An independent provider in the Tonbridge and Malling area

5. Mrs A complains about the care and treatment the Trust provided to her husband after he presented to its Emergency Department (ED) on 12 February 2024.

6. The Trust transferred Mr A to the Centre on 14 February 2024, and he returned to the Trust on 28 February 2024. Mrs A complains the Trust did not follow recommendations from the Centre. She also complains the Trust wrongly said her husband was medically fit and discharged him to a community hospital for physiotherapy on 9 March 2024.

7. The Trust later diagnosed Mr A with cancer, and he died on 20 April 2024. Mrs A says the Trust’s actions led to her husband’s cancer diagnosis being delayed and meant it was too late for him to receive treatment. She says she knows he had a rare and aggressive cancer, and the outcome may not have been different, but too much time was lost.

8. Mrs A has told us the Trust told her husband he did not have cancer, only to tell him a few weeks later that he did and there was nothing it could do. She also says he spent the weeks leading up to his death in pain and suffering. She says the physiotherapy treatment was extremely painful for him and he should have been receiving palliative care.

9. Mrs A says events were very upsetting for her and the family to witness and they have been left devastated by her husband’s death and the circumstances surrounding it.

10. Mrs A would like the Trust to apologise, make service improvements to stop the same failings from happening again and pay her a financial remedy.

11. Mr A was in his seventies at the time events took place. He attended the Trust’s ED on 12 February 2024 with upper back pain. The Trust carried out a CT scan which showed a soft mass on his spine, suspicious of cancer. A CT scan uses X-rays to create images of the body.

12. The Trust then carried out an MRI scan which showed impending spinal cord compression due to a tumour, likely a plasmacytoma. An MRI scan uses magnetic fields and radio waves to create images of the body. Plasmacytoma is a very rare form of blood cancer than affects plasma cells (a type of white blood cell that produces antibodies).

13. On 14 February 2024, Mr A started to feel electric shock like sensations over his legs. Later that day, he developed numbness in both legs as well as a loss of power and urinary incontinence. The Trust contacted the Centre and agreed to transfer him there for surgery.

14. The Trust transferred Mr A to the Centre later that day and he underwent emergency surgery. The surgery aimed to ease the pressure on his spinal column. The procedure involved decompressing the spinal canal and fixing it to prevent further injury to his spinal cord.

15. The Centre transferred Mr A back to the Trust on 28 February 2024. The Trust then discharged him to a community hospital for rehabilitation on 8 March 2024. Sadly, the Trust later diagnosed Mr A with a rare and aggressive cancer.

16. Mr A then very sadly died on 20 April 2024. We cannot begin to imagine what a difficult time this has been for Mrs A and her family. We know pursuing a complaint can also be incredibly hard particularly while grieving the loss of a loved one.

The Trust did not follow recommendations from the Centre

What happened:

20. The Centre transferred Mr A back to the Trust on 28 February. The medical team then referred him to the acute oncology team on 1 March. The Centre emailed the Trust a list of recommendations later that same day following a multi-disciplinary (MDT) meeting where it discussed Mr A’s case.

21. The Centre recommended a repeat biopsy three to six weeks after surgery, as well as an urgent ultrasound of the thyroid (a gland in the neck that produces hormones that regulate metabolism, energy levels and overall body function) and tumour markers (substances produced by the body in response to cancer) including myeloma screening (a type of blood cancer).

22. The acute oncology team reviewed Mr A on 4 March. They noted his tumour markers were normal and removed him from their list. They advised the medical team to re-refer him, if needed. The medical team then spoke with haematology on 7 March (the branch of medicine focussed on the blood) who did not feel Mr A had blood cancer.

23. The medical team found Mr A medically fit for discharge on 7 March. They discharged him to a community hospital for ongoing physical and occupational therapy on 9 March. We understand Mr A’s family contacted the Centre with concerns about his discharge a few days later.

24. The Centre contacted the Trust on 12 March asking why it had not done a repeat biopsy. A medical consultant replied saying histology (the branch of biology studying the microscopic structure of tissues and cells) showed no cancer and Mr A’s tumour markers were normal. The Centre then contacted the Trust by telephone, and the acute oncology team added him back to their list.

25. We understand the Trust then spoke with Mr A on 13 March. It explained the Centre had taken a biopsy during surgery, but the results were inconclusive. They said he needed further investigation for cancer of unknown primary source. Mr A then had the repeat biopsy on 3 April which showed a suspected sarcoma (a rare type of cancer).

26. The Trust partly upheld Mrs A’s complaint. It said the acute oncology team did not follow the Centre’s recommendations as it did not ensure a repeat biopsy had been organised before removing Mr A from their list. The Trust also acknowledged it was likely Mr A would not have had the repeat biopsy when he did if the family had not contacted the Centre.

27. The Trust apologised. It said the Centre recommended a repeat biopsy three to six weeks post-surgery, and it did one six weeks and six days after Mr A’s surgery. It said the acute oncology team now has a daily huddle before removing patients from their list which involves input from senior leaders.

28. The Trust said the outcome would have been the same had the repeat biopsy taken place sooner due to the rapid extent of Mr A’s disease. However, it acknowledged Mr A may have chosen to go home rather than be discharged to the community hospital for rehabilitation.

What we found:

29. The Trust had already made a diagnosis of likely cancer following the CT scan on 12 February and the MRI on 14 February. Usually, the biopsy taken during surgery would lead to the cancer diagnosis, but this did not happen in Mr A’s case. There was no obvious primary cancer site meaning NICE guideline 104 applies here.

30. Section 1.2.1 says to offer patients with cancer of unknown primary origin a biopsy guided by the patient’s symptoms and when clinically appropriate. Our adviser said a biopsy was mandatory in this case. They confirmed the Trust should have arranged a biopsy within three to six weeks of Mr A’s surgery.

31. Our adviser said responsibility for organising the biopsy lay with the medical team as Mr A was admitted to the Trust under their care. We consider not arranging the biopsy went against section 7c of GMC professional standards. This says doctors must promptly provide or arrange suitable investigations where necessary.

32. Looking at Mr A’s clinical notes, we have seen nothing to suggest the medical team or the acute oncology team considered arranging a repeat biopsy at the time. This meant the Trust discharged Mr A with no plan for any ongoing investigations into his condition delaying his cancer diagnosis.

Mr A’s discharge to the community hospital on 9 March 2024

What happened:

33. The Trust said the decision to discharge Mr A to the community hospital for rehabilitation was made by physiotherapy and occupational therapists following his spinal surgery. It said doctors documented there was no evidence of metastases at the time.

34. The Trust said when Mr A was re-admitted on 28 March his mobility had improved. It said this supports its decision to discharge him to the community hospital for rehabilitation. It also said the Centre recommended physiotherapy treatment.

What we found:

35. Our adviser said there is no specific guidance for this situation. However, in their experience, patients routinely need a period of rehabilitation following surgery for spinal cord compression. They also said a period of rehabilitation would have been clinically appropriate even had Mr A’s cancer been known at the time.

36. According to the NHS website, recovery from lumbar decompression surgery depends on your level of fitness and activity prior to surgery. However, it says it will take around four to six weeks to reach your expected level of mobility and function depending on the severity of your condition and symptoms prior to surgery.

37. The Trust’s decision to discharge Mr A to the community hospital for physiotherapy was in line with GMC professional standards. Section 7h says doctors should refer a patient to another suitability qualified practitioner when this serves their needs. However, the Trust’s communication with Mr A and his family was poor. We address this below.

Communication

What happened:

38. Mrs A says the Trust told her husband he likely had cancer before it transferred him to the Centre. She says it told him he did not have cancer following his return to the Trust and then later told him he did have cancer. Mrs A says this caused her husband and the family a great deal of distress.

What we found:

39. Looking at Mr A’s clinical records, we can see very little in the way of notes showing what information doctors gave him after his return from the Centre. We have seen no evidence the Trust told him the biopsy taken during surgery was inconclusive and he needed further tests. It appears doctors believed he did not have cancer at that time.

40. The Trust discharged Mr A to the community hospital for rehabilitation with no plan for any ongoing investigations. We can therefore understand why Mr A and his family were left unclear about what had happened, what his condition was and what needed to happen next in terms of his healthcare.

41. The Trust’s communication was not in line with GMC professional standards. Section 28 says doctors must give patients the information they want or need in a way they can understand. It says this includes information about their condition, likely progression, and any uncertainties about diagnosis and prognosis.

Impact

42. There was a small delay in the Trust carrying out the repeat biopsy. It should have been done between 6 March and 27 March (Mr A being in hospital up to 8 March) but it instead took place on 3 April. It also only happened as Mr A’s family contacted the Centre with concerns.

43. We asked our adviser what Mr A’s prognosis would have been had the Trust carried out the repeat biopsy sooner. They confirmed the outcome would have sadly been the same due to the aggressive nature of Mr A’s cancer. We hope this provides Mrs A with some reassurance.

44. We note Mr A had a scan on 25 March and got the results on 28 March. The scan showed he had cancer that had rapidly progressed beyond his spine. This means the cancer diagnosis may not have been made sooner had the repeat biopsy taken place towards the end of the recommended timescale.

45. The delayed biopsy and poor communication caused Mr A and his family uncertainty and distress at an already difficult time. Mr A and his family would have had a little more time to process what was happening and prepare. They would have also been less anxious had they not had to raise concerns themselves.

46. These failings also meant Mr A did not have all the information available to make informed decisions about his own care. Like the Trust, we recognise he may have decided not to go to the community hospital for physiotherapy. This must have been incredibly difficult for him with his condition. We recognise all these issues will add to the family’s bereavement.

47. The Trust has not yet taken appropriate action to put things right either for Mrs A or other patients. We recognise it has acknowledged and apologised for the delayed biopsy. However, it has not yet recognised or apologised for its poor communication or advised of any actions to improve this.

48. We understand the Trust has put a service improvement in place to stop the issue with the repeat biopsy from happening again. It says the acute oncology team now has daily huddles before removing patients from their list. We need more information about this so we can be assured the same thing will not happen again.

49. Our adviser said responsibility for organising the repeat biopsy fell with the medical team Mr A was under. We also need information about how the Trust will improve its service here.

1. Mrs A complains about the care and treatment the Trust provided to her husband, Mr A, following spinal surgery at a specialist neurological centre (the Centre) on 14 February 2024. Mr A very sadly died on 20 April 2025 following a cancer diagnosis.

2. We found the Trust delayed in carrying out repeat biopsy and only did the biopsy as Mr A’s family raised concerns. We also found the Trust did not clearly communicate with Mr A. We found no failings in the Trust’s decision to discharge him on 9 March 2024.

3. These failings did not impact Mr A’s prognosis, but they caused him and his family unnecessary distress. They also meant he did not have all the information he needed to make informed decisions about his own care. We therefore partly uphold this complaint.

4. We recommend the Trust writes to Mrs A to acknowledge and apologise for the failings we have found and the impact they have had. We also recommend the Trust takes action to stop the same failings from happening again and pays a financial remedy of £1,000.

50.We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

51.Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

What we found

52.Through investigating Mrs A’s complaint, we found:

• the Trust failed to carry out a repeat biopsy in line with recommendations by the Centre and only carried one out later as Mr A’s family raised concerns • the Trust failed to discharge Mr A with a plan for further investigations into his suspected cancer and • the Trust failed to communicate with Mr A so he understood what was happening.

53.These failings meant Mr A could not make informed decisions about his own healthcare. They also caused Mr A and his family additional distress at an already difficult time.

What the Trust should do

54.Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship. In line with this, the Trust should write to Mrs A to acknowledge the failings and impact we have found. It should do this by 5 January 2026 and send a copy to us.

55.Our Principles for Remedy say organisations should compensate people appropriately if they cannot return the person affected to the position they would have been in if the poor service had not occurred.

56.To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. Following this review, the Trust should pay Mrs A £1,000 in recognition of the injustice we have found. It should do this by 5 January 2026 and send us evidence it has done so.

57.Our Principles for Remedy also say organisations should look for continuous improvement and learn lessons from complaints to make sure poor service is not repeated. In line with this, the Trust should write to Mrs A with an action plan. It should do this by 26 February 2026 and send us evidence it has done so. The action plan should clearly set out the following:

• actions required • start date for each action • person/team responsible for each action • progress with each action • how each action will be reviewed when complete/evidence of completion • date of review of each action • date of completion for each action/when completed.