Mr A’s CT scan report
14. Mrs X complains Mr A and his family were not informed that a CT scan carried out on 6 March 2024 showed a mass in the lung. Mr A had another CT scan 17 days later, on 23 March 2024, where a cancer diagnosis was made. We can see from the evidence, the report from the scan on 6 March 2024 correctly identified lung nodules and enlarged lymph nodes in the chest and upper abdomen. Nodules are small masses of dense tissue, and lymph nodes are part of the body that filter harmful substances, including infections. However, no mass was reported.
15. We understand from our radiology adviser that signs such as marked soft tissue thickening around the lower oesophagus (gullet), extending into the posterior mediastinum (a space that contains various important structures in the chest area) and around the diaphragm were missed. Given that Mr A had reduced appetite and weight loss, as documented in his records, we understand from our radiology adviser that not reporting this mass was a significant omission.
16. We understand from our radiology adviser there is also a failing in the structure of the report. According to the RCR guidelines referenced above in our ‘evidence’ section, where there is a need for a long, descriptive report, it should conclude a short summary of key findings and their interpretation (with clinical advice on the next step in the management of the condition, if appropriate). The conclusion of the CT scan report does not state what the scan findings are likely to be caused by, nor that they are concerning for cancer, and there are no suggestions for clinical management. Therefore, the Trust failed to act in accordance with the RCR guidelines both in not reporting the mass and in structuring the report.
17. We have thought carefully about the likely impact of the above failings we have identified. Mrs X says her father may have lived longer if the cancer had been diagnosed sooner.
18. We found that Mr A’s cancer diagnosis was delayed by up to 17 days due to the failings in the CT scan report from 6 March 2024. This is because 17 days later Mr A had another CT scan, which did identify cancer. The evidence available to us, including our independent radiology advice, does not suggest the delay affected the clinical outcome for Mr A, given the cancer was sadly already at an advanced stage when it was diagnosed.
19. We also understand from our oncology adviser there is nothing to indicate Mr A would likely have avoided his rapid deterioration, as the underlying cause of his deterioration was not clear. We can also see that Mr A continued to deteriorate even after more urgent investigation and management following the CT scan on 23 April 2024 took place.
20. We have found no evidence the above errors led to or contributed to Mr A’s deterioration and very sad death at that time. However, knowing there was a delay in acting on the CT scan caused the family avoidable distress as it has contributed to their fear that not everything was being done to care for a loved family member. As the Trust has not yet recognised this error, it has not yet taken any action to put things right. We therefore will make recommendations.
Delay in diagnostic tests
21. Mrs X complains the Trust delayed diagnostic tests for Mr A, including a PET scan which was done on 15 April 2024. Mrs X queries why this was not done when the mass was found on her father’s CT scan on 23 March 2024.
22. According to NICE guidance CG104 referenced above in our ‘evidence’ section, PET scans are not part of the initial tests used to look for cancer. They are usually used later, if the initial tests do not show where the cancer started. The guidance says patients with a possible cancer of unknown primary should have a PET scan after an MDT discussion. This is what happened, as Mr A’s case was discussed at an MDT meeting on 8 April 2024, and a decision was made to arrange a PET scan for him. The scan took place on 15 April 2024.
23. Mr A had the PET scan a week after the decision to carry out the scan was made. We understand from our oncology adviser PET scans are highly specialised and relatively limited in availability and a week’s wait would be expected. We also understand from our oncology adviser that if a PET scan had been done sooner, this would sadly not have changed the outcome for Mr A.
24. Therefore, we can see the Trust followed applicable guidance when arranging and carrying out Mr A’s PET scan.
25. Mrs X also complains Mr A’s family were informed on several occasions that procedures such as a liver biopsy would be carried out but were later told they would not.
26. Our evidence shows that an MDT meeting took place on 25 April 2024 to review Mr A’s PET scan results. At that meeting, the team recommended that Mr A should have a liver biopsy.
27. However, we can see when Mr A was reviewed the following day, 26 April 2024, he required oxygen and was too breathless to lie flat. Because of this, the doctor decided he was not well enough to have the biopsy at that time. Our oncology adviser confirmed that the initial decision to recommend a liver biopsy was appropriate under NICE guidance CG104, and the decision to not proceed with it was also appropriate given Mr A’s changed condition at that time. Therefore, although the Trust did change the plan for the biopsy, this was in line with applicable guidance and appropriate in response to Mr A’s worsening clinical condition.
Communication
28. Mrs X complains on 23 March 2024 Mr A’s family were informed by a doctor that he had cancer and was expected to live for six months. They were advised a few days later that this information was incorrect as the cancer diagnosis was not confirmed.
29. We can see from the evidence that this was a verbal discussion, and there is no record of what was said in Mr A’s medical record. However, we can also see from the evidence that the issue of Mr A’s wife being told he had cancer and had six months to live was raised with another doctor on 27 March 2024. The doctor confirmed Mr A was under investigation for cancer but as yet there was no confirmed diagnosis. The Trust acknowledged in its response that this conversation of 23 March 2024 likely did take place, and it apologised for the misunderstanding caused.
30. We have found, on the balance of probability, it is likely this conversation happened, and the information given to the family was not accurate at that time. We recognise it would have been upsetting and confusing for Mr A and his family. This is a failing in communication by the Trust and not in line with NICE NG142, which emphasises the importance of good communication with patients and families.
31. From the evidence, we cannot say this affected Mr A’s care or the events leading to his sad death. What we can say is this would have caused avoidable distress to the family. We can see the Trust has taken appropriate steps to put things right by acknowledging this error, the upset it caused and apologising for this.
32. Mrs X complains the family were not informed by the Trust that Mr A was approaching the end of his life. Our oncology adviser said from Mr A’s medical records it appears likely he was approaching the end of his life on 26 April 2024, at which point it should have been recognised. In line with NICE guidance NG142 detailed in our ‘evidence’ section above, we understand his family should have been informed of this development at that time.
33. The Trust’s complaint response explains that, from Mr A’s medical emergency team (MET) assessment on 26 April 2024, ‘it was felt that he was sadly approaching the end of his life’. The Trust’s response letter further says the family were updated about this on the same day and it was agreed to keep Mr A as comfortable as possible until he died on 27 April 2024.
34. We can see from the medical records the MET assessment on 27 April 2024 was recorded at 19:57. The medical notes from this assessment indicate Mr A’s family were made aware after the assessment that he was actively dying. The next entry recorded 48 minutes later at 20:45 was the update the doctor gave to the family after Mr A sadly died. It says, ‘sadly soon after our review Mr A passed away’. Therefore, we can conclude he died shortly after the family were informed he was actively dying.
35. We have found no evidence in the medical records to indicate a discussion with the family about Mr A approaching the end of his life took place before 27 April 2024.
36. On the balance of probabilities, we conclude the family were not informed on 26 April 2024, in a way that they could fully understand, that Mr A was approaching the end of his life. We appreciate a conversation between hospital staff and the family may have taken place on 26 April, but communication of how unwell Mr A was by this time clearly was not effective.
37. We have found a failing in the Trust’s communication with Mr A’s family about him approaching the end of his life. NICE NG142 emphasises the importance of early recognition of dying and timely communication with patients and families, including planning for preferred place of care. As we cannot say this communication happened when it should have, we conclude Mr A’s family did not get the opportunity to consider how he and they may want to make arrangements for the last few hours of his life.
38. We cannot go as far as to say that Mr A was denied the arrangements he would have wanted in his final hours, as we cannot speculate what arrangements those might have been. We also note he died only 24 hours after the Trust identified he was in his final hours, and so it is unclear whether there would have been time to put in place the arrangements he and his family wanted, if he did indeed want different arrangements to those in place. What we can say is that this family have been left with the distress of not knowing whether more could have been done to explore and make those arrangements, and this is an injustice to them. We will therefore make the following recommendations.