Care and treatment
20. Mrs A says the Trust failed to diagnose her with skin cancer until mid-July 2024 which was not soon enough. She is particularly concerned that the doctor who first saw her in mid- June 2023 did not assess, diagnose and treat her correctly. She is further concerned that on several occasions after her first appointment the Trust cancelled follow-up appointments and did not rebook timely replacements.
21. The Trust said the doctor who saw Mrs A in mid- June 2023 thought she had impetigo and prescribed mupirocin ointment for this. It also said they arranged a swab test to look at possibilities of an ulcer, cellulitis or an infection of the skin and requested a four week follow up appointment.
22. The Trust said the next time staff saw Mrs A at the end of April 2024, they noted the results of the swab and arranged a small punch biopsy. It further explained that dermatology staff reviewed Mrs A in mid-July 2024 and told her she had squamous cell carcinoma in the left nostril and referred her urgently to the head and neck multi-disciplinary team.
23. In relation to Mrs A’s follow-up appointments being repeatedly cancelled, the Trust apologised and said it was unacceptable.
Dermatology appointments in mid-June 2023, end of April 2024 and mid-July 2024
24. In mid-June 2023, Mrs A attended the dermatology clinic at the Trust. A dermatology doctor reviewed her, noting she had a lesion on her left nostril ‘which appeared about four months ago following an episode of cold and coryza [common cold]’.
25. The doctor examined Mrs A’s nose and noted there was a crusty area on the lower part of her left nostril. They diagnosed impetigo (skin infection) and took a swab in order to test for infection, ulcers or skin conditions like cellulitis. The doctor also prescribed Mrs A with mupirocin nasal ointment (an antibiotic) and requested a routine follow-up appointment in four weeks.
26. NICE CKS, Impetigo, outlines how clinicians should diagnose impetigo by taking a history and examining the patient including what symptoms to look for.
27. Our adviser said that a diagnosis of impetigo was reasonable based on the history and examination conducted by the doctor. Because of this, they explained that the plan and treatment the doctor arranged was also reasonable. We understand from our adviser that cancer was correctly not suspected at this appointment.
28. Informed by our adviser, we consider the doctor, who saw Mrs A in mid-June 2023, acted in line with NICE CKS guidance in the actions they took.
29. At the end of April 2024, Mrs A saw a different doctor. They noted the outcome of the previous appointment. Mrs A told them that the nasal ointment had worked for a while but then stopped working and the lesion was now very tender meaning she could not blow her nose. Mrs A also reported that the lesion weeps and scabs over and was getting bigger.
30. The doctor noted the previous swab test showed no sign of infection causing bacteria. They examined Mrs A noting there was a 9x5mm nodule on the nose which was very tender and had an overlying green scab. The doctor thought Mrs A may have a nasal polyp and requested a small punch biopsy be taken from the lesion. A nasal polyp is a swelling in the lining of the nose containing inflammatory fluid.
31. British Association of Dermatologists guidance outlines how, when a doctor wants further information to care for and treat a skin lesion the right course of action is to take small biopsies of the skin.
32. We understand from our adviser that staff were correct not to suspect cancer at this appointment.
33. Informed by our adviser, we consider the doctor, who saw Mrs A at the end of April 2024, acted in line with British Association of Dermatologists, Getting it right first time guidance. This is because they requested a small punch biopsy to get further information about her lesion.
34. In mid-July 2024, Mrs A attended an appointment with a dermatologist who informed her that she had skin cancer in the form of squamous cell carcinoma (confirmed by the small punch biopsy) and referred her to the head and neck multi-disciplinary team for follow-up.
35. British Association of Dermatologists, Dermatology Acute Service Specification guidance outlines what should happen when a patient is diagnosed with squamous cell carcinoma.
36. Informed by our adviser, we consider the doctor who saw Mrs A in mid-July 2024, acted in line with this guidance because they referred her for appropriate follow-up based on her diagnosis.
37. In summary, we have seen no indications doctors did anything wrong at the appointments in mid-June 2023, the end of April 2024 and mid-July 2024. Our decision here is not meant to undermine the shock Mrs A experienced when she was told she had cancer. We fully appreciate this would have been very worrying at the time and afterwards.
Delay between mid-June 2023 and end of April 2024
38. The Trust arranged a follow-up appointment for Mrs A at the end of August 2023 following her appointment in mid-June 2023.
39. The Trust cancelled this appointment due to ‘sick leave’ and booked the next available appointment in mid-December 2023. The Trust cancelled this appointment too due to ‘staffing issues’ and rearranged the appointment for mid-April 2024. The Trust later cancelled and rescheduled this appointment (for the end of April which Mrs A attended). In the information the Trust provided to us it gave no reason for cancelling the appointment in mid- April. We note, in its response to the complaint, it said it cancelled this appointment because the clinic was changed to a paediatric clinic and staff booked Mrs A onto the next available adult follow-up clinic slot.
40. DHSC, Handbook to the NHS Constitution for England, explains that when a patient is on a non-urgent pathway they have the right to start consultant-led treatment within 18 weeks of referral.
41. Our adviser explained that given the doctor who saw Mrs A in mid-June appropriately diagnosed impetigo, did not suspect she had cancer and requested a routine outpatient follow-up appointment, it was correct for her to be placed on the non-urgent general dermatology pathway thereafter.
42. They further explained that, because the doctor diagnosed and treated her in mid-June, the 18 week standard, as outlined above, was met in terms of her original fast track referral from her GP and the 18 week standard started again from that point in terms of her follow-up appointment.
43. On that basis, while we appreciate the doctor in mid-June requested a follow-up appointment for Mrs A within four weeks which was initially arranged for late August (eleven weeks later), this was inside the 18 weeks outlined in DHSC guidance. We therefore consider the Trust did not do anything wrong here by arranging the appointment for the end of August.
44. We asked our adviser what should happen when a hospital cancels an appointment. They explained that for outpatient appointments there is no specific guidance. They went on to outline how, in Mrs A’s case, they would have expected the Trust to rebook the appointment according to the pathway she was on and her place on that pathway.
45. We think Mrs A should have had her follow-up appointment by the middle of October 2023 in accordance with the 18 week standard. Mrs A did not have this appointment until the end of April 2024 which was over six months later.
46. While we appreciate there were good reasons the Trust cancelled her appointment on several occasions, we consider Mrs A should have been seen sooner. This is an indication something went wrong.
47. We also asked our adviser about the actions the Trust has taken as a result of what happened.
48. The Trust said patients who are initially referred to the fast-track dermatology clinic (as Mrs A was initially by her GP) will now always be booked into fast-track follow-up clinics rather than general (routine) dermatology clinics if they require follow-up from their initial fast-track appointment.
49. Our adviser explained this action will minimise confusion about which pathway a patient is on. They said it will enable staff to track changed appointments through the fast-track pathway meaning staff will be more vigilant about re-booking appointments in a timely manner.
50. We fully appreciate that this situation was not ideal. We recognise the repeated appointment cancellations, albeit unavoidable, will have been very frustrating for Mrs A and we are sorry to hear this.
51. Thankfully, this delay did not impact on Mrs A’s skin cancer diagnosis. When a doctor saw her for her follow-up appointment at the end of April 2024, as explained earlier, they acted in line with guidance and correctly referred her for a routine biopsy. They did not suspect cancer at this point – this means that even if she had been seen earlier, on balance, cancer would not have been suspected.
52. We are also pleased to see that the Trust has apologised for the delay caused by cancelling the appointments and we consider it has taken appropriate action to prevent what happened from being repeated. This is in line with our Principles for Remedy which outline how an apology and making changes by revising procedures are appropriate remedies to put things right.
53. We will take no further action here.
54. Again, this decision is not made without recognising the frustration caused to Mrs A.
Events between the end of April 2024 and mid-July 2024
55. In early May 2024, the Trust carried out a biopsy. The results of this, showing Mrs A had skin cancer, were reported in early June 2024,
56. In mid-July 2024, doctors told Mrs A about her skin cancer diagnosis.
57. Our adviser explained that there is no specific guidance about how long it should have been before Mrs A had the biopsy following her referral at the end of April. They said the wait of less than two weeks was reasonable.
58. The Ombudsman’s Clinical Standard outlines how organisations must act in accordance with recognised quality standards, established good practice or both when delivering clinical care. In this situation, where there are no relevant clinical guidelines or standards, we have considered the professional judgement of our adviser which is based on established good practice.
59. We are satisfied the Trust arranged Mrs A’s biopsy in an appropriate timescale in line with our Clinical Standard.
60. The Royal College of Pathologists, Key performance indicators, explains how routine non-urgent samples should, in 80% of cases, be reported within 21 days.
61. It took 25 days for the Trust to report Mrs A’s results.
62. We do not consider this fell so far short of the Royal College of Pathologists guidance to say there are indications something went wrong here.
63. We asked the Trust for further information about why it took from early June until mid-July for Mrs A to be informed of her cancer diagnosis.
64. The Trust explained to us that following the results of the biopsy being reported, staff triaged them in mid-June. This led to the results being signed off five days later.
65. The Trust accepted there was a delay between the results of the biopsy being reported and staff triaging them. It also said that there was a further delay between staff signing the results off and the doctor informing Mrs A about them. It explained that its policy is for doctors to see patients within two weeks of the results being signed off when cancer is confirmed.
66. There are indications something went wrong here which resulted in a delay of up to a month. To clarify, this delay was between Mrs A’s biopsy results being reported and the dermatology department informing her of her cancer diagnosis in mid-July where the doctor appropriately started the treatment plan by referring her to the head and neck team.
67. We asked our adviser whether there was a clinical impact to Mrs A as a result of this delay. They explained that a delay of up to 30 days would not make a significant difference to the size of the lesion and therefore would not affect the type or extent of the surgery that she later had in mid-September 2024.
68. We consider that what went wrong did not have a clinical impact on Mrs A. We acknowledge she had to wait longer than she should have to be told about her cancer diagnosis which was upsetting. We hope she is reassured that the surgery she had was not affected and therefore the outcome was the same.
69. We also consider the Trust has acknowledged to us what went wrong in line with our Principles for Remedy.
70. The Trust also explained to us that at the time there was no cancer navigator in post. It said such people are the dedicated staff members who monitor timescales between a patient’s biopsy results being known and them seeing clinicians. The Trust told us it now has more staff in the department including in this role.
71. We are satisfied the Trust has taken appropriate action to ensure what happened here is not repeated.
72. This is in-line with our Principles for Remedy which outlines how organisations should learn from what went wrong.
73. We will take no further action here.
74. We, again, fully acknowledge how challenging a time this was for Mrs A and her family given her cancer diagnosis. We are really pleased that she got the surgery she needed and the Trust’s delays we have outlined did not affect this.