PET scan
18. Mrs K says on 7 November 2023, the Trust did not follow up on a PET scan which showed an anomaly on Mrs I’s colon. She says had the Trust investigated this properly, Mrs I may have been diagnosed with colon cancer earlier and she may have received better care and been more comfortable in her final weeks.
19. We reviewed this issue with the help of our surgeon adviser using Mrs I’s medical records.
20. Mrs I was admitted to hospital with shortness of breath, weight loss, cough and leg swelling on 23 October 2023. A respiratory consultant reviewed Mrs I after a computerised tomography pulmonary angiogram (CTPA) found pulmonary embolisms and a nodule. The respiratory consultant recommended a PET scan. Mrs I was discharged from hospital on 25 October pending further investigations.
21. The Trust carried out a PET scan on 7 November. The PET scan revealed a 46mm anomaly in Mrs I’s colon. This prompted the respiratory consultant to refer Mrs I on a two week lower gastrointestinal suspected cancer pathway.
22. A surgical registrar reviewed Mrs I on 27 November 2023 and discharged her the same day. The clinic discharge letter noted an abdominal and pelvic CT scan had been carried out on 24 October 2023 and showed no evidence of cancer.
23. The clinic letter also noted Mrs I was feeling well on the day, had recently gained weight and had no bowel symptoms. Mrs I told the surgical registrar she had undergone a colonoscopy a year ago and was told at the time she did not have cancer.
24. The surgical registrar stated they were discharging Mrs I in view of the CT results from October 2023, the fact she had no symptoms and ‘sounds like’ she had a colonoscopy a year ago.
25. In its final response the Trust said, with the benefit of hindsight, if a colonoscopy was arranged in November 2023, it would probably have picked up the colon cancer. The Trust went on to say it was unlikely to have changed the prognosis of the cancer as it was likely locally advanced at that stage given the extent of disease found during the surgery in February 2024.
26. Good Medical Practice says clinicians must adequately assess the patient’s condition taking into account their history, views and values and where necessary examine the patient. It also says clinicians must promptly provide or arrange suitable advice, investigations or treatment where necessary.
27. Colon cancer often presents with no symptoms and so relying on Mrs I having ‘no bowel symptoms’ was not appropriate. Also relying on a patient’s recollection of what tests they have had is not appropriate. Patient’s memory can be unreliable, and the quality of colonoscopy can vary considerably. Our surgeon adviser said, for example, poor bowel preparation or a difficult examination can make it difficult to be sure there is no cancer on colonoscopy.
28. The abnormal PET scan on 7 November should have prompted a specific diagnostic colonic test; either colonoscopy or CT colonography (a dedicated CT scan looking at the colon).
29. We have found the Trust did not adequately assess and arrange appropriate investigations in accordance with Good Medical Practice.
30. We will discuss the impact of this failing further on in our report.
Communication and consent
31. Mrs K says on 31 January 2024 the Trust told Mrs I she had colon cancer and consented her for emergency surgery to take place the following day with no family member or nurse with her to provide comfort and support.
32. We reviewed this issue with the help of our surgeon adviser using Mrs I’s medical records.
33. GMC guidance for decision making and consent states ‘Patients need relevant information to be shared in a way they can understand and retain, so they can use it to make a decision. To help patients understand and retain relevant information you should:
• share it in a place and at a time when they are most likely to understand and retain it • anticipate whether they are likely to find any of it distressing and, if so, be considerate when sharing it • accommodate a patient’s wishes if they would like anyone else – a relative, partner, friend, carer or advocate – to be involved in discussions and/or help them make decisions.’
34. The guidance also states, ‘In an emergency, decisions may have to be made quickly so there’ll be less time to apply this guidance in detail, but the principles remain the same.’
35. Mrs I should have been offered support even though her surgery was in an emergency setting.
36. The Trust said there was a plan to contact Mrs I’s family after the news was broken to Mrs I. It said this could have been improved by planning in advance for a member of her family to be present while disclosing the cancer diagnosis. Alternatively, a clinical nurse specialist in colorectal cancer could have been contacted in advance to be present and to liaise with the family.
37. The Trust said this may not always be possible due to the large volume of emergency surgical patients and the team probably did not have the time to make these arrangements. This has resulted in Mrs I being disclosed a likely cancer diagnosis without the support of her family or a clinical nurse specialist, which is regrettable.
38. The Trust also agreed there had been no communication with Mrs I’s family either before or after the surgery. We know from what Mrs K has told us, how upsetting this was for all the family.
39. We have found the Trust failed to include Mrs I’s family in discussions about her care and treatment or provide a nurse for emotional support. This is not in accordance with GMC guidance.
40. We will discuss the impact of this failing further in our report.
Consent
41. The evidence shows on 31 January 2024, Mrs I was asked to consent to emergency surgery at the same time as being told she had colon cancer. Mrs K told us the Trust did not give Mrs I the option to refuse surgery.
42. The consent form includes a pre-typed statement which says, ‘I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns of the patient’.
43. The Trust told us the consent process was undertaken by a senior registrar (a year four specialist registrar) who was in good standing with the General Medical Council (GMC) and had an exemplary professional portfolio. It said it would be unusual for a senior registrar at this level not to disclose the alternatives to surgery after a detailed consent process.
44. The Trust said, there was clear documentation about the likely intervention needed, potential risks and complications including death. However, there was no explicit written documentation about alternatives to surgery.
45. The Trust went on to say, the detail of the documentation is also dependent on the ability of the doctor to capture in writing all the information that was mentioned during the consent process. This can often be quite a lengthy process, and it may not always reflect accurately all the details of the events that took place. It is likely this was probably mentioned to Mrs I, but it was not captured in the notes. It said however, it could not be absolutely certain.
46. As we have already seen, Mrs I was alone during the consenting process, and we have no other witnesses to the conversation. Mrs K tells us Mrs I was not told she could refuse the surgery. The Trust has said it is likely given the experience of the registrar that Mrs I was given this option but could not be sure as it was not explicitly noted on the consent form.
47. We consider it is possible the surgeon did not write they had offered the option to refuse surgery as this was a pre-typed statement on the consent form, and they may have relied upon that to cover this part of the consenting process.
48. Due to this, we cannot say in all certainty the Trust did not give her the option to decline surgery.
49. Our Service Model Guidance (SMG) says in section 3.38: in reaching a decision, we should consider the evidence provided to us by all parties including eyewitness accounts provided by the complainant and others present, and what is documented in the records.
50. Section 7.10 of our SMG says that in some cases, there may not be enough evidence, or the evidence is so equally balanced that even on the balance of probability we cannot come to a view.
51. In line with our SMG, we have carefully considered all the evidence provided including Mrs K’s account and the Trust’s response. We have considered if we can make a decision on the balance of probability, taking a view that something is more likely than not to have happened based on the available evidence.
52. Taking all of this into consideration, we cannot say it is more likely than not the Trust did not give Mrs I the option to decline surgery. We do not wish to diminish Mrs K’s account of events, and we recognise her distress in relation to this matter. We have unfortunately not seen enough evidence to convince us either way.
Impact of failings identified
53. We sought advice from our surgeon and physician advisers to consider the impact of the failings we have identified.
54. We saw the Trust should have requested a repeat colonoscopy or CT colonography on 7 November 2023 in accordance with GMC’s Good Medical Practice.
55. Generally, patients will be seen within two weeks if cancer is suspected and so we can say the Trust could potentially have diagnosed Mrs I with colon cancer on or around 21 November 2023. Mrs I was eventually diagnosed with colon cancer on 31 January 2024 and so this equates to a delay of around ten weeks.
56. The operation notes suggest the cancer was advanced and had spread to the surface of the small bowel. Our surgeon adviser told us based on the histology report the final staging of the cancer was T3 (the tumour had grown through the outer layer of the bowel), N2b (many of the lymph nodes or glands associated with this part of the bowel were involved with tumour) and poorly differentiated (the cancer cells show signs of being particularly aggressive). There were also tumour deposits in the fat surrounding the bowel which is also associated with poor prognosis.
57. The histology report from February 2024 describes the tumour as measuring 60x60x55mm in size. This compares to a reported abnormality of 46mm in November 2023. There will be some inaccuracy in comparing the sizes due to different measuring techniques (histology versus scan) but even allowing for this, we have seen evidence the tumour increased in size between November 2023 and February 2024.
58. TNM staging is a standardised system used to classify the extent of cancer spread, helping guide treatment decisions and predict outcomes. We cannot say the TNM staging of the cancer, which affects the overall chances of survival, would have been different had it been operated on in November.
59. The factors described above show this was a particularly aggressive type of cancer and fast growing but the most significant characteristic in determining long term survival is the N (nodal) status and we have no way of knowing if the nodes were involved in November or not.
60. We do know, the progression of the tumour from November to February led to the obstruction of Mrs I’s bowel and requirement for emergency surgery.
61. Our surgeon adviser told us it is not possible to say whether a delay in diagnosis made a difference to the eventual outcome as Mrs I died from complications of multiple strokes and frailty rather than from colon cancer.
62. We considered whether the emergency surgery could have caused Mrs I to have a stroke. Our physician adviser reviewed Mrs I’s medical records to help us understand this.
63. A study from the National Library of Medicine describes how stroke after surgery is a recognised risk and the factors associated with increased risk including advanced age and hypertension were present in Mrs I.
64. Mrs I had several comorbidities (when two or more medical conditions exist simultaneously in a patient) including type 2 diabetes, chronic kidney disease, hypertension and hypercholesterolemia (high levels of bad cholesterol in the blood). There was also a history of recent pulmonary embolism requiring anticoagulation with apixaban (a blood thinning agent). All these factors can increase the risk of stroke at any stage.
65. An MRI scan carried out on 13 February 2024, shows multiple strokes and it is possible Mrs I suffered some of these even prior to the surgery.
66. We cannot say the emergency surgery directly caused Mrs I’s stroke. Additionally, our physician adviser told us, her risk of stroke before, during and after the operation would have been the same had the surgery been elective or emergency.
67. We consider there was a failure to adequately assess and diagnose Mrs I in November 2023 causing a ten week delay, in which time the tumour grew large enough to cause an obstruction requiring emergency surgery. This caused shock and distress to Mrs I and her family.
68. We consider this also meant an earlier opportunity to diagnose colon cancer was missed and in turn Mrs I lost the opportunity to discuss her options in a non-emergency setting. This may have given her time to think about how she wanted to proceed with her care and treatment.
69. We consider these events have caused Mrs K considerable distress and she has been left with uncertainty as to how Mrs I’s journey may have been different had she been diagnosed with colon cancer in November 2023.
70. In its final response the Trust did not acknowledge the impact of this failing or provide an apology or any remedy. We have made a recommendation at the end of the report to address this.
Communication and support
71. We next considered the impact of the Trust failing to communicate with the family and ensure she had support when discussing the cancer diagnosis and emergency surgery. Mrs K told us as a result of her mother being told she had colon cancer with no one to support or comfort her, they found her devastated and in tears. She said the family were heartbroken to see their mum alone and so distressed.
72. Mrs K tells us they were not given a clear explanation about the risks of surgery or any alternatives. She says had Mrs I been given the choice she may have declined the surgery in favour of spending quality time with her family in her final weeks.
73. We have already discussed how we cannot say for certain the Trust did not tell Mrs I she had the option to refuse surgery.
74. We do however consider had the Trust communicated with Mrs I’s family before the surgery took place and ensured someone was with her during the consenting process, then her family would have had the opportunity to ask about the different options and help Mrs I decide how she would like to proceed.
75. We cannot say with all certainty Mrs I would have made a different decision had the Trust communicated with her family and provided support during the consenting process.
76. We consider the impact of this failing to be emotional distress to Mrs I and her family and the missed opportunity to fully consider her options with the support of her family.
77. In its final response the Trust stated an apology had already been given to Mrs K for failing to communicate. It also stated it had reminded its surgical team and junior doctors, about the importance of maintaining regular contact with the patient’s family members.
78. Our complaint standards say organisations should look for continuous improvement and use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service and apologise when things go wrong.
79. We think the actions of the Trust should ensure the relevant standards are met and are in line with our complaint standards. We hope this provides some reassurance to Mrs K.
80. Mrs K also seeks a financial remedy, and we have made a recommendation to address this at the end of the report.