A practice in the Somerset area

6. Mrs G complains about the care provided to her father, Mr W, by the Trust between March and 4 November 2022.

7. Mrs G says the Trust did not:

• appropriately consider her father’s symptoms, including night sweats, muscle aches and increasing pain, and did not arrange appropriate tests when making a diagnosis • did not recognise her father’s cancer following an X-ray in June 2022 • consider and act on the further information provided by the Practice after the initial referral to the orthopaedics team was made in May 2022 • arrange appropriate tests during an emergency department (ED) admission in August 2022 and did not scan Mr W’s hip, leg and pelvis area • appear certain of the primary site of Mr W’s cancer, and Mrs G wonders if this affected the care her father was provided.

• did not provide appropriate pain relief on his readmission to the Beacon Ward and did not give appropriate pain medication advice on her father’s discharge.

8. Mrs G says that as a result of these failings, her father’s cancer diagnosis was delayed. She says his cancer was at stage four at the time of diagnosis. Mrs G feels her father’s death could have been avoided had his cancer been diagnosed sooner.

9. Mrs G says these failings have caused their family considerable distress. She says her father was not as comfortable as he should have been after his diagnosis, which added to their overall concerns about the care the Trust provided.

10. Mrs G is seeking apologies, an acknowledgment of failings, service improvements and a financial remedy.

11. Mr W (aged 77) was referred to the Trust for ongoing hip pain in May 2022.

12. The Trust arranged an X-ray on 16 May 2022. The results of the X-ray showed osteoarthritis (a condition that causes joints to become painful and stiff) in the lower back and mild arthritis (a condition that affects the joints and causes pain, stiffness and swelling) in both hips.

13. Mr W’s GP practice contacted the Trust in July 2022 as he was experiencing recurrent falls, increased pain, and had new symptoms of night sweats and muscle aches.

14. Mr W attended the Trust’s ED on 2 August 2022 due to pain in his hip and right buttock (the pelvis). His recent falls were also noted. The Trust arranged an MRI scan (a type of scan that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body) of the lumbar spine and a CT scan (a test that takes detailed pictures of the inside of the body) of the head, to check for any underlying cause of Mr W’s symptoms.

15. The MRI showed a disc prolapse (occurs when a soft cushion of tissue between the bones in the spine bulges outwards), which was felt likely to explain Mr W’s symptoms. No concerns were noted on the CT scan of the head.

16. Mr W attended the ED again on 9 August 2022, following a further fall. Blood tests at this time showed Mr W had low calcium, which had not been a concern on his previous tests. This led to further tests and scans for Mr W, which led to the diagnosis of metastatic lung cancer. This is cancer that began in the lungs and has spread to other areas, including the bone of the pelvis.

17. The Trust arranged tests to check for possible targeted treatment options for Mr W. Sadly, Mr W’s condition deteriorated during this time, and he was not well enough for targeted cancer treatments.

18. Mr W died on 4 November 2022.

19. Mrs G explains she and her family continue to experience significant distress as a result of these events. They wonder if Mr W’s cancer could have been diagnosed and treated sooner. It is for these reasons that she has brought her complaint to us.

Consideration of symptoms – May to July 2022

24. Mrs G says the Trust did not appropriately consider her father’s symptoms, including night sweats, muscle aches and increasing pain, and did not arrange appropriate tests when making a diagnosis. She says an X-ray taken in June 2022 did not recognise his cancer and was not clear. She feels further investigations should have been arranged.

25. We have sought advice from our orthopaedic adviser to consider this concern, in line with the GMC guidance ‘Good medical practice’. This says:

‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:

• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.’

26. Mr W was initially referred to the Trust for ongoing hip pain in May 2022. The Trust arranged an X-ray of the the spine and hip. The X-ray showed mild arthritis in hip and arthritis in the lumbar spine. Mr W had a telephone consultation with the specialist musculoskeletal practitioner on 20 July 2022 where a provisional diagnosis of mild arthritis of hip was made and a face-to-face appointment was arranged.

27. The GP contacted the Trust’s orthopaedic assessment service again on 25 July 2022, due to concerns about Mr W’s recurrent falls and increased pain and asked for consideration of an MRI scan.

28. The MSK specialist contacted Mr W for a further telephone assessment on 28 July 2022. Mr W reported his pain had improved, so it was agreed that he would continue with the same plan and a face-to-face assessment would also be arranged.

29. Our orthopaedic adviser explains Mr W’s symptoms between May and July 2022 were appropriately addressed and appropriate tests were undertaken, in line with the GMC guidance. There was no history of any symptoms related to cancer or any suggestion of this on X-rays or blood tests.

30. We note Mrs G’s concern that her father had significant bone metastases when his cancer was diagnosed only a few months later. She wonders how this was not visible on the initial scans.

31. The Trust’s clinic letter of 22 September 2022 explains Mr W’s CT scan had shown an abnormality in the right lung, the lymph glands in the centre part of the chest, the left adrenal, left kidney and right pelvis, as well as a small abnormal area in the left pelvic bone. A biopsy of the right pelvis also showed a cancerous tumour which appeared to be quite aggressive in nature.

32. The BMJ article ‘Diagnosis and referral of adults with suspected bony metastases’ explains that ‘initial diagnosis [of bone metastases] can be difficult as lesions may not be visible on radiographs until 50-70% of bone has been destroyed.’

33. Our oncology adviser has reviewed Mr W’s scan in June 2022. They explain the initial plain X-rays were not suggestive of cancer and explain it can be difficult to identify cancer when there is also degenerative disease. They note that even when the cancer diagnosis was known, a review of the X-rays only shows subtle changes, which would have been very difficult to identify as cancer.

34. Overall, we do not see failings in relation to the consideration of Mr W’s symptoms between May and July 2022.

Further information provided by the Practice

35. Mrs G says the Trust did not consider and act on the further information provided by the Practice after the initial referral to the orthopaedics team was made in May 2022. She says the Practice contacted the Trust a number of times to seek advice, make the team aware of further concerning symptoms, and ask that Mr W’s referral be expedited.

36. We can see the Practice contacted the orthopaedic team on 25 July 2022 regarding increasing pain and Mr W had telephone consultation on 28 July 2022. Our orthopaedic adviser explains Mr W’s blood tests were essentially normal and were not concerning for a cancer diagnosis. It is unclear from the GP records whether these were communicated to the orthopaedic team, or the communication was received. However, as the blood tests were normal this would not have led to any change in the assessment.

37. The initial referral was a routine referral. The communication regarding expediting this was made on 25 July 2022 following which Mr W had further telephone assessment, where it seems the symptoms were better. Our orthopaedic adviser explains it is unlikely the referral could have been expedited further considering the telephone assessments undertaken.

ED attendance 2 August 2022

38. Mrs G says the Trust did not arrange appropriate tests during her father’s ED attendance on 2 August 2022, and did not scan Mr W’s hip, leg, and pelvis area. Mrs G feels the Trust did not consider the full history of her father’s symptoms when assessing him.

39. Mr W was assessed by the ED doctor. He reported he had had a right leg pain since late March to early April. Mr W made the ED doctor aware he had had a fall two weeks ago and had experienced sciatic symptoms (a dull ache from right thigh to foot) and that this had resolved. He reported no back pain but was experiencing right buttock pain.

40. The ED doctor completed an assessment of Mr W’s hip, in line with the GMC guidance ‘Good medical practice’. This noted Mr W had a full range of movement on his hip and no pain.

41. Based on the assessment and clinical examination, it was felt that Mr W’s pain may instead be related to his back. This is in line with guidance ‘Approach to the adult with unspecified hip pain’, which explains that back issues can present as hip pain. This guidance says:

‘Compression of lumbosacral nerve roots or of peripheral nerves can manifest as hip pain. Nerve-related pain is often associated with paraesthesia or an “electric” sensation and typically radiates along the course of the nerve, as opposed to the focal pain associated with an isolated musculoskeletal injury.’

42. As there was a concern that the pain may be radiating from the back, it was appropriate that this was considered with more urgency. This is because complications from back pain (such as nerve compression) can be more urgent than complications from the hip. Mr W had also had a recent hip X-ray which had not shown any concerns.

43. In addition to the above, the NICE guidance ‘Sciatica (lumbar radiculopathy): Red flag symptoms and signs’ provides details about ‘red flag’ symptoms (symptoms which may indicate something is significantly wrong) symptoms for cancer. Mr W met the criteria for two of the listed red flags, as he was over 50 years old and was experiencing increasing unremitting pain. Mr W had also had a recent hip X-ray which had not shown any concerns. Our orthopaedic adviser explains it was therefore appropriate that Mr W’s back and sciatic symptoms were considered with urgency.

44. In line with this, the doctors arranged an MRI scan of the lumbar spine and a CT scan of the head (arranged due to Mr W’s fall and concern that he had a brain injury), to check for any underlying cause of Mr W’s symptoms.

45. The MRI scan of the spine showed a far lateral disc prolapse at L4/5 (the two lowest vertebrae of the lumbar spine), which was felt likely to explain the symptoms. A far lateral disc prolapse occurs when the disc ruptures sideways (lateral), rather than the more common backwards (posterior) or backwards and laterally (posterolateral). This occurs in only 5% of disc prolapses and compresses the exiting nerve root (rather than the descending nerve root).

46. The CT scan of Mr W’s head was normal and showed no lesions or bleeding.

47. The consultant wrote to Mr W’s GP on 6 August 2022 to advise they had discussed treatment options for the disc prolapse with Mr W by telephone and had referred him for an epidural infection under CT guidance. A review was also to be scheduled for four weeks later.

48. With hindsight, it is understandable that the family feel it would have been appropriate to scan the hip, leg and pelvis area, in light of the later findings. However, based on the clinical findings at the time of this appointment, Mr W’s symptoms were more suggestive of a concern with the back rather than the hip. Mr W’s symptoms were also in keeping with the results of the MRI scan of the spine, and therefore we have not seen further tests were needed at this time.

49. We therefore have not seen failings in the care provided on the ED attendance on 2 August 2022.

50. We have also sought additional advice from our oncology adviser, in light of Mr W’s later cancer diagnosis. They explain the Trust’s investigations into Mr W’s symptoms at this time were in line the NICE guidance ‘Lung cancer: diagnosis and management’.

51. Our oncology adviser explains that scans provide a snapshot of the clinical situation. Unfortunately, it is very common for patients to have ongoing symptoms without there being any suggestion of cancer on the scans. Sadly, the cancer may only become apparent as the disease progresses.

52. This was the case for Mr W when he returned to the Trust on 9 August 2022, following a further fall. Blood tests at this time showed Mr W had low calcium, which had not been a concern on his previous tests. This led to further tests and scans for Mr W, which led to the diagnosis of metastatic lung cancer.

53. We do not doubt how shocking and distressing this diagnosis will have been for Mr W and his family. We hope this further information provides some reassurance around the events leading to this diagnosis.

Primary site of the cancer and treatment

54. Mrs G says that following the recognition of Mr W’s cancer, the Trust appeared uncertain of the primary site of the cancer, and she wonders if this affected the care her father was provided. We recognise this aspect remains an area of significant concern and uncertainty for Mrs G.

55. Our oncology adviser has reviewed Mr W’s scans, molecular test results and the conclusions of the multidisciplinary team (MDT). They explain Mr W’s symptoms and presentation were in keeping with metastatic lung cancer. Our oncology adviser explains the tests sometimes may not fully fit with the standard diagnosis but explains Mr W’s diagnosis was appropriate in line with what was known.

56. We also considered the plan for treating Mr W’s cancer. The initial plan for palliative radiotherapy to the painful hip was appropriate with the aim of alleviating his pain. This was in line with the NICE guidance ‘Lung cancer: diagnosis and management’. In relation to palliative radiotherapy, this says to ‘provide palliative radiotherapy, either as symptoms arise or immediately, for eligible people who cannot be offered curative treatment.’

57. Part of a patient’s eligibility for cancer treatment is determined by their general well-being and activities of daily life. To measure this, the NICE guidance uses the World Health Organisation (WHO) categorisation of a patient’s performance status. This categorises patients as:

‘0: able to carry out all normal activity without restriction

1: restricted in strenuous activity but ambulatory and able to carry out light work

2: ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours

3: symptomatic and in a chair or in bed for greater than 50% of the day but not bedridden

4: completely disabled; cannot carry out any self-care; totally confined to bed or chair.’

58. Mr W’s health at the time of his diagnosis was good, meaning he was a candidate for systemic anticancer treatment (SACT). However, the NICE guidance says treatment choices are dependent on the ‘molecular test results looking for actionable mutations.’ This means looking to see which targeted response/drug would potentially be most effective for the specific type of cancer. These tests can often take a few weeks to come back.

59. Unfortunately, Mr W deteriorated rapidly whilst waiting on the test results and he was no longer fit enough for any form of SACT. Our oncology adviser explains this rapid deterioration is sadly quite a common problem for diagnosed lung cancer patients.

60. We appreciate the family will understandably feel Mr W could have received treatment had the tests been more prompt. Sadly, we would not consider this to be a failing, as the tests were requested in line with the guidance and were needed to inform the type of treatment suitable for Mr W’s cancer. The time taken for these to be completed was not outside of the usual timescales.

61. Overall, we recognise the significant effects these events had on Mr W and his family. We have not seen evidence of failings in the diagnosis made by the Trust, or in the decisions made around Mr W’s treatment.

Pain management

62. Mrs G says the Trust did not appropriately manage her father’s pain. She says he did not receive appropriate pain relief on his last admission to the Beacon Ward on 30 September 2022 and was also discharged without appropriate pain relief on 19 October 2022. Mr W then needed admission to a hospice to help get his pain under control.

63. The Trust’s response of 13 February 2023 apologies that Mr W was discharged without an appropriate explanation of when and how to take his medications. It explains it is working to improve this by having a pharmacy colleague discuss the medications with patients or their carers prior to discharge.

64. We consider the actions taken by the Trust here are appropriate, in line with our ‘NHS Complaint Standards’. We therefore do not consider further action is needed in relation to Mr W’s discharge.

65. Mrs G also complains that her father did not receive appropriate pain relief on his admission on 30 September 2022. The Trust’s response says Mr W was taking Zomorph 20mg and Oramorph 5-10mg (both morphine-based pain relief medications) four times a time, but these were not prescribed at his admission and there are no notes to suggest why these were omitted. The Trust apologised for this.

66. The Trust goes on to note that Mr W may not have needed the higher doses of pain relief, as he had recently had radiotherapy for pain control in his hip.

67. We have sought nursing advice to consider this concern. Our nursing adviser explains Mr W’s admission was for pain management. Sadly, the Trust has confirmed it does not have the medication administration charts. This means we have not been able to clearly see which medications were administered to Mr W.

68. We have therefore considered the written clinical and nursing records. These note Mr W refused pain relief on 1 October 2022, and he did not appear to be in pain. The records on 3 October 2022 note the pain relief was having a good effect for Mr W. By 4 October 2022, Mr W’s pain was well managed.

69. Based on the evidence we have seen, it seems more than likely that Mr W needed pain relief at his admission, as the admission was for pain management. As noted by the Trust, his pain medication was not provided at admission. We therefore consider this was a failing and will likely have meant Mr W experienced continuing pain, which could have been prevented. This will also have added to the distress the family were experiencing at an already difficult time.

70. Whilst we can see the Trust has apologised for the omission of the pain relief, we have not seen it has taken action to provide feedback and improve its service, so this failing does not occur again.

71. We have also not seen that the Trust has acknowledged the lack of medication administration charts. This has meant we have not been able to provide as full a picture of the management of Mr W’s pain, as we only have limited references to his pain management until 3 October 2022, when the notes suggest the pain relief was having a good effect.

72. We consider this has left an impact of uncertainty, as we are unlikely to be able to say that Mr W’s pain was appropriately managed at the start of his admission. We consider this will have caused distress to his family at an already difficult time. We therefore make recommendations to address these failings at the end of our report.

1. We have considered Mrs G’s complaint about the care and treatment provided to her father (Mr W) by the Trust. Mrs G feels opportunities were missed to recognise and treat her father’s cancer, and manage his pain appropriately, before his death on 4 November 2022. We do not underestimate the significant concern and distress Mrs G and her family will have experienced during this time.

2. We have not seen delays or failings in the diagnosis and management of Mr W’s cancer. We recognise Mr W was experiencing a number of concerning symptoms, but consider appropriate investigations were arranged based on what was known at the time.

3. We have seen a failing in the management of Mr W’s pain during his admission on 30 September 2022. The Trust has also not been able to provide appropriate pain records for this admission. We consider this will leave Mrs G with uncertainty because we are unable to say Mr W’s pain was appropriately managed at the start of his admission.

4. We have not seen the Trust has taken appropriate action to address the impact of the failings we have seen. We have therefore made recommendations at the end of our report.

5. Overall, it is for these reasons that we partly uphold this complaint. We explain this further in our report below.