A medical centre in the Hampshire area

A. The Practice

5. Miss J complained that when her father, Mr K, attended the Practice from March 2019 there were delays taking prompt action to arrange appropriate investigations into his symptoms.

6. Miss J said earlier investigations would have led to an earlier diagnosis of cancer and treatment. She believes her father’s death was avoidable. She added that her mother is heartbroken.

7. Miss J wanted an acknowledgement, apologies, and improvements. She also wanted a financial payment in recognition of what they have been through.

B. Hampshire Hospitals NHS Foundation Trust

8. Miss J complained about how the Trust managed the urology care and treatment of her father from March to September 2019. She said when the Trust fitted a catheter in March 2019, they did not inform her father it should be changed in six weeks’ time and there was no support arranged.

9. She also complained the Trust did not take appropriate actions when several investigations in March 2019 raised suspicious findings. She added that, following the cancer diagnosis being shared with her father at the beginning of August 2019, the consultant behaved in a disrespectful and uncaring manner and there was no support provided.

10. Miss J said there was a resulting delay in changing her father’s catheter which led to his kidney injury and a hospital admission. There was a delay of five months (from March to August 2019) in the Trust diagnosing her father’s bladder cancer and sharing this information with him and his family. The Trust repeatedly told her father and his family incorrectly there was no sign of cancer.

11. Miss J said with an earlier diagnosis her father could have received treatment sooner which may have made a difference to his prognosis and symptom control. She believes her father’s death was avoidable. Miss J added that if her father had received an earlier diagnosis his family would have had more time to be prepared and to say goodbye. Miss J said her mother is heartbroken.

12. Miss J wanted an acknowledgement, apologies, and improvements. She also wanted a financial payment in recognition of what they have been through.

13. Mr K had a history of bladder cancer.

14. On 18 February 2019 Mr K attended the Practice with symptoms of painful urination and blood in his urine. The GP made a two-week wait referral to the Trust. They carried out investigations including upper tract imaging, flexible cystoscopy, and kidney ultrasound.

15. On 12 March 2019 the Urology Multi-disciplinary Team (MDT) decided he should be seen in the outpatient clinic. In the meantime, Mr K’s renal function deteriorated and on 15 March 2019 he was admitted to hospital as an emergency with acute kidney injury and chronic kidney disease. The following week he had bilateral nephrostomies (an opening between the kidney and the skin) and subsequent stents (which allow urine to drain in the normal fashion, from the kidney into the bladder). He was discharged on 1 April 2019.

16. On 9 June 2019 Mr K was admitted to hospital with sepsis and acute kidney injury. On 15 June 2019 he was transferred to a different Trust. He was discharged on 24 June 2019.

17. On 2 July 2019 Mr K’s GP made a two-week wait referral to the Trust’s colorectal service. He was seen on 18 July 2019. On 25 July 2019 an MRI scan showed a large pelvic mass which proved to be malignant and of bladder origin (invading backwards into the rectum). On 5 August 2019 the consultant discussed the likely diagnosis of cancer.

18. On 4 September Mr K was admitted to hospital. Sadly, he died during this admission. The certified cause of death was metastatic bladder cancer.

A. The Practice

22. Miss J complained there were delays taking prompt action to arrange appropriate investigations into her father’s symptoms. She said this contributed to the delay in diagnosing his cancer.

23. On 18 February 2019 Mr K attended the Practice with symptoms of painful urination and episodes of incontinence. The GP noted blood in his urine and his history of bladder cancer. He made a two-week wait (2WW) referral. This was appropriate and in line with section 1.6.4 of the NICE guideline on the recognition and referral of suspected cancer.

24. From this point the management of Mr K’s urology care and treatment was under the urology consultants. The Practice would then await further direction from them, as necessary, for example, with regard to blood tests or medication.

25. In the meantime, in the middle of March 2019 Mr K was admitted to hospital with acute kidney injury and underwent surgery to address kidney swelling (nephrostomies). He was discharged on 1 April 2019.

26. The next contact with the Practice was at the end of May 2019. The GP saw Mr K on 31 May 2019. He was experiencing urinary leakage and faecal incontinence. Our GP adviser said, from the information recorded, this appears to have started in hospital. The GP took a swab, asked for a sample, and booked blood tests. This was appropriate in the circumstances and in line with section 15b of the GMC’s Good Medical Practice. This states a doctor must ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’.

27. Although Mr K was under the care of the Trust’s urology consultants, Mr K asked the GP to make private referrals to a urologist and a bowel specialist. The GP records document on 3 June 2019 that both referrals were made on a private basis.

28. The GP records show the GP called Mr K on 7 June 2019 with the blood test results (‘all stable but suggest monitoring by repeating in two weeks’). The GP also prescribed supplements for low folate levels. The GP documented Mr K was ‘still troubled by a leaking catheter’.

29. The GP understood Mr K was going to wait to see a private urologist, as well as still being under the NHS urology consultants. Our GP adviser said this was understandable in the circumstances.

30. On 9 June 2019 Mr K was admitted to hospital with sepsis and an acute kidney injury. Later that month he was transferred to a kidney centre.

31. After discharge from hospital, on 2 July 2019 a locum GP from the Practice saw Mr K who was having problems with diarrhoea. It appears he told the GP his colorectal appointment had been missed due to his recent hospital admission. The GP made a two-week wait referral to the colorectal team. Our GP adviser said based on the presenting symptoms (change in bowel habit) at that time this referral was appropriate and in line with section 1.3.1 of the NICE guidelines.

32. It appears that this urgent colorectal referral sadly ultimately resulted in the diagnosis of Mr K’s cancer.

33. Miss J expressed concern to us that the GP should have identified the presence of cancer sooner when she examined Mr K, given that the cancer diagnosis was made shortly afterwards. Our GP adviser said the only omission appears to be on 31 May 2019. Mr K was complaining of bowel incontinence. Our GP adviser said it would have been good practice to carry out a rectal examination in line with the GMC’s Good Medical Practice. This is where a doctor uses their finger to check for any problems inside the patient’s bottom.

34. Nevertheless, it is documented the GP visually examined Mr K’s anus. She documented that his perianal skin was inflamed and ‘sore-looking’. In any event, because of the consultation, the GP also made an urgent colorectal referral. This would have happened if a rectal examination was carried out which suggested anything untoward.

35. We found the Practice’s management of Mr K’s urology care and treatment from February 2019 was carried out in a timely manner and was in line with the relevant national guidelines. Our GP adviser said there were no avoidable delays on the part of the Practice.

36. Overall, we found no failings by the Practice.

B. Hampshire Hospitals NHS Foundation Trust

Management of urology treatment from March 2019

37. Mr K was referred to the Trust with non-visible haematuria (blood in the urine) and urinary symptoms, on a background of previous bladder cancer.

38. A urology consultant saw Mr K on 4 March 2019 and referred him for an ultrasound of his renal tract. An ultrasound uses sound waves to create an image of the internal organs. It is used to find out if the ureters (the duct by which urine passes from the kidney to the bladder) or kidneys are blocked.

39. The urology consultant also arranged a flexible cystoscopy, a camera examination of the bladder, to check for any problems. This was in line with section 5.4 of the EAU guidelines.

40. The ultrasound scan showed obstruction to both kidneys. The cystoscopy was also abnormal, identifying a ‘suspicious nodular area’. Our urology adviser said this is an abnormal finding. At cystoscopy the bladder should appear smooth and pale rather than inflamed (red) and nodular. Bladder cancer cannot be diagnosed by appearance alone, but the possibilities are either infection, benign (non-cancerous) growth, or cancer. Our urology adviser said in this particular area of the bladder it could also be an extension of the prostate gland, also known as the middle lobe of the prostate.

41. When arranging these investigations, the urology consultant also referred Mr K for an outpatient appointment with another urologist in the Trust. This would have been an opportunity to review the ultrasound and cystoscopy results. Unfortunately, this appointment did not take place. The reason for this is not clear.

42. On 12 March 2019 the Urology MDT discussed the results of Mr K’s ultrasound scan (7 March 2019) and decided he should be seen in an outpatient clinic.

43. Sadly, in the meantime Mr K’s kidney function deteriorated. On 15 March 2019 he was admitted to hospital as an emergency with acute kidney injury (sudden damage to the kidneys that causes them to not work properly), chronic kidney disease (long term condition), and recently discovered bilateral hydronephrosis (swollen kidneys). A catheter was fitted on 15 March 2019 during this admission.

44. On 18 March 2019 Mr K had bilateral nephrostomies (an opening between the kidney and the skin). The nephrostomy tubes (tubes draining directly into the kidney through the skin) were replaced with internal stents. Our urology adviser said this is standard practice and avoids the patient having two bags on the outside, which would be necessary with nephrostomies.

45. The BSIR guidelines state stents can stay in place for three to six months. This was acknowledged in the discharge summary. The plan was to change the stents in six months in line with the guidelines.

46. Mr K was discharged home on 1 April 2019 with an indwelling catheter.

47. Miss J complained the Trust did not arrange appropriate follow-up for her father’s catheter to be changed and it was left in too long. It is recorded in the hospital discharge summary that the GP should ask the district nurses to change the catheter in three months, that is, the end of June 2019. This is in line with the NHS information on catheters.

48. However, it appears the communication with Mr K and his family about this should have been better. In addition, the Trust said they made a referral to the community team, but no timeframe was given.

49. The Trust said because of its investigation the team will review the catheter pathway to ensure clear guidance is given to the community teams and patients themselves about the catheter care. This is in line with the Ombudsman’s Principles which state public organisations should ‘tell the complainant when lessons have been learnt as a result of their complaint’.

50. The discharge summary for this admission recorded Mr K ‘underwent flexible cystoscopy which showed only evidence of previous BCG therapy’. BCG treatment is the main treatment for non-muscle-invasive bladder cancer. This was not an accurate summary. The result of that investigation showed an abnormal area.

51. Our urology adviser said an abnormal flexible cystoscopy would normally lead to a cystoscopy under general anaesthetic, and a biopsy or resection (surgical removal) of bladder tumour. Section 5.8 of the EAU guidelines states ‘Carcinoma in situ is diagnosed by a combination of cystoscopy, urine cytology, and histological evaluation of multiple bladder biopsies’. This did not happen.

52. In addition, in the Trust’s response it confirmed that on 14 March 2019 orthopaedic team scans (to review Mr K’s titanium hip replacements) noted bilateral ureteric dilatation and thickening. The radiologist saw he had undergone treatment for this and was under the urologists. The Trust said it did not think this needed to be highlighted as a significant finding. It added that due to a backlog the scan took a month to report. Mr K’s bladder was not well visualised on the subsequent CT scan on 21 March 2019 but the report states ‘direct visualisation of the bladder is recommended’. Again, this did not happen.

53. We found there were missed opportunities to carry out further investigations to reach an earlier diagnosis. We have considered the impact of this later in this report.

Management of treatment from July 2019

54. In June 2019 Mr K was admitted to hospital with sepsis (the body’s response to an infection) and acute kidney injury. Later that month he was transferred to a different Trust. He was discharged on 24 June 2019.

55. On 2 July 2019 Mr K’s GP made a two-week wait referral to the colorectal service, as he was having problems with diarrhoea.

56. From this stage the Trust managed Mr K’s care and treatment in line with the EAU guidelines and the NICE guidance on the management of bladder cancer. He was seen on 18 July 2019. On 25 July 2019 an MRI scan showed a large pelvic mass. Sadly, this was malignant. On 5 August 2019 the consultant discussed the likely diagnosis of cancer. Investigations suggested this was more likely to be a primary bladder cancer, rather than a bowel cancer.

57. The Urology MDT discussed Mr K’s case on 13 August 2019. The extent of the disease became apparent following an MRI scan.

58. They found Mr K had stage 4 bladder cancer that had extended through the bladder wall. In this case patients should be considered for palliative radiotherapy. Our urology adviser said this referral was actioned in a timely manner.

59. Sadly, Mr K’s health deteriorated quickly. We appreciate this was a shock for Mr K and his family. We have seen nothing to suggest anything wrong with the management of his treatment at that time. However, we understand this will be of little comfort to his family in these sad circumstances.

60. In summary we found the management of Mr K’s treatment from July 2019 onwards was appropriate and in line with the EAU guidelines and the NICE guidance on management of bladder cancer.

Consultant’s behaviour

61. At the beginning of August 2019 Mr K was told he had a tumour between his bladder and bowel. The colorectal team referred him back to the urology team to arrange palliative radiotherapy. Miss J said later that month her father had an appointment with the urology consultant. She complained he made no eye contact and said they could only offer palliative care and radiotherapy. She said her father stood up to shake his hand and he folded his arms and turned away.

62. Miss J said after her complaint about this, she had a meeting with the consultant, and he said he was sorry. She said this is not good enough.

63. Section 46 of the GMC’s Good Medical Practice states that a doctor must be ‘polite and considerate’. From the account provided by Miss J the consultant does not appear to have been as polite and considerate as he should have been.

64. We do not doubt this was upsetting for Mr K and his family at an already difficult time. The consultant has already acknowledged that he should have acted differently. This was appropriate in the circumstances.

65. The consultant apologised for the way he conducted the consultation, both in person and through the complaints process. He said he did not mean to not shake Mr K’s hand and he did not intend to cause offence. He said if he could go back and change what happened he would do so. He apologised unreservedly that his behaviour added to the upset at an already incredibly difficult time. This was the correct action to take. This is in line with the Ombudsman’s Principles which state when something has gone wrong ‘an apology, explanation, and acknowledgement of responsibility’ is appropriate. We found that no further action is required here.

Impact

66. There were missed opportunities to carry our further investigations and diagnose Mr K’s cancer earlier.

67. If the abnormalities identified on 7 March 2019 (ultrasound) and 28 March 2019 (flexible cystoscopy) had been acted on promptly, Mr K would have been listed for a cystoscopy and bladder tumour resection. This did not happen.

68. Mr K’s GP referred him to the Trust under the two-week wait rule. In cases of any suspected cancer, in line with the DOH Cancer Waiting Times, the patient should be seen within 14 days of referral, a diagnosis made by 31 days, with treatment starting within 62 days of initial referral, at the latest.

69. Therefore, Mr K should have had a diagnosis by 21 March 2019. However, he did not receive a cancer diagnosis until over four months later. This was understandably upsetting for Mr K and his family. It is not surprising that his family questions whether an earlier diagnosis might have changed the sad outcome. We have considered this carefully.

70. If he had been diagnosed at this point, Mr K would have had further staging investigations to determine the extent of the disease. Our urology adviser said the presence of obstructed kidneys in March 2019 suggests the bladder cancer had progressed locally at that stage. However, as there were no staging investigations it is difficult to be more specific.

71. Our oncology adviser said it is likely this was muscle invasive bladder cancer and would have been staged as T3b (UICC TNM System), that is, Stage 3. This means the cancer cells have spread beyond the bladder muscle. The bladder cancer cells have grown into the layer of fatty tissue that surrounds the outside of the bladder and are large enough that they are visible using an imaging test or they can be felt by a healthcare professional.

72. Mr K developed muscle invasive bladder cancer that extended locally into his rectum resulting in his death. We found there was a delay in establishing a diagnosis and a resulting missed opportunity to offer treatment.

73. The Trust has already apologised for how it managed Mr K’s care and that it did not diagnose his bladder cancer earlier. It recognised that the abnormal investigation results in March 2019 should have raised concerns about active bladder cancer. The Trust said this should have been escalated to the family about the severity of his condition and the suspicion of bladder cancer. This was appropriate in the circumstances and is in line with the Ombudsman’s Principles that say ‘when things have gone wrong, public bodies should explain fully and say what they will do to put matters right as quickly as possible’.

74. The Trust said it would address the points found during its investigation through its formal governance. These include: escalation of results from the MRI scan, ultrasound scan and flexible cystoscopy; review its bladder service provision at Basingstoke Hospital; making improvements to the catheter management pathway and emergency urological ward care, registrar training and its letter and appointment reminder system following someone’s death. Our urology adviser said the Trust appears to have taken appropriate actions to avoid a recurrence.

75. The Trust extended its ‘heartfelt apologies’ that it did not diagnose Mr K’s bladder cancer earlier. It said whilst this may not have changed the treatment or outcome, it would have given him and his family more time to prepare and support each other. We found this does not fully recognise the impact of the delay on Mr K and his family.

76. If the diagnosis had been made sooner, the Trust would have offered Mr K radiotherapy treatment in line with the EAU guidelines. The aim of radiotherapy in this situation is to cure the cancer or, if this is not possible, to delay the progression by shrinking the cancer and helping with symptoms, such as bleeding or pain.

77. Our oncology adviser said it is impossible to predict how effective radiotherapy will be in any individual. Radiotherapy for all stage 3 cancer has the potential of cure in around 50% of all patients treated. However, from what we have seen Mr K’s cancer was more advanced (bilateral ureteric obstruction). Our oncology adviser said the expectation of cure would have been lower, approximately 20-30%.

78. When radiotherapy is given, approximately 75% will gain a response. This is clinically judged by a reduction in their symptoms, and radiologically by a reduction in tumour size. Unfortunately for many patients after a period, usually a few months, the disease will grow again. It is difficult to know the impact treatment would have had on delaying the progression of the cancer into his rectum. Nevertheless, it seems possible the treatment would have halted the progression and avoided the difficulties that rectal involvement caused him. The Trust has not acknowledged this.

79. As explained earlier, no staging investigations were carried out and so we cannot say if the cancer had already spread by March 2019. However, our oncology adviser said the average survival of patients who fail curative radiotherapy is around 9-12 months. It seems likely if he had been diagnosed earlier and received radiotherapy treatment Mr K would have lived longer. However, depending on whether the cancer had already spread, and if so, the extent, unfortunately he may not have had much extra time.

80. An earlier diagnosis would have allowed Mr K additional support and earlier access to palliative treatment options in line with the NICE guidelines. It seems more likely than not that during his final months he could have had a better quality of life, with less pain and discomfort.

81. The deterioration of Mr K over a relatively short time meant his loss was a shock for his family. This would unquestionably have had a significant impact on their ability to grieve or to come to terms with his death.

82. We agree with the Trust’s view that it is not possible to say with any certainty whether the sad final outcome might have been different. However, we do not underestimate the impact of this uncertainty on Miss J and her family.

83. An earlier diagnosis would have meant Mr K and his family would have had some understanding of the situation. While they would still have had the anxiety of undergoing investigations for the source of the cancer, they would have had a better understanding of what was happening. Mr K and his family would also have had the opportunity to come to terms with the diagnosis and to make plans. Instead of this he and his family had the anxiety and worry of repeated hospital attendances and not knowing what was wrong. Miss J told us she repeatedly asked clinicians if her father’s bladder cancer had returned and was told no. We realise this is distressing for her. Tragically his family had to witness Mr K in pain and discomfort for months. We cannot underestimate how upsetting this was for them.

84. We found the Trust has not gone far enough to acknowledge this. Therefore, we have made some recommendations for further work.

1. We have carefully considered Miss J’s complaint about the delay in diagnosing her father’s cancer. We understand this has been a very difficult and distressing time for all the family, after the sad loss of her father, Mr K.

2. We found the Practice managed Mr K’s urology care and treatment in line with the relevant national guidelines. We agree with Hampshire Hospitals NHS Foundation Trust that there were missed opportunities there to diagnose Mr K’s cancer earlier. It has already acknowledged this and apologised. However, we found the Trust has not recognised the full impact of this delay on Mr K and his family. There was a missed opportunity for treatment that would have reduced Mr K’s pain and discomfort in the final months of his life. Timely radiotherapy treatment may have also delayed the progression of his cancer.

3. Therefore, we do not uphold the complaint about the Practice. We partly uphold the complaint about the Trust.

4. We recommend that the Trust provides an acknowledgement of, and apology for, the full impact of the delay, and makes a payment of £2950 to Miss J to recognise this.