Treatment
27. Firstly, we considered the time taken for the Trust to arrange Mr A’s treatment for oesophagus cancer. To help us understand what should have happened our oncology adviser referred us to the NHS England delivering cancer waiting times guidance.
28. It says patients should receive treatment within 62 days of a GP referral. It also says treatment should start within 31 days of the decision to treat.
29. Mr A received his diagnosis on 14 November 2022. Ms A and Ms B are concerned that he did not receive treatment until 6 March 2023. We recognise this was worrying and caused distress.
30. We have seen Mr A’s GP referred him for suspected upper gastrointestinal tract cancer on 17 October 2022. In line with the 62-day target, treatment should have started by 18 December 2022. Mr A’s treatment started eleven weeks late.
31. When considering this eleven-week delay, we looked at the NHS England waiting times for suspected and diagnosed cancer guidance.
32. It says the 62-day target standard states that 85% of patients should be seen within 62 days of the referral date. Our oncology adviser explained that some patients have complex diagnostic pathways. Oesophageal cancer patients do not always meet this target because of its complexity.
33. Our oncology adviser helped us understand the Trust was arranging a nasal jejunal tube. This means there would be a pause to the 62 day waiting time rules to allow clinical improvement to feeding so that Mr A could tolerate his treatment better.
34. Because of this, it is reasonable to accept there was a delay between the referral and decision to treat. This means Mr A fell into the 25% of patients who do not meet the 62-day target. We have decided the Trust acted in line with the NHS England waiting times for suspected and diagnosed cancer guidance.
35. We then considered whether the treatment started within 31 days of the decision to treat. The oncologist made their decision to treat after the Trust inserted the nasal jejunal tube. The time from the oncologist deciding to treat and the start of treatment was five and a half weeks (39 days).
36. The Trust accepts it delayed treatment by eight days, and the medical records confirm this. This is not in line with the NHS England delivering cancer waiting times guidance.
37. We have found that the Trust delayed the commencement of Mr A’s treatment by eight days, and this is a failing.
Impact
38. Ms A and Ms B said the delay in treatment left them feeling it reduced their brother’s survival chances. We recognise their brother’s death has had a significant impact on their family.
39. Our oncology adviser helped us understand that even with earlier treatment, Mr A would have still developed metastatic cancer (the spread of cancer) and would have moved onto palliative treatment at the same time and sadly died when he did.
40. Our oncology adviser explained there is a considerable time when cancer is not visible. Most cancers divide slowly with a growth rate somewhere around 130 days. The delay of eight days in Mr A starting treatment, made no impact to the risk.
41. We recognise this experience has been distressing for Ms A and Ms B. We do not underestimate how worrying this time will have been for them both.
42. Ms A and Ms B told us that the Trust initially told their brother treatment would start in December. As the time passed, he and his sisters were concerned about the delay.
43. When the Trust accepted it delayed treatment, it did not give an explanation about the impact of this. The explanations we have been able to give the complainants in our report should alleviate any ongoing worry about this delay. We accept that it did lead to uncertainty and a feeling that the delay reduced their brother’s survival chances.
44. They were left not knowing if their brother’s prognosis could have been any better if the Trust had started treatment sooner. The Trust could have reduced Ms A and Ms B’s concern and worry about the impact of the delay.
45. We have seen the Trust provided an apology. To some extent, our decision helps to remedy some of the injustice through the explanation we have provided. However, we have decided the Trust has not done enough to put this right and have made recommendations.
Communication about prognosis
46. We then considered the Trust’s communication around prognosis when Mr A’s condition became palliative in April 2023. To help us understand what should have happened, our oncology adviser referred us to the GMC, Good medical practice.
47. It provides guidance about communicating effectively and says doctors should give patients the information they want or need to know.
48. When the Trust first diagnosed Mr A, the aim of treatment was potentially curative with a plan for chemotherapy, radiotherapy and surgery. The Trust arranged a CT scan in April, which sadly showed the development of metastatic cancer in the liver and lungs.
49. Our oncology adviser helped us understand that at this point the treatment became palliative with a life expectancy of less than one year.
50. An MDT discussed Mr A’s treatment on 24 April, and it requested an oncologist see him in clinic to discuss palliative care.
51. With the help of our oncology adviser, we have not been able to identify any evidence of the oncology team communicating Mr A’s prognosis either face to face or in a letter.
52. The next appointment was with a locum oncologist on 21 July. The Trust’s letter said Mr A’s usual oncologist was on leave, a discussion took place about tolerating chemotherapy with no major side effects and the doctor would arrange a CT scan.
53. We have not seen any evidence the Trust discussed Mr A’s prognosis with him in line with GMC’s Good medical practice. We have decided that this is a failing.
Impact
54. Ms A and Ms B said their brother’s death has had a significant impact on their family and the Trust’s poor communication around prognosis made this worse.
55. They said the treatment gave them some hope. They were not prepared for the end of his life. Their brother was distraught and could not come to terms with the fact that the end was so close.
56. Had the Trust shared this essential information with Mr A, his sisters would have known the prognosis and been able to prepare for this. They were left not knowing what this was.
57. The Trust’s poor communication around prognosis caused additional distress when Mr A deteriorated and died. His sisters were not prepared for this to happen when it did and this added to their grieving process. It made their experience worse during a time that was already very difficult for them.
58. We have not seen that the Trust has taken any action to put this right and have made recommendations.
Mattress
59. We then considered whether the Trust provided Mr A with the correct mattress during his admission in September 2023. The Trust said it nursed Mr A on a soft foam mattress. It accepted it should have changed this to an airway mattress when his skin began to deteriorate.
60. To help us understand what should have happened, our nurse adviser told us pressure ulcer risk assessments are an important aspect of pressure area care as they support decision making.
61. Following an assessment, nurses can identify if pressure relieving equipment is appropriate. If it is, they should identify what type of equipment would be suitable for reducing the patient’s risk of either worsening pressure damage or new pressure damage.
62. We looked at NICE guidance for pressure ulcers. It says nurses should assess pressure ulcer risk for adults. Nurses should use a validated scale to support clinical judgement. It also says nurses should reassess pressure ulcer risk if there is a change in clinical status.
63. We also looked at NICE quality standard for pressure ulcers. It says patients at high risk of developing pressure ulcers are provided with pressure redistribution devices. They work by reducing or redistributing pressure, friction or shear forces. Devices include highspecification mattresses, pressure redistribution cushions and equipment that offloads heel pressure.
64. It also says using pressure redistribution devices as soon as possible can prevent pressure ulcers developing and help to treat them if they do arise, ensuring patient safety and improving the experience of people at high risk of pressure ulcers.
65. Mr A attended A&E on 7 September. The Trust assessed his risk of pressure area breakdown on 8, 9, 16 and 23 September. He scored 19 on 8 September.
66. The scale is made up of a number of evaluations in determining the patient’s risk. Once the score has been added up, medical professionals are left with an assessment of the patient’s pressure sore risk. A score of ten plus means ‘at risk’, 15 plus means ‘high risk’ and over 20 means ‘very high risk’ of pressure sore development.
67. The initial score of 19 meant Mr A was high risk and should have been on a pressure redistributing device as per NICE guidance and quality standard for pressure ulcers. This would have been an alternating or low air loss pressure relieving mattress. This did not happen, and we have decided it is a failing.
Impact
68. Ms A and Ms B said it was distressing seeing their brother develop bed sores and upsetting witnessing his pain and discomfort.
69. On 22 September, the medical records show Mr A had a sore bottom and coccyx.
70. From 24 September nurses were applying dressings to the sacrum and on 27 September, they noted the sacrum was red and blanching. The nurses documented the skin was intact and not showing any signs of skin damage. The palliative care team requested an air mattress to prevent pressure damage on 27 September.
71. There is nothing in the medical records to suggest that Mr A developed a pressure ulcer or that the skin began to break. Ms A told us her brother developed ‘sores’ and was in pain.
72. We have seen from the medical records that both Mr A’s sisters visited during this time, this will have been difficult to witness. There was a missed opportunity to prevent this and reduce Mr A’s risk of developing sores and pain.
73. We have not seen that the Trust has taken any action to put this right and we have made recommendations.