NHS in England Not Upheld Search on PHSO website

Nottingham University Hospitals NHS Trust

P-004625 · Report · Decision date: 16 January 2026 · View Nottingham University Hospitals NHS Trust scorecard
Complaint (AI summary)
Ms L complained the Trust failed to diagnose her mother's myeloma and amyloidosis from April 2020 to September 2022, potentially affecting her prognosis and causing distress.
Outcome (AI summary)
Complaint not upheld. No failings were found in the Trust's management of Mrs D's condition or its failure to diagnose myeloma and amyloidosis earlier.

Full decision details

The Complaint

6. Ms L complains the Trust did not diagnose her mother’s myeloma and amyloidosis from April 2020 to September 2022.

7. Ms L believes earlier diagnosis and intervention would have made a significant difference to her mother’s long-term prognosis and would have limited her suffering. Mrs D and her family were greatly distressed by the failings in her care, and the family remains distressed.

8. Ms L wants answers to her questions about the care provided to her mother by the Trust, the Trust to fully acknowledge the failings in her mother’s care, take responsibility for the mistakes and apologise. Ms L also wants the Trust to take action to prevent this happening to other patients. She would like a financial remedy for the impact of failings in her mothers care.

Background

9. In March 2020, Mrs D’s GP referred her to the Trust’s Haematology Assessment Service. She attended an appointment on 16 April 2020. A consultant haematologist informed her she did not have myeloma. They planned to carry out blood tests regularly in case myeloma developed.

10. Mrs D had telephone consultations with the Trust between 25 June 2021 and July 2022. The Trust told her that, based on her blood test results, she did not need treatment.

11. On 31 March 2022, she collapsed at home, and an ambulance took her to a different Trust. She told the other Trust she had experienced increasing breathlessness over several months. She had an MRI scan (magnetic resonance imaging uses magnetic fields and radio waves to create detailed images of the inside of the body) on 29 April. The other Trust reported the results of the MRI in September. It diagnosed her with myeloma and amyloidosis.

12. Mrs D underwent several courses of chemotherapy from October to December which was not curative. The amyloidosis had caused irreparable damage to her heart, leading to heart failure. Mrs D sadly died on 3 June 2023.

Findings

Management of MGUS

16. The Trust diagnosed Mrs D with light chain MGUS in April 2020. MGUS itself is not blood cancer (myeloma). People with MGUS do have a higher risk of developing myeloma and amyloidosis in the future.

17. On 16 April, she attended an appointment at the Trust, and a clinician told her she did not have myeloma. They initially arranged to monitor her with blood tests every three months and then extended this to every six months.

18. The Trust managed Mrs D’s blood tests through nurse led clinics. The Trust asked Mrs D to go for blood tests, and it reviewed the results. It would then arrange to speak to her in telephone appointments.

19. Mrs D had telephone appointments on 25 June and 1 October in 2020. In 2021, she had telephone appointments on 21 January and 22 July. She went on to have telephone appointments on 20 January 2022 and in July of that year. During the telephone calls, clinicians told her that her blood test results were normal, and she did not need any treatment.

20. Our adviser helped us to understand the six-monthly nurse led clinics and telephone appointments were appropriate and in line with the BSH’s ‘Investigation and management of monoclonal gammopathy of undermined significance’ which says:

‘Newly diagnosed MGUS patients should have appropriate blood tests (FBC, creatinine, serum calcium, paraprotein and serum FLC levels) performed six months after diagnosis, with annual follow-up thereafter, although the interval can be longer for patients with low-risk MGUS and further investigations reduced if life expectancy is short.’

21. We consider the Trust acted in line with the above guidelines and provided appropriate and timely testing following Mrs D’s diagnosis of light chain MGUS. Therefore, we have not found failings in this part of the complaint.

22. Ms L specifically complained that the Trust did not review her mother face to face (apart from on one occasion). She also told us her mother’s condition deteriorated, she became more breathless, and her mobility declined. She says the Trust should have seen her mother face to face and had it done so staff would have noticed her deterioration.

23. Mrs D’s medical notes do not show that she raised any concerns about a deterioration in her health until July 2022. At this point, she told the Trust she was suffering from atrial fibrillation (an irregular heartbeat in the upper chambers of the heart) and ongoing cardiology involvement (from another Trust). We recognise this is not her family’s recollection and they say she did raise concerns about breathlessness.

24. Our adviser explained that nurses overseeing the clinic were able to review Mrs D’s blood test results in line with their role but would not necessarily have had a full understanding of the symptoms of amyloidosis. Our adviser explained it would therefore be the role of a GP to consider any new symptoms Mrs D had and make appropriate referrals.

25. Our adviser helped us to understand the Trust’s management of MGUS through nurse led clinics and telephone appointments fell within the above BSH guidelines and is usual practice for the management of her condition.

26. The Trust acted appropriately and in line with the above BSH guidelines. Therefore, we have not found failings in this part of the complaint.

Diagnosis of myeloma and amyloidosis

27. Ms L also complains the Trust did not diagnose her mother’s, myeloma and amyloidosis from April 2020 to September 2022.

28. Amyloidosis is a general term for a group of conditions where an abnormal protein, called amyloid, builds up in the body’s tissues. The amyloid protein folds abnormally, creating amyloid deposits.

29. Although the amyloid deposits in amyloidosis are not themselves cancerous, the condition can be associated with myeloma. Patients with MGUS have a higher risk of developing both myeloma and amyloidosis and as per the above BSH guidelines should undergo regular blood tests.

30. Mrs D’s medical records show her light chains remained elevated but stable. A high amount of light chains in a blood test can indicate myeloma.

31. The Trust also checked Mrs D’s cardiac markers (substances released into the bloodstream when the heart is damaged or under stress). This included ProBNP (a protein produced by the heart’s ventricles) and troponin levels (a protein found in heart muscles). It also included, her urinary albumin (a protein which can indicate kidney problems) to creatinine ratio (a waste product which can indicate kidney problems) all of which were normal.

32. Our adviser helped us to understand the Trust carried out appropriate blood tests in line with the above BSH guidelines. They further explained amyloidosis can be difficult to detect and there is no failsafe test to detect this.

33. Additionally, our adviser confirmed the Trust’s interpretation of Mrs D’s test results was accurate. They explained results did not show signs of amyloidosis or myeloma prior to her hospitalisation in April 2022 and subsequent test results with a different Trust.

34. Therefore, we do not find failings in the Trust’s lack of diagnosis of amyloidosis or myeloma. There is not anything further it should have done to investigate Mrs D’s symptoms or to treat her elevated light chains.

35. We appreciate Ms L told us Mrs D’s health deteriorated over this period of care. We acknowledge how difficult this would have been for her family to witness. We hope our final report provides some reassure there was nothing further the Trust should have done to diagnose and treat her at the time.

Conclusion

36. We have found, the Trust managed Mrs D’s condition appropriately through regular blood tests and without face-to-face appointments. Additionally, we have not found it should have diagnosed her with amyloidosis or myeloma, or that it should have provided treatment for these conditions. We find it reviewed her and carried out appropriate blood tests in a timely manner, in line with the above BSH guidelines.

Our Decision

1. We have carefully considered Ms L’s complaint about the care and treatment provided by Nottingham University Hospitals NHS Trust (the Trust) to her mother, Mrs D.

2. We appreciate the incredibly difficult time Ms L and her family have been through and continue to go through, following the sad loss of Mrs D. We do not underestimate how hard it is to make a complaint at this time.

3. We have not found failings in the Trust’s management of Mrs D’s light chain MGUS. Monoclonal gammopathy of undetermined significance is a blood condition which is characterised by abnormal light chains in the blood. Light chains are y-shaped proteins that help the body fight infection.

4. In addition, we have not found the Trust should have diagnosed Mrs D with myeloma (a type of blood cancer) and amyloidosis (a group of rare conditions in which a protein called amyloid builds up in the body which can impair bodily functions).

5. We have therefore decided not to uphold this complaint.

Other Decisions About Nottingham University Hospitals NHS Trust

P-004830 · 13 Feb 2026
Mrs H complains about aspects of care and treatment the Trust provided to her late husband, Mr H, relating to …
Closed After Initial Enquiries
P-004584 · 7 Jan 2026
Mrs E complains the Trust failed to operate on her colloid cyst. She also complains about the way the Trust …
Upheld
P-004481 · 16 Dec 2025
Mr X brings his complaint to us regarding his partner's care and treatment outside our time limit.
Closed After Initial Enquiries
P-003745 · 25 Aug 2025
Mr A complains about the care two Trusts provided his grandson in 2023. He complains that both organisations failed to …
Closed After Initial Enquiries
P-003694 · 30 Jul 2025
Mrs B complains the Trust failed to identify her severely disabled son, P, had a serious abdominal condition until it …
Upheld
View all decisions for this organisation →