Colorectal cancer diagnosis
16.Mrs E complains the Trust diagnosed Mr R with colorectal cancer following emergency surgery in August 2023. She explained the Trust did this without taking a biopsy of Mr R’s tumour. Mrs E explained that once Mr R did have biopsies taken, the diagnosis was pancreatic cancer and there was a poor prognosis.
17.Mrs E explained this caused a lot of false hope and distress to her and the family as when they were first told about the colorectal cancer, Trust staff told them that Mr R could potentially have treatment for this. We are very sorry that this happened and understand the significant distress this situation caused to Mrs E, Mr R and their family.
18.In its complaint response, the Trust explained that in August 2023, Mr R’s CT scan results showed a large mass which was obstructing his bowel, and the bowel was showing signs of ischemia (lack of blood flow). The Trust explained a radiologist reported on the CT scan and said the mass looked like a locally advanced colonic cancer which was invading into the spleen, pancreas and stomach.
19.A colorectal surgeon performed emergency surgery on Mr R shortly after his CT scan was reported. The surgeon found areas of necrosis (dead tissue) in the right colon and superficial tears, caused by the bowel obstruction from the tumour. The surgeon identified the tumour mass was fixed (a mass of cells that is immobile, feeling anchored or attached to underlying tissues because it is connected to other structures in the body), and it therefore could not be removed during the surgery.
20.After it was identified the tumour was fixed, the surgeon performed an open extended right hemicolectomy (a procedure to remove a diseased section of the large intestine, including the right colon, a portion of the transverse colon and surrounding lymph nodes). Following surgery, the Trust noted that an ongoing management plan for the tumour needed to be established due to lack of surgical options.
21.The Trust explained that Mr R was discussed at the colorectal cancer multidisciplinary team meeting (MDT), and clinicians decided the diagnosis was colonic cancer. Mrs E explained she feels biopsies should have been taken before any sort of diagnosis was given. We understand her concerns around this as when Mr R did have biopsies taken in October 2023, the Trust diagnosed him with pancreatic cancer which had a poor prognosis and Mr R decided not to have any treatment for this. We therefore appreciate Mrs E’s comments in respect of being given false hope when the diagnosis of colonic cancer was given.
22.There are no guidelines which specifically say biopsies should always be taken before giving a diagnosis of cancer. But as we go on to explain below, we would always expect doctors to share relevant information with patients and their families based on the best available evidence at the time.
23.Our Principles of Good Administration state organisations must act in accordance with recognised quality standards, established good practice or both when delivering clinical care. Therefore, in this situation, we will use the professional judgement of our adviser which is based on established good practice.
24.Our colorectal adviser explained that until a biopsy is performed, any diagnosis is presumed but not confirmed.
25.In this case, Mr R’s pre-operative CT scan suggested a colon cancer which was locally advanced. Our colorectal adviser said the mass that was identified involved Mr R’s stomach, spleen, pancreas and colon so, the primary origin of the cancer could have been from any of these organs.
26.Our colorectal adviser explained that a radiologist can provide a provisional diagnosis based on assessing where the epicentre of the cancer seems to be focussed. In Mr R’s case, the mass appeared to be centred on the colon which our adviser said would make it the more likely primary source of the cancer.
27.Our colorectal adviser told us that it seems logical to take a biopsy at the time of a patient’s operation. However, bowel cancers arise from the inner lining of the bowel and during an operation a surgeon can only see and touch the outer lining of the bowel. Our colorectal adviser said that if a biopsy is made from the outer layer into the core of the mass, this could have led to a perforation of Mr R’s bowel.
28.It is our colorectal adviser’s view that the Trust’s surgeon was correct not to take a biopsy during Mr R’s surgery.
29.The relevant GMC guidance says: ‘You must make sure that the information you give patients is clear, accurate and up to date, and based on the best available evidence.’
30.We have seen that the diagnosis of colorectal cancer the Trust gave to Mr R was based on a consultant radiologist’s report of a CT scan. As the CT scan showed the main mass of Mr R’s tumour to be centred on the colon, we consider it was appropriate for the Trust to give a diagnosis of colorectal cancer. The diagnosis was based on the information the Trust had available at the time (CT scan), which we consider to be in line with the above quoted guidance in respect of information being given based on the best available evidence.
31.We are sorry to learn that once a biopsy of Mr R’s tumour was taken, the diagnosis was different to the initial diagnosis. Mrs E explained to us that following the diagnosis, she was under the impression Mr R could have had treatment for colorectal cancer. We can understand how this led to feelings of false hope for Mr R, Mrs E and their family.
32.In summary, we have found the Trust reasonably diagnosed Mr R with colorectal cancer based on the findings of his CT scan. This was the best evidence the Trust had available given it was not appropriate to take a biopsy during Mr R’s surgery in August 2023. We consider this was done in line with relevant guidance. We acknowledge the importance of Mrs E’s complaint, and we are sorry to hear how the events have impacted on her and the family. We thank her for giving us the opportunity to look into her concerns and we hope she is reassured by what we have seen.
Flexible sigmoidoscopy cancellation
33.Mrs E told us that the Trust incorrectly cancelled Mr R’s flexible sigmoidoscopy procedure following his surgery in August 2023. She explained this meant Mr R was discharged without having the procedure and this led to a 26-day delay in his treatment pathway. Mrs E added that after Mr R was discharged, the family did not hear anything from the Trust about any follow up appointments.
34.Mrs E says she feels the delay in Mr R’s treatment pathway ultimately contributed to his premature death. We are very sorry to hear how these events have had an impact on Mrs E and the family, and we acknowledge the distressing situation they experienced. We understand the importance of her complaint.
35.The Trust explained that after Mr R’s surgery, he was discussed at the colorectal cancer multidisciplinary team meeting (MDT). The outcome of this MDT meeting was to allow Mr R to recover from his surgery and then obtain a biopsy as an inpatient. The Trust arranged a flexible sigmoidoscopy for early September 2023.
36.The Trust explained that on the day of the planned flexible sigmoidoscopy, a consultant did a ward round and cancelled the procedure. The consultant then produced a plan which said to provide colorectal nurse contact details and to discharge Mr R.
37.The surgeon who carried out the surgery in August 2023 reviewed the events and confirmed there must have been a misunderstanding or miscommunication within the Trust, and believes it was thought that Mr R’s tumour had been removed during his surgery. The Trust explained that this was the reason for the flexible sigmoidoscopy being cancelled by mistake and this caused the delay in Mr R’s treatment pathway. The Trust apologised on behalf of its medical team for the oversight.
38.The Trust also explained that Mr R was due to have an outpatient follow up appointment six weeks after his discharge, which is standard for all emergency surgery patients.
39.The relevant GMC guidance says:
‘In providing clinical care you must:
carry out a physical examination where necessary promptly provide (or arrange) suitable advice, investigation or treatment where necessary.’
40.The Trust has accepted that the flexible sigmoidoscopy was cancelled in error which led to a delay in Mr R’s treatment pathway, and it has apologised for this. We consider there to be failings here. The actions of the Trust, specifically in cancelling this procedure, fall outside of what is expected as outlined in the above quoted guidance.
41.Given Mr R had recently undergone emergency surgery, we understand how difficult it was for him, Mrs E and the family to learn that this procedure had been cancelled in error.
42.We spoke to an oncology adviser to understand Mr R’s clinical situation and the impact the delay in his pathway had on him.
43.Our oncology adviser explained that the re-arranged flexible sigmoidoscopy failed to make a diagnosis as the biopsies came back as negative. Our oncology adviser confirmed that with hindsight, the flexible sigmoidoscopy results reinforced that Mr R’s cancer was likely arising from outside the colon.
44.Given that the biopsies from the flexible sigmoidoscopy were negative, our oncology adviser explained that there would have been delays even if the procedure was not initially cancelled in error, to allow for a further MDT discussion and planning a guided biopsy.
45.Mr R was diagnosed with pancreatic cancer in November 2023, following a guided biopsy. Our adviser told us that pancreatic cancer is an extremely poor diagnosis with limited survival. Our adviser explained that if there were no delays in Mr R’s pathway, palliative chemotherapy would have been the only option which would have had limited benefits.
Informed by our oncology adviser’s view, we have found the 26-day delay in Mr R’s treatment pathway had no clinical impact on him.
46.Our oncology adviser explained that the only way in which Mr R’s outcome could have been different would have been if he accepted palliative chemotherapy. The records show the Trust gave Mr R the option of discussing this with an oncologist at the time of his diagnosis, but he decided against this. Our oncology adviser told us that if Mr R had palliative chemotherapy, he would have had no more than an additional three to four months of life.
47.We understand Mrs E feels the delay in Mr R’s pathway contributed to his premature death. Given that Mr R declined palliative chemotherapy once a diagnosis of pancreatic cancer was given, we have found that the delay in his pathway did not directly contribute to his death. We consider that on balance it is likely Mr R would have declined palliative chemotherapy if he was given the same diagnosis and treatment options 26 days earlier.
48.Whilst we have found the delay did not contribute to Mr R’s death and had no clinical impact, we acknowledge the significant emotional distress that Mr R, Mrs E and their family experienced during this period.
49.Mr R had undergone emergency surgery and was given a diagnosis of cancer. After he was discharged, the family did not hear anything from the Trust and had to chase this up themselves. It was only at this point that the Trust identified the flexible sigmoidoscopy was cancelled in error.
50.We consider this caused additional distress for Mr R and his family and added to what was already a very difficult situation. We consider this is an injustice to them, which could have been avoided if the failings we have identified above did not happen. Mr R and his family were worried that he was not getting the treatment he deserved which could have meant a poorer prognosis due to the delay in his pathway.
51.Mrs E explained to us that when Mr R did not hear anything from the Trust after his discharge, he felt forgotten about and suffered from anxiety and depression as a result. We can understand why the events caused this and we are sorry to learn of how he felt during this time.
52.Our principles for remedy state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right. Our principles say: ‘An appropriate range of remedies will include:
• an apology, explanation, and acknowledgement of responsibility • remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures to prevent the same thing happening again; training or supervising staff; or any combination of these’
53.We acknowledge the Trust has already apologised and accepted responsibility for Mr R’s flexible sigmoidoscopy being cancelled in error. We are pleased to see this and consider these actions to be in line with our principles for remedy.
54.When making her complaint, Mrs E queried what measures the Trust has put in place to ensure other patients’ procedures are not cancelled incorrectly.
55.The Trust said that the cancellation was due to a misunderstanding and miscommunication within the ward team, and feel there is not any procedure that could be put in place to prevent honest human error.
56.It is vital organisations learn from complaints and look to make improvements when things have gone wrong. We do not think it is sufficient to say this was human error without adequately reflecting on what happened and making efforts to prevent recurrence. We accept that human error cannot always be eradicated but we would expect an organisation to identify opportunities to reduce the risk of mistakes occurring.