was frail, malnourished and physically weak due to the lack of nutritional input which could have been obtained via NG tubes or PICC lines during the lengthy hospital admissions.
84. Mr A says, if the Trust had managed Mr R’s nutrition properly, Mr R may not have been so frail. Sadly, Mr R died aged 51 from Aspirational Pneumonia, Pulmonary Emboli, Oesophageal Tumour, Protein Deficiency and Cerebral Palsy.
85. Based on the above we have found there is a failing with this issue
Mr R’s concerns for his own health
86. Mr A tells us the Trust labelled Mr R as a ‘hypochondriac’ due to his past medical history of mental health issues. He says the Trust failed to take Mr R’s concerns about his own health seriously and did not care for him effectively.
87. Medical records show Mr R attended or was admitted to the hospital on a number of occasions between 5 August and 27 November 2021. His attendances or admittances were:
• 5 August – 23 August: attended ED (emergency department) with abdominal pain, vomiting, and black stools • 24 August - 8 September: attended ED vomiting blood and abdominal pain • 11 September: difficulty swallowing - It is noted he is becoming frail and may not be eating • 14 September – 20 September: attended ED with abdominal pain, chest pains, and shortness of breath • 20 September - attended ED laceration over eyebrow • 10 October – 11 October: self-harm • 16 October – 17 October attended ED: chest pains and vomiting • 20 October - Patient says suicidal and chest pains • 11 November – 14 November: attended ED with chest pain and vomiting and not able to tolerate any oral intake including medication • 19 November – 20 November: attended ED feeling gravely unwell and reports struggling to swallow medication • 27 November – 21 December: admitted due to prolonged seizures, known epilepsy, unable to swallow medication 3 days
88. We have looked at each of these admissions or attendances with our physician adviser.
89. Our consultant physician adviser tells us Mr R had many comorbidities and had been experiencing some mental health issues during his attendances at hospital. Some of his admissions were due to physical health concerns and some were concerning his mental health. Often, there was a combination of both.
90. Mr R’s physical symptoms appear to have been taken seriously by staff at the Trust. There is no documentation in the notes that show staff had labelled Mr R as a “hypochondriac”, nor had they dismissed his concerns as being linked to his mental health.
91. As far as the records show, our adviser says the trust appropriately investigated Mr R’s concerns in line with relevant GMC Good Medical Practice Guidelines which say “explains clinicians have a duty to ‘adequately assess’ a patient’s condition. They should ‘promptly provide suitable investigations’ to investigate their symptoms and ‘formally record’ any clinical findings in a ‘clear, accurate and legible’ way’.
92. Our adviser has also looked at the multiple discharges and says the Trust appears to have addressed all presentations appropriately. It appears that on each admission, the trust adequately treated Mr R in relation to what he attended with, and it discharged him appropriately.
93. In Mr R’s final admission in November, he presented with multiple clinical issues, and we can see he received treatment for each illness he presented with. The Trust took his social circumstances into consideration when discharge planning. We have not found any failings by the Trust in relation to the discharge.
94. The adviser also confirms considering GMC guidance the records show that throughout his multiple admissions, when Mr R raised mental health concerns, the Trust referred him for the appropriate assessments by psychiatrists and gave him the appropriate treatment by the specialty he required. The records appear to show that the Trust gave Mr R the correct treatment, in order to manage his anxiety and he was reassured by staff appropriately.
95. Based on the above we have not found any failings with this issue.