Mrs A complained about the Health Board’s management of her father, Mr C’s, pancreatitis (an inflammatory condition of the pancreas) and subsequent diagnosis of pancreatic cancer. The investigation focused only on whether Mr C received appropriate medical management and intervention between January 2023 and January 2024, relating to his pancreatitis; whether Mr C’s pancreatic cancer should have been investigated and diagnosed earlier; whether appropriate treatment was provided to Mr C following his diagnosis of pancreatic cancer; and, whether an appropriate palliative care plan was put in place, and implemented for Mr C.
The investigation found that Mr C’s management before and after his cancer diagnosis was clinically appropriate and there were no missed opportunities to diagnose pancreatic cancer sooner. Whilst Mr C’s presentation included symptoms which were similar to pancreatic cancer, appropriate and extensive investigations did not identify cancer during 2023, with the possibility of pancreatic cancer identified only in early 2024. However, there were shortcomings in the level of service Mr C received from the dietetics service due to limited documentation to evidence appropriate actions. In addition, there were also communication shortcomings due to a disconnect in communication which meant a lack of clarity for the family about Mr C’s management. Complaints a) and b) were upheld to this limited extent.
The investigation found when Mr C received a formal diagnosis of cancer, it was metastatic and incurable and therefore the recommendation for palliative chemotherapy was the correct management plan. In terms of dietetic service involvement, the community dietetic team made an appropriate referral/handover to the hospital dietetic service in February 2024 due to Mr C’s hospital admission. According to acute nutrition support standards, the earliest the hospital dietetic team would have seen Mr C was the day before he died. However, had they seen him as planned, this might have allowed them to provide supportive nutritional care within this very short time frame. Due to this uncertainty, complaint c) was upheld to this very limited extent.
Whilst no formal palliative care plan was prepared for Mr C after he was told of his cancer diagnosis, some relevant actions and discussions did take place. It is relevant to take account that national guidance instructs that a palliative care plan should not be completed until the last days of life. As palliative chemotherapy was being planned at that time, clinicians considered that there were treatment options available. The investigation found that, on a finely balanced basis, because of the suddenness of Mr C’s decline, it was appropriate not to complete a palliative care plan for him. Complaint d) was not upheld.
The Health Board agreed to apologise to Mrs A for the identified failings and to share the report with its Nutrition and Hydration Steering Group for learning.