Identifying spread of cancer
26. Mrs E complains staff took too long to carry out scans to identify her father’s cancer had spread. She says staff showed a lack of urgency as it took them ten days to confirm his cancer had progressed. She believes her father did not receive adequate care or support during this time.
27. Our adviser explained there is detailed guidance on initially diagnosing cancer. There is no specific guidance about when or how doctors should investigate whether an existing cancer has spread or whether there are secondary cancers.
28. In lieu of specific guidance, we sometimes refer to GMC’s good medical practice which says doctors must provide a good standard of practice and care. They must adequately assess a patient’s condition and take account of their medical history. Doctors must examine patients and promptly provide or arrange suitable advice, investigations and treatment.
29. Mr A went into hospital with known existing bladder cancer and severe chronic kidney disease. Staff diagnosed him with a urinary tract infection and an acute kidney injury, both of which staff treated during the first six days of his admission.
30. He underwent several investigations between 28 March and 4 April. On 4 April, clinicians noted Mr A likely had secondary cancer which had spread from his primary cancer in the bladder.
31. Clinical records show staff focused on diagnosing and treating Mr A’s acute kidney injury and urinary tract infection before carrying out further investigations.
32. Our adviser said these conditions would explain Mr A’s symptoms and why he was unwell. They said it is standard clinical practice to first treat any acute or reversible conditions before pursuing further investigations. Meaning the decision to treat these first was in line with GMC guidance.
33. We can see staff carried out further imaging and investigations once Mr A’s condition had stabilised. Our adviser reviewed the records and confirmed all scans were completed and reported on promptly. This was in line with GMC guidance which says doctors must promptly arrange suitable investigations.
34. We recognise Mr A’s family considers scans should have taken place sooner because they feel they had less time with him than they should have. We are sorry for the distress this caused.
35. We do not consider staff delayed investigating whether Mr A’s cancer had spread. The evidence shows staff investigated Mr A for spread of cancer once they had treated his urgent medical conditions. This was in line with GMC guidance. We have seen no indication of failing in this aspect of the complaint.
Move to palliative care
36. Mrs E complains staff took too long to move her father to palliative care. She considers they should have done this much sooner than 5 April. She says the palliative care team were amazing, but the family only benefitted from their support for a short time.
37. The relevant guidance for this aspect of the complaint is NICE guidance on ‘care of dying adults in the last days of life’. This says doctors should assess for signs and symptoms that may indicate a person is entering the last days of life and review any available investigation results that could suggest this.
The guideline lists a range of possible changes including: •agitation or reduced level of consciousness •mottled skin or noisy respiratory secretions •progressive weight loss, increasing fatigue or loss of appetite •changes in communication, mobility or social interaction.
38. Our adviser said with hindsight we can see Mr A was dying during his admission, as he died the day after staff discharged him. They said this is not always clear at the time of events. They explained clinicians must make decisions based on how a patient is responding to treatment and whether recovery remains possible.
39. In this case, staff were actively treating Mr A’s urinary tract infection and acute kidney injury. Our adviser said these were potentially reversible causes of his deterioration and it was reasonable for staff to hope his health might improve.
40. Clinical records show Mr A’s condition was not improving despite treatment. On 30 March, staff identified he likely had secondary cancer and carried out a biopsy two days later to investigate this. The results confirmed the presence of secondary cancer.
41. Around this time Mr A’s infection markers were raised, and he tested positive for COVID-19. On 5 April he developed significant breathing difficulties. Our adviser noted staff moved Mr A to palliative care when it became clear his condition was not improving, and he was approaching end of life. They said this approach was consistent with NICE guidance.
42. Our adviser explained doctors and nurses can often manage palliative care needs without a specialist referral. They said in this case the timing of the palliative care referral was prompt and consistent with good medical practice.
43. We have seen that once staff sent the referral they worked with the palliative care team to arrange the package of support Mr A needed for discharge.
44. We understand Mr A’s family would have preferred him to be at home for longer. We recognise how distressing it was that he died so soon after leaving hospital. We are sorry for the sadness this caused.
45. Overall, our adviser said staff recognised and responded to Mr A’s deterioration in a timely and clinically appropriate way. We have not seen any evidence that staff delayed referring Mr A to palliative care. We have seen no indication of failing in this aspect of the complaint.
Discharge
46. Mrs E complains staff took too long to discharge her father on 7 April. She says the family were left waiting until late in the evening for staff to send him home. She says the family told staff early in the day that Mr A wanted to come home, but it took more than nine hours for transport to arrive.
47. She also says that when transport arrived at around 10.45pm, staff did not know Mr A was at end of life because they had not included this in the referral.
48. Our adviser said there are no specific standards or guidelines setting out expected timescales for discharge in these circumstances. In lieu of these, we refer to GMC guidance which highlights the importance of listening to patients. This says doctors should respond to patient’s preferences and involve others in their care in line with their wishes.
49. Clinical records show as late as 6 April, staff were arranging for Mr A to go to a hospice, but no beds were available. On the morning of 7 April, Mr A’s family told staff he had a bad night and now wished to go home. Staff began arranging this shortly afterwards.
50. Our adviser explained this was a complex discharge as Mr A required support in place at home. They noted staff managed to organise this and get him home the same day. Our adviser described this as impressive given the practical challenges involved. They commented that in many hospitals staff would struggle to achieve this within the same day.
51. Our adviser said it is common practice for hospitals not to send older patients home in the evening. They said staff supported Mr A and he was able to die at home. This was in line with both his and his family’s wishes.
52. We understand the ambulance staff did not seem to know Mr A was approaching the end of his life. If they had known, it might have meant he could have gone home sooner. We cannot say this with any certainty as we do not know what the ambulance demand or waiting times were that day.
53. We recognise Mrs E wanted her father to go home much earlier in the day. We understand she found it distressing that he arrived home late at night.
54. There is no specific guidance that specifies timeframes for discharging patients receiving end of life care. Our adviser said staff acted in line with GMC guidance by quickly changing the discharge plan and ensuring Mr A could go home that day. We have not seen an indication of failing in this aspect of the complaint.
COVID-19 test
55. Mrs E complains staff asked her and her brother to do a COVID-19 test. She says they did not see staff ask any other patient’s family members to do this.
56. Mr A’s admission took place between March and April 2022 when hospitals were still managing the impact of the COVID-19 pandemic. Our adviser explained that while there was national guidance on testing for patients, there was no specific national guidance covering testing for visitors. Local arrangements were in place, and these could vary depending on local COVID-19 rates, outbreaks and hospital policy at the time.
57. Our adviser noted that national guidance, such as NHS England’s ‘Living with COVID-19: Visiting healthcare inpatient settings principles’ encouraged hospitals to allow visiting wherever possible but permitted flexibility. Our adviser said this meant hospitals were able to introduce stricter measures if an outbreak occurred on the ward. This included asking visitors to test.
58. In Mr A’s case his family were able to visit and the requirement to test did not prevent them from seeing him. It is not clear from clinical records when staff asked Mr A’s family to do COVID-19 tests or what the specific circumstances were in the hospital at the time. We know around 13 days into his admission Mr A tested positive for COVID-19. This suggests there was likely an outbreak or active infection management on the ward at the time which could explain why staff were asking visitors to test.
59. Our adviser said given the situation at the time, when hospitals were still responding to changing COVID-19 conditions, it would have been standard practice for staff to ask visitors to complete a test.
60. In its response to the complaint the Trust says at the time of Mr E’s admission it was still asking relatives to provide evidence of a negative COVID-19 test.
61. It is not possible for us to say which other visitors were or were not asked to test as this information would not be recorded and relates to other patients. We recognise Mr A’s family did not see staff ask other visitors to test. This does not mean staff were not asking other visitors to test.
62. We understand that being asked to take a test was frustrating for Mr A’s family, particularly in the context of their wider concerns and at such a difficult time. Taking the test enabled them to visit, which was especially important given Mr A was approaching the end of his life.
63. Our role is to decide whether what happened fell so far below an expected standard that it amounts to a failing in service or care. Based on the evidence available we consider it was reasonable for staff to ask the family to take a COVID-19 test as this enabled them to visit Mr E. For this reason, we have seen no indication that anything went wrong in this part of the complaint.
Communication
64. Mrs E complains the Trust incorrectly told her it had sent her father’s medication home by taxi on 7 April 2022. She says this did not happen and this added unnecessary distress at an already distressing time.
65. The Trust first said it had done this in its complaints response in October 2022. In its second response in August 2023, it confirmed there was no record of staff booking any taxi and apologised for the inaccurate information.
66. The Trust apologised again in its final response. It clarified that some of Mr E’s medication contained controlled drugs which legally staff could not have sent via taxi. It said it had reminded staff to give clear information to patients and families and to document steps they had taken.
67. Our principles of good administration say organisations should provide information that is clear, accurate and complete. We consider the Trust did not meet this requirement when it gave Mrs E incorrect information about her father’s medication.
68. We recognise Mrs E was grieving the loss of her father. The Trust’s miscommunication will have caused avoidable upset at an already painful time. She experienced this additional upset for around nine months until the Trust confirmed its earlier information had been wrong.
69. We can see the Trust has apologised, acknowledged the impact of its mistakes and taken steps to prevent similar issues in future. Having considered this in line with our remedy guidance, we are satisfied these actions are proportionate to the injustice Mrs E experienced.
70. For these reasons we have decided to take no further action in Mrs E’s complaint.
71. We understand how upsetting these events have been for Mrs E and her family. We hope we have been able to provide some reassurance that we have carefully considered her concerns, and we thank her for bringing this complaint to our office.