East and North Hertfordshire NHS Trust

Trust A

5. Mrs A complains the hospital delayed referring Mr A to the cancer centre for treatment, after his diagnosis of stomach cancer in September 2018. She says this delay contributed to Mr A’s life being shortened, as he had deteriorated and was too unwell for treatment by the time of his appointment.

6. Mrs A also complains that after the diagnosis staff did not tell Mr A his cancer was incurable. She says it was distressing to get this news when he went to the cancer centre. She is very upset the Trust’s complaint response incorrectly says staff told Mr A his cancer was incurable on 25 September 2018.

7. Mrs A would like Trust A to improve its services and procedures so other patients and families do not have a similar experience.

Trust B

8. Mrs A complains staff at the cancer centre took too long to see Mr A after a referral from Trust A in October 2018.

9. She says this contributed to Mr A’s life being shortened, as he had deteriorated and was too unwell for treatment by the time of his appointment.

10. Mrs A would like the Trust to improve their services and procedures so other patients and families do not have a similar experience.

11. In July 2018 Mr A was referred by his GP to Trust A with suspected lower gastrointestinal cancer (cancer of the large bowel and the rectum). He was seen at Trust A the same month and several investigations were carried out.

12. In September Mr A was diagnosed with upper gastrointestinal cancer - stomach cancer. After a multidisciplinary meeting (MDT – a meeting that takes place between health care professionals, to discuss individual patient cases) at the end of September, a decision was made to refer Mr A to Trust B for treatment. Mr A attended a clinic appointment on 4 October at Trust A where the plan and referral were discussed with him.

13. On 11 October the referral letter was sent to Trust B. This was received by Trust B on 23 October.

14. Trust B arranged a clinic appointment for Mr A on 13 November. Mr A was too unwell to start treatment and was referred back to Trust A and admitted to hospital. He was discharged on 11 December. No decision about treatment was made, as he needed hospital treatment to settle his symptoms first. Unfortunately, Mr A was not well enough for Trust B to decide about his first definite treatment.

15. Mr A was readmitted to Trust A on 25 December following a fall at home. Mr A sadly died in hospital in early January 2019.

Trust A - Issue one: delay in referral from Trust A to Trust B

19. A cancer pathway is a patient’s journey from the first suspicion of cancer, through to clinical investigations, diagnosis, and treatment. Cancer waiting times guidance, explains the service standards within which patients with cancer (including suspected cancer) should be seen. The targets relevant to this complaint are:

• no more than 62 days wait between the date the hospital receives an urgent referral for suspected cancer and the start of treatment (operational standard is 85%) • no more than 31 days wait between the meeting at which the patient and doctor agree the treatment plan and the start of treatment (operational standard is 96%).

20. It is not expected that all patients will be seen and treated within these timeframes as this depends on a patient’s individual cancer pathway. The operational standards above are therefore set to allow some patients to break these standards due to medical reasons or choice.

21. After Mr A’s referral to Trust A, a number of investigations were carried out. In Mr A’s case the 62-day target date from GP referral to first treatment was on 27 September 2018.

22. On 25 September Mr A had a chest computerised tomography (CT) scan, he was diagnosed with stomach cancer and told about this in a surgical clinic appointment the same day. After this appointment, an MDT was held on 28 September where it was agreed that he should be seen in the gastroenterology clinic and referred urgently to Trust B for treatment. Although the 62-day target had passed at this point, our adviser explained that after Mr A’s diagnosis, an MDT was needed to discuss the results so far, and to make a plan for his care.

23. Mr A was seen for a clinic appointment again on 4 October where the plan and referral were discussed with him. The decision to treat is the date the patient agrees to a treatment plan. So, for Mr A this was 4 October and when the 31-day target began.

24. In its complaint response, Trust A said it is their clinical protocol that a referral is discussed with a patient before it is made.

25. The SOP between Trust A and Trust B explains the processes to be followed for the management of cancer patients (which was in place at the time of the events). The SOP says that when a decision is made in the MDT for a patient to be referred for oncological treatment, the MDT coordinator will tell the oncology service manager to book an appointment with the particular consultant oncologist.

26. From reading the SOP, this first step can happen before the patient is told about the need for the referral, and according to this, Trust A should have contacted Trust B to arrange an appointment for Mr A after the MDT on 28 September. There is no evidence this happened in Mr A’s case. An appointment was not booked at Trust B until it got the referral on 23 October 2018.

27. Trust B can get cancer referrals by post/hard copy or email. Trust B explained to us that when they are received by hard copy, they are taken over to the Trust by a consultant.

28. The referral from Trust A was sent to Trust B on 11 October (one week after the clinic appointment where the referral was discussed with Mr A). Trust A said the one-week delay was caused by administrative staff shortages. It appears the referral was sent by post or hand delivered. Trust B said it received the referral on 23 October.

29. What we can see is that there was a delay of around 13 days in the referral being sent to Trust B. There was then a further delay of 12 days before Trust B received it, based on the information we have seen, the reason for this further delay is unknown.

30. The 31-day target for Mr A to start treatment was 3 November. Mr A was seen at Trust B on 13 November. This is a ten-day breach of the target.

31. Our principles of administration state that organisations should behave helpfully, dealing with people quickly, within reasonable timescales and within any published time limits.

32. GMC guidelines say that when doctors assess, diagnose or treat patients, they must quickly provide or arrange suitable advice, investigations or treatment where necessary and refer a patient to another practitioner when this serves the patient’s needs.

33. In line with these guidelines, we would expect that urgent cancer referrals are dealt with in a timely manner so that patients are seen within the targets set, where possible. It does not appear this happened in Mr A’s case.

34. The evidence suggests that Trust A did not deal with Mr A’s referral in line with the SOP or the guidelines set out above, and this meant an appointment was not booked earlier causing a delay in the referral being sent to Trust B. We find this was a failing.

35. We have thought about if this had any impact on Mr A. We did this by speaking to our adviser.

36. Mrs A says this delay contributed to Mr A’s life being shortened, as he had deteriorated and was too unwell for treatment by the time of his appointment. She says that meant he lost the opportunity to start treatment for the cancer, that could have lengthened his life.

37. We know that when Mr A was seen at Trust B, he was too unwell for treatment and sadly he never became well enough start treatment for cancer.

38. Our adviser explained that the tests Mr A had leading up to his diagnosis identified that his prognosis was really poor, there was evidence that his cancer was widespread, and unfortunately that meant there was no chance of a cure, and sadly his survival rate was low.

39. We know there was a delay in Trust A referring Mr A for treatment, and it is likely if this delay had not happened, he would have been seen sooner at Trust B. But we cannot say what would have happened if that delay had not happened. This is because even if Mr A had been seen sooner at Trust B, we do not know if he would have been well enough to start cancer treatment at that time, or if he would have responded positively to treatment. This leaves Mrs A in the very difficult position of not knowing what would have happened had Mr A been seen earlier, and this is an injustice in itself.

40. We therefore partly uphold this part of the complaint. We recognise how upsetting this was for Mrs A and the worry it caused. We cannot put things right for Mr A, but we have made recommendations for Trust A to do that for Mrs A and to take action to improve things for the future. These recommendations are set out at the end of this report.

Issue two – Communication and complaint response

41. GMC guidelines state that doctors must give patients the information they want or need to know in a way they can understand. They should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.

42. Mr A was seen in a surgical clinic appointment on 25 September where he was told about the diagnosis of stomach cancer. Mrs A has told us they were told at the clinic appointment that surgery followed by chemotherapy and radiotherapy would give Mr A the best chance of survival, and the Trust did not tell Mr A that his cancer was incurable.

43. There are no clinic notes available from the appointment on 25 September, so we have considered the clinic letter that was sent after the appointment. This states that the bad news was shared with Mr A, he was told that his cancer was widespread, it did not look like there was any treatment that could cure it and surgery was probably not an option, but he should be considered for chemotherapy.

44. Mr A had another appointment on 4 October, there are no clinic notes available, so we have considered the clinic letter that was sent after the appointment. In this letter it is noted that Mr A was made aware of the outcomes of his most recent investigations and about the referral that was being made. It is difficult to know exactly what was said to Mr A, but it seems he was told about his diagnosis and the next steps of his treatment pathway.

45. We have two different accounts about whether Mr A was told his cancer was incurable and these are hard to resolve.

46. Our adviser said that Mr A had evidence of widespread cancer and his prognosis was poor because of this. They also explained that unfortunately there is no cure for the type of cancer Mr A had, and surgery would not have been possible.

47. Considering the evidence we have available and what our adviser told us, we think it is likely that Mr A was told that his cancer was not likely to be curable, and that the next step in his treatment plan was to be referred for possible chemotherapy. That is not to say we do not believe what Mrs A has told us. The message within the appointments, may not have been understood in the way it was supposed to have been. We recognise this was a very upsetting time for Mr and Mrs A.

48. The evidence suggests that it was communicated to Mr A that his cancer was not likely to be curable, as well as information being given to him about the next steps of his treatment plan. This is in line with the GMC guidelines mentioned above.

49. Mrs A is also unhappy that the Trust’s response dated 7 January 2020 states they were told at the appointment on 25 September that Mr A’s cancer was incurable.

50. Our principles of complaints state that organisations should investigate complaints thoroughly and fairly, basing their decisions on the available facts and evidence.

51. We have considered the clinic letter from 25 September and the Trust’s response. The clinic letter states that it was explained to Mr A that it did not look likely that Trust A could cure the cancer. The Trust’s complaint response states the clinic letter explained this. This seems to reflect what Mr A was told. This is in line with our principles of complaints as the Trust’s response has been based on the evidence within the clinic letter.

52. We realise how upset and shocked Mr and Mrs A were to learn that Mr A’s prognosis was poor. The evidence available to us suggests he was told his cancer was unlikely to be curable and the Trust’s response letter reflects this. We therefore do not uphold this part of the complaint.

Trust B - Issue three – delay in appointment following a referral

53. As explained under issue one, our principles of administration say that organisations should deal with people quickly and within reasonable timescales.

54. To consider what happened when Trust B received the referral from Trust A, we have looked at its internal emails.

55. Trust B got the referral from Trust A on 23 October. On 25 October Trust B booked Mr A into a new patient slot for an appointment on 13 November. We looked at the reasons for the delay in the appointment being booked.

56. The clinics taking place before 13 November were either already fully booked or not available, due to staff leave. The internal emails from the Trust suggest it tried to look for an earlier appointment but could not find one available for Mr A.

57. We recognise the 31-day target to start treatment was breached. If Trust B had got the referral earlier (without the delays) it may have been able to book Mr A into an earlier appointment slot. However, the evidence suggests Trust B did what it could when it got the referral, to see Mr A at the earliest appointment available. This is in line with our principles of administration. We therefore cannot say it did anything wrong.

58. We understand how difficult this wait must have been for Mr and Mrs A and we are sorry to hear that he was never well enough to start treatment. Trust B did what it could to book an appointment for Mr A at the earliest opportunity and this is in line with our principles of administration. We therefore do not uphold this part of the complaint.

1. We have carefully considered Mrs A’s complaint about her late husband’s, Mr A’s, care and treatment. We thank Mrs A for discussing her concerns with us. We recognise how difficult it can be to discuss the events complained about since Mr A’s sad death.

2. We have found that London North West University Healthcare NHS Trust (Trust A) delayed referring Mr A to the cancer centre for treatment. But we cannot say what would have happened if there was no delay. This leaves Mrs A in the very difficult position of not knowing what would have happened had Mr A been seen earlier, and this is an injustice itself. We have also found that Mr A was told about his prognosis in line with relevant guidelines and Trust A’s complaint letter shows this.

3. We therefore partly uphold the complaint about Trust A. We have recommended that Trust A writes to Mrs A to accept the failing and do an action plan to prevent the failing happening again.

4. We have also found that East and North Hertfordshire NHS Trust (Trust B) did what it could to see Mr A at the earliest appointment available. We therefore do not uphold the complaint about Trust B. We do recognise the worry the wait caused for both Mr and Mrs A, and we hope our explanations provide some reassurance to Mrs A.