The Christie NHS Foundation Trust

3. Mr I complains about the service provided to his wife, Mrs I, by the Trust from September to February the following year.

4. He says the Trust failed to detect a tumour on his wife’s left kidney. Mr I says as a result of the failing, his wife’s diagnosis of kidney cancer and treatment for kidney cancer were delayed which may have accelerated her death.

5. In bringing this complaint, Mr I seeks an apology, acknowledgement of failings by the Trust, an explanation as to how the tumour was missed, service changes and financial remedy for the death of his wife.

6. In 2018, Mrs I received treatment for anal cancer at the Trust. As the cancer had spread to the tissue around the anus, surgery was not possible. Mrs I underwent chemotherapy and radiotherapy to reduce the size of the cancer. We understand this was a difficult time for Mr and Mrs I.

7. The medical records show Mrs I had a Positron Emission Tomography (PET) CT scan on 7 April. A PET scan uses a mildly radioactive drug to show up areas where cells are more active than normal. It is often conducted alongside a CT scan, which uses X-rays to build a three-dimensional picture of the areas scanned. The medical records show that the post-chemoradiotherapy PET CT scan on 7 April demonstrated mild abnormality in the pelvis. It was concluded by the Trust that this was likely to be inflammation following treatment but there was no evidence of cancer spread to the kidney, lungs, or liver.

8. Mrs I had a further PET CT scan on 4 September and was reviewed in the clinic on 4 October. She was told her kidneys were normal and she had no bladder problems. The Trust planned to carry out a review three months later where they would perform an MRI scan.

9. Mr and Mrs I travelled to France. On 22 October, Mrs I attended a local French hospital after becoming unwell. She had blood in her urine. A local scan showed the presence of a tumour on her left kidney and Mr I says the French doctors advised an immediate return to the UK. Mr and Mrs I were understandably concerned.

10. On 23 and 24 October, Mr I contacted the Trust by phone and spoke to an oncologist. The Trust’s response outlines that the Trust’s consultant advised Mr I the symptoms were likely related to an infection. This was because the scan the Trust completed in September had not shown any abnormalities, and Mrs I had suffered similar problems in the past which had been resolved with antibiotics.

11. The consultant advised the doctors in France should be asked to administer antibiotics and complete a blood test to determine any issues with the kidneys. When Mr I contacted the Trust on 24 October, he advised the hospital in France had said it did not think Mrs I’s symptoms were related to her kidneys. This was because her symptoms were improving, and her haematuria (presence of blood in her urine) had completely resolved. The doctor in France had some doubt about the initial view regarding the presence of a tumour and wanted to repeat investigations in a week. Mr I expressed his concern but was reassured by the Trust there was no need to return to England. This was because Mrs I was likely to have had an infection, and it is rare for cancer cells to migrate to the kidneys. We appreciate it was really upsetting for Mr and Mrs I to discover that the cancer had returned and that it was not detected sooner.

12. When she returned to the UK, Mrs I provided the Trust with a paper report from the hospital in France. The hospital in France could not send the Trust the actual films from its scan as they were not allowed to send them out of the country. Without the actual scans the Trust were unable to identify what had been picked up on the scan and continued to conduct its own scan. On 3 December, Mrs I had a PET CT scan at the Hospital which showed a possible infection in her left kidney. She was reviewed by a nurse clinician on 10 December, and it was recorded that she appeared to be recovering well.

13. When Mrs I became increasingly unwell two months later, in February, Mr I took her to a local hospital near their home. The local hospital carried out a scan on 18 February. The scan revealed an abnormality to her left kidney and a subsequent biopsy confirmed it to be cancerous. Mrs I also had tumours on her lungs. This was understandably a traumatic experience for Mr and Mrs I.

14. Mrs I’s case was reviewed by the Trust two months later, on 14 March. The Trust said the scans in September and December of the previous year were correctly reported and gave no indication of cancer. It concluded Mrs I developed rapidly progressive metastases (the spread of cancer) from her anal cancer to her left kidney. The trust advised ’it was diagnosed at the earliest opportunity’. Mrs I sadly died on 18 November.

18. The ASMO-ESSO-ESTRO Anal Cancer guidance states that approximately 10%–20% of patients suffer distant relapse. This is the spread of cancer cells from the place where they first formed to another part of the body. This guidance says, ‘The most common sites for anal cancer to spread to are the para-aortic nodes (lymph nodes that lie in front of the lumbar vertebrae), liver, lungs and skin. These usually appear relatively late and in the context of local persistence or recurrence of disease following treatment. The prognosis in this group is poor with only 10% of patients with distant metastases surviving 2 years or more.’ The guidance does not mention that anal cancer commonly spreads to the kidneys. Our clinical adviser supported that this is not a common area for the cancer to spread to.

19. The guidance does not outline the kidneys as a common site which would need to be checked or reviewed. Our adviser supported this and confirmed that a spread of anal cancer to the kidneys is rare.

20. GMC Guidance ‘Good Medical Practice’, section 15, states: ‘promptly provide or arrange suitable advice, investigations where necessary’. This requires doctors to undertake relevant scans and assessments related to the conditions and symptoms presented. In this case this relates to the PET-CT scan the Trust conducted.

21. The NHS website outlines under ‘tests and next steps for kidney cancer’, the scans expected for testing for cancer. It states when looking at whether the cancer has spread, a PET scan will be used. Our adviser commented that the PET-CT scan was the correct scan.

22. We can see from Mrs I’s medical records the Trust conducted a PET CT scan on 3 December, to identify if the anal cancer had spread. As we can see from the medical records and the Trust’s response, the scan was discussed at an MDT (Multidisciplinary Team) meeting and Mrs I was further reviewed on 10 December. The Trust reports there was no indication of kidney problems during this time. A further review was scheduled for three months' time.

23. As outlined in the anal cancer guidelines, the spread of anal cancer would likely be in specific areas. Kidneys are not one of the common areas for this type of cancer to spread. The Trust did scan Mrs I’s kidneys but found no indication that the cancer had spread.

24. The Trust were advised by Mr and Mrs I that a scan in France in October had identified the abnormality in Mrs I’s left kidney. The Trust were unable to obtain the scans taken in France, and the scan used in France is not a scan used in the UK for this diagnosis. The Trust performed the appropriate scan, in line with NHS guidance. The appropriate investigation was carried out in line with the GMC guidance referenced above.

25. We asked our clinical adviser if the PET CT scan on 4 September, before Mr and Mrs I’s trip to France, showed any sign of the spread of cancer. Our adviser commented that the scan shows a very subtle abnormal uptake in the upper pole of the left kidney, which in retrospect is likely to represent spread from the anal cancer. Our adviser went on to explain that this finding has been picked up with the prior knowledge that an abnormality is present in this area. This may not be the case when first looking at the scan. They advised it would be extremely difficult to conclude this is a ‘miss or discrepancy’ as the overwhelming majority of radiologists would undoubtedly fail to see this subtlety. Particularly in light of the clinical information that anal cancer rarely spreads to the kidney.

26. We have considered whether the Trust, having been told by Mr and Mrs I that an abnormality was identified in the left kidney, should have picked this up in its PET CT scan. The Trust have advised in its complaint response dated 17 October that the spread of the cancer was extremely rare in nature, and previous reviews showed no abnormalities. The Trust have also advised that Mrs I had previous infections, which contributed to its view that Mrs I had suffered an infection while in France.

27. Our clinical adviser has provided comments on the likelihood of this abnormality being identified as cancer in the initial scans. The clinical adviser has said the abnormality in the initial scans is very subtle and in retrospect is likely to indicate the spread of cancer. They have gone on to advise that this is only with the knowledge that the spread did indeed happen. Given the rare nature of this spread it would be extremely difficult to conclude this was a miss or a discrepancy.

28. When the cancer in Mrs I’s kidney was identified on 18 February, by a scan, the mass was larger and considered as a new presentation. Given this new presentation of malignancy (the presence of cancerous cells that have the ability to spread to other sites in the body), we can now see the small abnormality in the original scans from September and December were indications of the spread of cancer.

29. The Trust reviewed the scans from 4 September at an MDT meeting on 14 March the following year. The Trust reported that ‘the MRI scan of the pelvis in September showed no evidence of a recurrence of the anal tumour and on review the kidneys still appeared normal. The scan [from 3] December suggested that the right kidney was a little larger with some altered signals likely to be an infection’. The Trust’s MDT concluded that the scans from September and December were reviewed and reported correctly, and Mrs I unfortunately developed rapidly progressive spread of cancer into her left kidney. We appreciate this may be distressing for Mr I, but we hope we have explained clearly how this view is with the benefit of hindsight.

30. We considered the rare spread of anal cancer to the kidneys, and the indications of abnormalities on the previous scans. We also considered the relevant guidance which outlines the Trust undertook the relevant scans and tests. To support our decision, we considered the clinical advice we received which confirmed that, at the time, the signals seen in earlier scans were not clear indicators that the cancer had spread to the kidneys.

31. Our radiologist adviser states that diagnosing the cancer in the left kidney earlier would not have significantly changed Mrs I’s prognosis. She was unfortunate to have had an aggressive form of anal cancer which had already spread to the left kidney. The subsequent CT scan on 18 February showed the cancer was present in the lungs, adrenal glands and increased in size in the left kidney. Mrs I could have received chemotherapy a few months earlier if it had been detected sooner. Unfortunately, due to the aggressive nature of the cancer this would not have improved her outcome. Based on our considerations of these views, unfortunately Mrs I would have likely not had a better chance of survival. We know this is a difficult outcome for Mr I, and we are sorry for his loss.

32. We appreciate that this is a very rare case, and we cannot guarantee that this would not happen again. It is always a learning point for the Trust when these incidents occur. We can see that the Trust have provided an explanation and consideration of this event.

33. It is very unfortunate that the spread of cancer to Mrs I’s kidneys was not identified by the Trust earlier. We can see no failing by the Trust in not picking up the spread of cancer. The Trust’s consultants conducted the appropriate scans and recorded clearly in Mrs I’s medical records their reasoning for determining the scans showed an infection. The consultants also demonstrated that in making this decision they considered other factors such as symptoms resolving and improving, and previous infections. The follow up review on 10 December showed Mrs I was recovering from the apparent infection.

34. We appreciate the position Mr and Mrs I were in was a traumatic one, and the advice they had received from the clinicians in France was that the abnormality was present. It is understandable they feel the cancer could have been picked up earlier. Given the rareness of this type of spread, and the different scans used in the UK, it is evident the Trust were not able to clearly see an indication the cancer had spread. The Trust did follow the relevant guidance, as outlined above. It is extremely unfortunate the spread was not picked up in the scans the Trust conducted, but our view is that the rareness of the spread, the size of the mass and the more likely prognosis that it was an infection, demonstrate no failings on the part of the Trust.

35. Therefore, we have concluded to not uphold this complaint.

1. The views set out below provide our conclusions on this case.

2. Our view is to not uphold this complaint. According to the evidence we have seen, the Christie NHS Foundation Trust (the Trust) carried out appropriate assessment and scans. Due to the rare migration of anal cancer to the kidney we can see no service failure by the Trust. We can also reasonably conclude that the outcome for Mrs I would sadly not have changed had she started treatment earlier. We appreciate the impact events have had on Mr I, and we are sorry for the loss of his wife.