Ashford and St Peter's Hospitals NHS Foundation Trust

7. Mrs Y complains the Trust discharged her husband, Mr Y, in May 2023 and failed to obtain further investigations, such as a biopsy, for him when he presented with worsening symptoms of swelling, pain in his tongue and trouble swallowing.

8. Mrs Y told us this failure meant the Trust did not obtain the relevant tests which would have allowed it to diagnose Mr Y’s cancer sooner. Mrs Y says she is left not knowing whether this could have resulted in a better outcome for her husband.

9. To resolve her complaint, Mrs Y is seeking an apology and service improvements to ensure this does not happen to others.

10. Mr Y was first referred to the Trust by his dentist in 2020 after having trouble swallowing and difficulties with a swollen tongue.

11. In December 2020, the Trust obtained a biopsy which found Mr Y had lichen planus without dysplasia. Lichen planus is a condition where your immune system mistakenly attacks parts of your skin or the inside of your mouth and may form into white patches or painful sores. ‘Without dysplasia’ meant the Trust found no signs of abnormal or pre-cancerous cells.

12. In November 2022, Mr Y attended an appointment at the Trust’s Oral and Maxillofacial clinic and explained he had lichen planus present on his tongue for two and a half years.

13. The Trust obtained an urgent biopsy in the same month for Mr Y which found he had mild dysplasia with chronic hyperplastic candidiasis. This means there were some cells in the biopsy which looked abnormal. The Trust confirmed Mr Y had a persistent fungal infection in his mouth and said it would review Mr Y again.

14. In March 2023 Mr Y returned to the Trust’s clinic. It examined his tongue and noted it was showing signs of inflammation but said this was from his biopsy site and so was likely to be due to that process.

15. On 11 May 2023, Mr Y attended the clinic again. The Trust discharged him with no concerns.

16. Mrs Y explains at his review in May 2023, Mr Y was still complaining of the same symptoms he initially reported. She says the Trust should have at least obtained a scan or further biopsy, rather than discharging her husband. She says his pain and difficulty swallowing had got worse, along with struggling to talk.

17. Mrs Y told us they consulted a private doctor in September 2023 who referred Mr Y to another Trust (Trust B). In October 2023 Trust B obtained a biopsy from Mr Y’s tongue which revealed a tumour. It diagnosed Mr Y with advanced tongue cancer and removed part of his tongue and lymph nodes. Mrs Y told us her husband was scheduled to undergo radiotherapy but unfortunately, by December 2023 his health declined and was deemed too unwell for the treatment.

18. Mr Y sadly died on 13 February 2024 from tongue cancer which had spread to other parts of his body.

25. Mrs Y complains the Trust did not carry out appropriate tests for Mr Y and instead discharged him in May 2023. She says if the Trust had carried out further investigations, such as a biopsy, it would have been able to diagnose his cancer sooner, which would have allowed for a better outcome.

26. In its response to Mrs Y’s complaint, the Trust explained Mr Y had a long history of lichen planus. It said because this condition can sometimes turn cancerous, it arranged an urgent biopsy for Mr Y in November 2022.

27. Mr Y’s medical records confirm he attended a consultation at the Trust in early November 2022. He told the clinician he had been diagnosed with lichen planus on his tongue approximately two and a half years prior. Mr Y said he was concerned the affected area had got bigger and he was experiencing constant discomfort. Mr Y also felt the area had ulcers. The Trust obtained a biopsy of Mr Y’s lesion at the time. A lesion is any abnormal change or damage in the tissue of the body. It can appear on the skin, inside the mouth, or in internal organs.

28. In December 2022, Mr Y’s records show he had a phone consultation with the Trust to discuss the biopsy results. As we have explained, the Trust found he had some cells which looked abnormal. It said the lesion on his tongue was made up of thickened cells and was inflamed. It also diagnosed a persistent fungal infection (chronic hyperplastic candidiasis). The Trust planned to review Mr Y in a further three months.

29. In early March 2023 Mr Y attended the Trust again for a face-to-face appointment. His medical records show he reported his tongue still felt swollen and he was having difficulty swallowing. Mr Y also said he was experiencing sharp pain in the area and that it was spreading to his ear. The clinician also remarked it was very painful to touch.

30. The clinician examined Mr Y and said the area was inflamed but it showed no signs of infection or swollen lymph nodes (lymph nodes are small glands found throughout the body that help fight infection). The clinician advised Mr Y to continue using mouth rinses and a medicated mouth spray to manage his symptoms. The clinician also discussed the possibility of a second biopsy if Mr Y’s symptoms did not improve.

31. In May 2023, Mr Y was seen by a clinician at the Trust’s maxillofacial outpatient clinic. His medical records do not show that he reported any new symptoms at this appointment, nor do they record whether previous symptoms were still present. The clinician examined Mr Y’s mouth and described the findings as unremarkable, with no signs of swollen lymph nodes. They also referred to the biopsy carried out in November and noted its findings. Based on the biopsy results and the normal examination, the clinician said they were reassured. Following this consultation, the clinician wrote to Mr Y’s GP to confirm that he had been discharged from the Trust’s care.

32. We reviewed Mr Y’s records with our maxillofacial adviser to understand if the Trust acted appropriately when it discharged Mr Y in May 2023 without any further investigations. We understand it was appropriate for the Trust to obtain a biopsy of Mr Y’s tongue and the affected area in November 2022 and that this was reported as non-cancerous.

33. We understand from both our advisers that the symptoms reported by Mr Y in March 2023 should have led to a further biopsy. This is because by this point, his symptoms had not only persisted since the initial biopsy but had worsened. Mr Y reported experiencing ongoing pain, swelling and difficulty swallowing. In our view, taking no further action to re-biopsy at that time is not in line with GMC’s ‘Good Medical Practice’ guidance, section 7(c), which says clinicians should ‘promptly provide (or arrange) suitable advice, investigation or treatment where necessary’.

34. Furthermore, we can see Mr Y’s records show the clinician had noted ‘induration’ (a hardening of the tissue). Our maxillofacial adviser explained that these signs and symptoms were highly suspicious, and we can see this should have prompted the Trust to arrange a repeat biopsy for Mr Y.

35. We also looked at Mr Y’s biopsy results from November 2022 with our oncology adviser. These results showed low grade dysplasia, which means some cells were abnormal and could potentially turn cancerous. Our oncology adviser said that, because dysplasia had already been found, the Trust should have taken a closer look to see if anything unusual was still present, in line with the GMC guidance above.

36. In a study published in Journal of Fungi called ‘Oral chronic hyperplastic candidiasis and its potential risk of malignant transformation: a systematic review and prevalence meta-analysis’ from October 2022, research showed that a long-lasting type of yeast infection in the mouth, chronic hyperplastic candidiasis, can increase the risk of oral dysplasia becoming cancerous. As we have explained above, we can see the Trust diagnosed this condition when Mr Y had his biopsy in November 2022.

37. Our maxillofacial adviser explained usually clinicians treat patients with fungal infection, as Mr Y had, with antifungal medicine. After the infection is gone, our maxillofacial adviser said clinicians usually do another biopsy because treating the fungal infection often returns the abnormal cells to normal. They explained there is a low threshold for repeating biopsies in this instance, meaning repeat biopsies are often arranged, and particularly when symptoms persist or worsen.

38. Our oncology adviser also told us it is common for clinicians to repeat a biopsy when a patient’s symptoms do not go away, or if they worsen. In Mr Y’s case, they said the Trust should have considered this approach, in line with the GMC guidance referenced above, especially since his symptoms had not improved.

39. Considering the study and the GMC guidance, along with the advice and the evidence we have seen, we consider it a failing that the Trust discharged Mr Y in May 2023 without arranging a biopsy. Specifically, we think that given Mr Y’s lesion remained symptomatic and unresolved in March 2023, the Trust should have taken further action then.

40. The published study we have referenced makes it clear that when an oral lesion such as lichen planus fails to improve, or where it gets worse, there is a risk to patients developing cancer. Because of this risk, we consider the Trust should have taken another biopsy of Mr Y’s lesion when it did not get better in March.

41. As we have identified a failing, we have also reviewed the evidence on how missing a further biopsy likely impacted Mr Y. We explored with our advisers what a biopsy in March would likely have shown, had this taken place.

42. Mr Y’s records show in October 2023, Trust B diagnosed him with an advanced form of cancer which affects the skin or lining of organs (squamous cell carcinoma). In this case, it was his in his mouth. It said Mr Y’s cancer was at stage four, the most serious stage, and noted this had spread to his lymph nodes in his neck and that he needed major surgery.

43. In the same month Trust B carried out surgery which included removing part of Mr Y’s tongue and his lymph nodes on both sides of his neck. It also carried out a tracheostomy, which means it created an opening in Mr Y’s neck to help him breathe.

44. Our oncology adviser explained that tumours do not grow at a steady rate. The growth of a tumour can speed up or slow down at different times. This means we cannot say what stage Mr Y’s cancer was at in March, or how far it had spread. We recognise sometimes a biopsy does not identify cancerous cells because it only samples a small part of the affected area. However, by October 2023, Mr Y’s cancer had spread to his lymph nodes. Our oncology advice indicates the evidence therefore support the views the cancer had already started spreading six months earlier.

45. At that time, in March 2023, Mr Y was already showing clear symptoms including pain radiating to his ear, trouble swallowing, and a firm area on the side of his tongue. Our maxillofacial adviser agreed that Mr Y likely had cancer by March 2023 and that the cancer had likely already started to spread by then. They explained these symptoms are signs which suggest the cancer had already become invasive. Although there was no mention of swollen neck glands in March, the spread seen in October makes it more likely than not that neck disease was already developing.

46. We understand from both advisers that if Mr Y had been diagnosed in March 2023, he would likely have had scans and then surgery within about two months. They said Mr Y’s cancer was very aggressive, so earlier treatment might not have stopped it from spreading. It may have allowed him to have less extensive surgery, but we cannot say, even on the balance of probabilities, that earlier surgery would have made a significant difference to the sad outcome for Mr Y, given how aggressive his cancer was.

47. While an earlier diagnosis may not have changed the outcome for Mr Y, it may have led to less extensive surgery and given Mr Y the opportunity to consider different treatment options. We therefore consider this was a missed opportunity to diagnose and allow Mr Y the opportunity to make decisions about treating his cancer sooner.

48. We understand this has had an impact on Mrs Y as it has left her not knowing what might have been different for her husband, had the errors we have identified not taken place. In turn, we can see this has created frustration and distress at a very difficult time for her.

49. The Trust has not identified that anything went wrong in the care it provided to Mr Y. We have therefore set out at the end of this report recommendations to remedy the impact Mrs Y has suffered.

1. We are very sorry to hear of the circumstances of Mrs Y’s complaint. She has told us the death of her husband has been devastating for her. We extend our sincere condolences for her loss.

2. We consider it a failing that the Trust discharged Mr Y in May 2023 without carrying out appropriate investigations. At that stage, we consider he was experiencing worsening symptoms which were clear signs that should have prompted further investigation by the Trust. The evidence we have received indicates that by March 2023, Mr Y’s symptoms had already worsened to a point where a biopsy would have been indicated. Therefore, we consider when the Trust reviewed Mr Y in May, the need for a biopsy was even more urgent. A biopsy is a test to check whether a person’s cells in a certain area of the body show signs of abnormalities, including cancers.

3. We consider that if the Trust had obtained a biopsy for Mr Y at the earliest point it was clearly appropriate to do so, which was March 2023, it is likely it would have identified a tumour in his mouth and considered treatment options available to him. On balance, we cannot say this would have prevented Mr Y’s death, but we consider it may have allowed Mr Y to avoid having more invasive surgery and would have given him the opportunity to explore treatment options available to him. Our view is this has left Mrs Y with avoidable frustration and distress at an already very difficult time.

4. The Trust did not identify the failing we have found and so has not taken any actions to remedy the impact it caused. We have described the recommendations that we consider will put right the impact Mrs Y has suffered.

5. We therefore partly uphold this complaint. We appreciate these events have been very distressing for Mrs Y and we are grateful to her for discussing this complaint with us in these upsetting circumstances.

6. We recommend the Trust create an action plan to prevent the failings we have identified from happening again. We also recommend the Trust write to Mrs Y to apologise for the failings and the impact we have seen.

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.

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. In line with this we recommend the Trust writes to Mrs Y to acknowledge the following failing

• the Trust discharged Mr Y in May 2023 without arranging biopsy for Mr Y at the earliest point it was clearly appropriate to do so, which was March 2023.

52. The Trust should recognise and apologise for the impact caused to Mrs Y by this failing, as set out in our report.

53. The Trust should send its letter to Mrs Y within one month of this report and share a copy with our Office.

54. We recommend the Trust complete an action plan to address the failings we have identified. This could include work to raise the awareness of when biopsies should be repeated for patients with early signs of abnormal mouth tissue or a long-lasting type of yeast infection in the mouth. It may also include updating guidance staff. We are likely to ask the Trust to complete this action plan within three months of this report and share a copy of its plan with this Office, Mrs Y, NHS England and the Care Quality Commission.

The action plan should set out:

• what the Trust will do, or has done, to prevent these issues from occurring again. If it has already made changes, it should explain how it has established these actions are appropriate to prevent the issues from recurring • the name of the person or team responsible for each action • when the actions will begin and when they will be complete (or when they occurred) • how the impact of the actions will be measured and monitored.