Communication about the cyst
18. On 6 November 2020, Mr O attended the Trust for a colonoscopy. The Trust performed this because of a change in his bowel habit. During the procedure the scope could not be fully passed and, as a result, the Trust booked an MRI scan of his colon. This scan showed an incidental finding of a cyst in Mr O’s right kidney.
19. On 31 November 2020, Mr O attended the Trust for the MRI scan. On 8 January 2021 the Trust spoke with Mr O over the phone to inform him of the MRI findings. The Trust informed him there was a 2cm Bosniak 3 cyst in his right kidney.
20. At this point we see from the records, the Trust explained to Mr O there was approximately a 50% chance that the small mass was cancerous, but such masses, even when cancerous, tend to be relatively slow in their progression. For this reason, the Trust opted for an active surveillance strategy, of which they informed Mr O of during the phone call. The Trust booked an additional MRI scan in three months’ time.
21. Mr O’s next MRI scan was at the end of March 2021.This showed no significant change compared to December 2020 and the Trust informed Mr O of this. The Trust opted to continue with surveillance and scheduled Mr O for a repeat scan in 2022.
22. Following Mr O’s MRI in December 2022, the Trust informed him the cyst had ‘shown no evidence of any change in size’. As a result of this, the Trust booked Mr O for a further scan in a year’s time. We can see from the Trust’s complaint response that the cyst measured 25x22mm at this time.
23. Following Mr O’s MRI in December 2023, the Trust again sent a letter that stated the scan showed ‘a Bosniak 3 right renal (kidney) cyst with no changes from the previous MRI’. The Trust booked Mr O for a further MRI in one year’s time, as per the yearly surveillance plan. We can see from the Trust response that the cyst measured 26x24mm at this time.
24. As seen in the second complaint component, from March 2024 onwards Mr O attended the Trust on multiple occasions with new symptoms. The Trust carried out various tests within this time, including another MRI which revealed the cyst to be measuring at 27mm in April 2024.
25. At this point the Trust reiterated the risk of malignancy for a Type 3 Bosniak cysts, informing Mr O that this was 30-50%. The Trust told Mr O the plan remained the same from this point; a further surveillance scan was to be performed in October or November 2024.
26. Our adviser explained that the Trust acted appropriately in communicating with Mr O about his cyst throughout the years of surveillance meetings. They said it was in line with guidance to be transparent about the likelihood of his cyst being cancerous in 2020, something that the notes show the Trust reiterated in April 2024.
27. GMC 2013 guidance says doctors must give patients the information they need to know. In providing Mr O this information directly following the first MRI scan in November 2020, we are satisfied the Trust acted in line with this guidance.
28. Our adviser suggested that annual surveillance was an appropriate plan to monitor Mr O’s cyst and the communication that followed these meetings were also in line with guidance.
29. Section 15 of the GMC 2013 guidance states in providing a good standard of care, doctors must promptly provide or arrange suitable advice and investigations. Our adviser stated these annual surveillance meetings were in line with what is expected, and the Trust communicated the outcome after every annual meeting in line with GMC 2013 guidance.
30. We appreciate Mr O’s concerns in hearing the changes to the size of his cyst during the complaints process. Our adviser considered these to be very small increases. They explained it was reasonable for the Trust to consider the cyst stable and its changes to be negligible. Therefore, we consider the communication about the size of the cyst was appropriate.
31. We appreciate this was a very distressing period for Mr O and his family and we do not underestimate its impact on their lives.
32. We have found the Trust communicated in line with national standards and have seen no indication that something went wrong. As a result of this, we will not be taking this complaint any further.
Identifying that the known cyst was cancerous
33. Mr O attended the Trust’s same day emergency care (SDEC) on 9 March 2024. He was presenting with blood in his urine and pain in his left side. The Trust took blood samples and performed an ultrasound. The Trust diagnosed Mr O with a urinary tract infection (UTI).
34. We understand from Mr O’s clinical records his GP placed him on the two week wait 2WW suspected cancer pathway for urology on 11 March 2024.
35. As part of the pathway, Mr O had an appointment with urology on 21 March 2024. The Trust performed an ultrasound of the known cyst. Staff noted the cyst had increased slightly in size but considered it to be stable. The Trust also performed flexible cystoscopy (a flexible cystoscopy is a minimally invasive procedure where a thin camera is inserted through the urethra into the bladder). This showed normal findings apart from an enlarged prostate that was protruding inside the bladder.
36. Between the 28 March 2024 and 18 April Mr O experienced continuous problems with his bladder, attending SDEC on three separate occasions. On 28 March, he provided the Trust with a urine sample which showed traces of blood. As a result, the Trust tested Mr O for an infection. This came back negative. Despite this, the Trust prescribed a seven-day course of Ciprofloxacin 500mg (antibiotics) anyway.
37. On 4 April, Mr O was unable to pass urine, so the Trust fitted a catheter. A catheter is a flexible tube inserted into the body to drain fluids. The Trust performed a CT scan of Mr O’s cyst on 4 April, the results of which confirmed his cyst had marginally grown in size from 25mm to 27mm.
38. On 5 April, Mr O attended the Trust again because his catheter was leaking. Staff flushed it through and refitted it. Traces of blood were spotted in his urine, which staff attributed to trauma of the penis. Staff starting Mr O on a trial without catheter care plan on 18 April 2024.
39. A multidisciplinary urology cancer meeting took place on 18 April 2024. The Trust acknowledged the marginal increase in Mr O’s cyst and decided to repeat the MRI as per the annual surveillance protocol at the end of 2024.
40. GMC 2024 guidance says in providing clinical care doctors must:
a)adequately assess a patient’s condition(s), taking account of their history, including I.symptoms II.relevant psychological, spiritual, social, economic, and cultural factors III.the patient’s views, needs, and values b)carry out a physical examination where necessary c)promptly provide (or arrange) suitable advice, investigation or treatment where necessary d)propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs e)propose, provide or prescribe effective treatment based on the best available evidence f)follow our more detailed guidance on professional standards, Good practice in proposing, prescribing, providing and managing medicines and devices, if you prescribe g)consult colleagues or seek advice from your supervising clinician, where appropriate h) refer a patient to another suitably qualified practitioner when this serves their needs.
41. We can see that in accordance with the GMC 2024 guidelines, the Trust investigated Mr O’s new symptoms appropriately. On 9 March 2024 he attended SDEC presenting with blood in his urine and discomfort. From the medical records we can see the Trust took Mr O’s bloods and performed a urine dip.
42. Having obtained the available evidence, our adviser confirmed the Trust reasonably diagnosed him with a UTI. When Mr O attended SDEC on 28 March 2024 Mr O presented with similar symptoms. We understand that even though Mr O’s urine sample was negative for protein and nitrates, the Trust still prescribed antibiotics to see whether this relieved the symptoms. We understand from our adviser this was in line with guidance.
43. Similarly, when Mr O attended the Trust on 4 April 2024 unable to pass urine, they provided effective treatment in the form of a catheter.
44. While Mr O was attending the Trust for his symptoms, his GP also referred him under the 2WW cancer pathway for suspected cancer. The adviser explained that Getting it Right Frist Time (GIRFT) is a national NHS England programme that reviews and benchmarks NHS services.
45. It has created a document that our adviser said sets out the best practice in this instance; ‘Urology: Towards better care for patients with Kidney cancer, June 2023’. This guide describes the key features of a good kidney cancer service, illustrating what is good practice for a management pathway.
46. The adviser explained that the approach taken by the Trust in response to Mr O’s symptoms was in line with the GIRFT guidance and was thus appropriate. One of the documents key quality actions is that all patients with suspected kidney cancer should be upgraded to the local cancer pathway. Mr O was appropriately referred under the 2WW pathway, in line with the ‘Good practice kidney cancer pathway’.
47. The pathway states to diagnose kidney cancer, the patient should undergo a CT or MRI scan. We understand the Trust performed a CT scan on Mr O on 4 April, the results of which confirmed his cyst had marginally grown in size from 25mm to 27mm but remained within reasonable parameters. This is something that the adviser agreed with, describing the cyst as stable at this point.
48. As per the pathway, a specialist multidisciplinary team (MDT) meeting should take place to ensure the representation of various disciplines in any decision making. These meetings seek to confirm diagnoses, ratify and recommend appropriate treatment options. Mr O’s case was discussed at one of the Trust MDTs on 18 April 2024 to inform the management decision making of his cyst.
49. Within this meeting, the Trust concluded that whilst Mr O’s known cyst had increased slightly in size since his previous MRI taken the year before, the most appropriate course of action was to continue with annual surveillance. Our adviser agreed this was a reasonable decision given the relative stability of the cyst’s size.
50. As such, we can see the Trust appropriately considered Mr O’s symptoms from a perspective of kidney cancer. The Trust performed the necessary scans and MDT meeting outlined in the kidney cancer good practice pathway, addressing Mr O’s symptoms as they arose throughout this time; all of which the adviser deemed to be appropriate care.
51. The advisor did highlight it would be best practice in Mr O’s case to be transparent with the patient about the potential risk of cancer with this type of cysts. As we have established in the first complaint issue, our adviser was satisfied the Trust did this in line with guidance.
52. As for the decision to keep Mr O on annual surveillance following the MDT meeting, the adviser also deemed this to be an appropriate course of action, and in line with the GMC 2013 guidance section which says to arrange suitable investigations where necessary. Given that the cyst had marginally increased from 25mm in November 2023 to 27mm in April 2024 he agreed that it seemed to be relatively stable.
53. The adviser suggested Mr O’s urinary tract symptoms were most likely attributable to his enlarged prostate, of which was in line with the Trust’s diagnosis. The advisor made clear that by having a type 3 Bosniak cyst it is always reasonably likely that the patient may have cancer.
54. As such, we understand from our adviser the Trust reviewed and investigated Mr O’s symptoms in line with guidance. We have not seen any indications of failings. We hope this is explanation helps Mr O understand what happened.