Oxford University Hospitals NHS Foundation Trust

6. Mrs Y complained to the Trust that it delayed giving her husband, Mr Y, a diagnosis of B-cell lymphoma (lymphatic cancer) between August 2021 and February 2022.

7. She says because of this there was a missed opportunity for earlier treatment which led to a poorer prognosis, and her husband’s premature death. The delay resulted in additional distress for Mrs Y and her family.

8. Mrs Y wants the responsible clinician to answer her seven questions which she sent to the Trust. Mrs Y is happy with the improvements the Trust planned, but wanted to be reassured the Trust has been acting on them.

9. What follows is a summary of events obtained from the complainant and the Trust. We have not included all of the details as those involved are already aware of the information. However, we have included this background to put the complaint in context.

10. Mr Y’s GP referred him to the Trust on 6 August 2021 for changes in his bowel habit under a two-week wait pathway (an NHS referral system for suspected cancer cases). The Trust was also investigating Mr Y’s ulcerative colitis (UC) and prostate cancer.

11. Mr Y had a scan on 19 August 2021, and this showed a retroperitoneal mass (a mass in the anatomical space behind the peritoneum. It houses the kidneys, pancreas, and adrenal glands). The multi-disciplinary team (MDT) reviewed the scan and recommended a CT guided biopsy (the use of a CT scan to visualise an area of concern and collect a tissue sample).

12. The Trust communicated the result of the scan to Mr Y on 29 November 2021, several months later. The Trust gave Mr Y a diagnosis of B-cell lymphoma on 10 February 2022.

13. The Trust accepted it delayed Mr Y’s diagnosis by not arranging the CT guided biopsy. When it realised the error and arranged the biopsy, it acknowledged it had to postpone it further due to staff not telling Mr Y that he needed to stop taking his anticoagulation (to prevent clotting) medication beforehand.

14. The Trust said the delays contributed to Mr Y being less well before starting treatment. The Trust’s haematology consultant explained the delay did not affect his treatment options, but accepted it did reduce his prognosis, with chemotherapy, by 10-15%.

15. The Trust met with Mr Y and Mrs Y on 19 May 2022 and agreed the scope for its SI. The Trust prepared its SI report on 2 September and met with Mr Y and Mrs Y on 8 October to discuss the outcome. Mr Y sadly died on 4 December 2022.

16. The Trust met with Mrs Y on 27 January 2023 to discuss the actions it planned to take. Mrs Y was satisfied the actions would prevent other patients having a similar experience. Mrs Y asked the Trust seven questions about its findings, and it answered them on 12 March 2024.

19. The Trust accepted there were errors in the care it provided to Mr Y and prepared an SI report. It said there were errors because:

• there was confusion about which clinician was responsible for following up the MDT’s recommendation Mr Y needed a biopsy and it accepted this led to delays in Mr Y’s investigations and diagnosis • the Trust incorrectly cancelled Mr Y’s appointment to discuss the retroperitoneal biopsy because he already had an appointment for his UC, meaning it removed him from the two-week wait pathway (the process for investigating suspected cancer) • when it did arrange the biopsy, staff did tell Mr Y he needed to stop taking his anticoagulation medication beforehand, which resulted in a further delay.

20. The Trust prepared an action plan, it said:

• the role and responsibility of relevant staff, and who needs to complete which actions following an MDT needs to be very clear for patients being treated on a two-week wait pathway • for patients being treated on a two-week wait pathway, there needs to be a 'summary findings' form and a standard operating policy (SOP) to ensure staff have, and consider, all the information before removing a patient from the pathway • it will review and update local clinical guidelines about the use of anticoagulation medication before radiology procedures.

21. The Trust apologised for the errors in Mr Y’s care and the impact this caused. It also met with Mrs Y to explain its findings and the actions it planned to take.

22. Our Principles for Remedy say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. Our Principles for Remedy are reflected in our NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

23. Our NHS Complaints Standards say when an organisation investigates a complaint it should ‘explain why things went wrong and identify suitable ways to put things right for people. It should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned’.

24. Mrs Y told us she is satisfied the actions the Trust put in place following its SI would prevent other patients having a similar experience. She wanted to know if the Trust has completed its actions and make sure it has learnt from its mistakes. We have got some further information from the Trust to reassure us of this. The Trust:

• arranged a meeting to share learning and be confident in establishing a clear role and responsibility for pathway leads and referrers for completing actions arising from MDT meetings. It will set this out at the MDT meeting • is now using a new two-week wait outcome form, which the matron is auditing to check when patients are removed from the pathway • has reviewed and updated the protocols and procedures for anticoagulation use prior to radiology procedures and the radiology team now ensures it gives the correct advice to patients.

25. We understand this tragic event has been a very upsetting and distressing time for Mrs Y. We have seen that the Trust has reflected on this, carried out its own investigation, accepted it did wrong and apologised in line with our Principles for Remedy and NHS Complaints Standards. In agreement with Mrs Y, it has made service improvements to identify suitable ways to put things right and change its process. We have seen evidence from the Trust that it has followed the actions it planned to take, which is what Mrs Y wanted to know by bringing her complaint to us. .

26. Our Principles of Good Complaint Handling say organisations should ‘take responsibility for the actions of their staff and those acting on behalf of the public body’. On 12 March 2024, the Trust’s clinical governance lead answered the seven questions Mrs Y raised about her husband’s care, rather than the specific clinician involved. The Trust explained this was because they had enough information from its investigation to answer them, and the named clinician had provided their comments during the SI process. We are of the view this approach was reasonable because the questions Mrs Y asked, were about the Trust’s actions and it acted in line with our Principles of Good Complaint Handling.

27. We recognise the heartbreaking circumstances of Mrs Y’s concerns. This must have been an incredibly upsetting and difficult experience for her. We hope on the evidence of what the Trust has done, can bring some closure to her concerns.

1. We have carefully considered Mrs Y’s complaint about Oxford University Hospital NHS Foundation Trust (the Trust). We are sorry to hear about the tragic events that led to Mrs Y’s concerns. We understand this has been an extremely upsetting time for her and her family. We send our condolences for their loss. We were saddened to read about what happened leading to her husband’s death.

2. We saw the Trust carried out a Serious Incident (SI) investigation, investigated this complaint and highlighted errors in its care provided to Mr Y. It accepted this had an impact on Mr Y’s prognosis.

3. The Trust sent an apology to Mrs Y and prepared an action plan to make service improvements. Mrs Y is happy with the improvements planned, but wanted to be reassured the Trust has been acting on them. Having received further evidence from the Trust, it is our view the Trust has taken appropriate action.

4. We consider it was reasonable for the Trust’s clinical governance lead to answer Mrs Y’s seven specific questions about her husband’s care, rather than the named clinician.

5. This means we have decided not to consider Mrs Y’s complaint further. We have explained the reasons for our decision within this statement. Our decision is not made without recognition of the tragic impact caused by the events. We hope our statement clearly explains why we have made our decision.