The Christie NHS Foundation Trust

7. Ms Q complains about aspects of care her mother, Mrs N received at the Trust in October 2019 and August 2021. Ms Q specifically complains that: • During an appointment in October 2019, the Trust did not clearly explain the extent of Mrs N’s cancer diagnosis and gave an unrealistic prognosis of five to ten years.

• During the same appointment, Mrs N was told her ‘lungs are clear’, despite the presence of multiple pleuro-parenchyma nodules.

• Mrs N was not told she had developed a ‘malignant pleural and likely malignant pericardial effusion', and she was not given clear explanations of these conditions and what further warning signs to watch for after a CT scan in January 2020. Mrs N was incorrectly told instead the fluid was caused by chemotherapy.

• On 28 May 2021 the Trust did not inform Mrs N’s private clinician about her history of pleuro-parenchymal nodules and did not explain her history of a malignant pleural effusion.

8. Ms Q says the lack of information meant the family were not clear on Mrs N’s prognosis and could have been better prepared for her death. Ms Q says the experience has been devastating for her and her family.

9. Ms Q wants acknowledgments and service improvements.

10. Mrs N was diagnosed with breast cancer in August 2019. She had surgery at a different hospital and was referred to the Trust in September.

11. Mrs N started chemotherapy treatment in November 2019 at the Trust and saw doctors there until June 2021.

12. In April 2021, Mrs N started to suffer with shortness of breath, chest pain and an ongoing cough. She was seen at another hospital and was diagnosed with a respiratory tract infection and pleural effusion (a condition where excess fluid builds up in the space around the lungs) and was discharged with antibiotics.

13. Mrs N attended the same hospital again ten days later, where an X-ray was carried out and reported as ‘no change’. Mrs N was discharged with a plan for her to attend again as an outpatient for an echocardiogram (a scan of the heart).

14. Mrs N’s condition worsened and she continued to suffer with chest pain and breathlessness. The family arranged for Mrs N to be seen by a privately funded clinician in May 2021.

15. Sadly, Mrs N became more unwell and died at home on 5 June from cancer related complications.

Prognosis given in October 2019

21. Ms Q complains her mother was given an unrealistic prognosis of five to ten years by a doctor at the Trust during an appointment in October 2019. She says this was inaccurate.

22. Mrs N was seen by a consultant oncologist at the Trust on 24 October 2019 to discuss her diagnosis of breast cancer.

23. We have listened to an audio recording of this appointment and Ms Q asked ‘how long?’. We assume this was in relation to Mrs N’s prognosis as the doctor went on to talk about how long she may live with various treatments.

24. During the appointment, the doctor said, ‘patients live for several years; the likelihood is it’s going to be between five and ten years, but I don’t know’. The doctor went on to say, ‘it just depends on the volume of cancer in the bones and whether we can get it down and keep it down’.

25. The doctor discussed the possibility that the cancer may have spread to Mrs N’s bones and explained various treatment options.

26. Mrs N had HER-2 negative breast cancer (HER-2 refers to the level of protein in the cells) and was being treated with abemaciclib (a drug that blocks cancer cell growth).

27. The monarch study started in 2014 and completed in 2018. The trial looked at the effect of abemaciclib in patients with HER-2 negative breast cancer and concluded that patients in this group showed a median survival rate of 66.8 months (around five and a half years).

28. The Trust told us it is difficult to give a definite answer when someone asks for a prognosis on their estimated survival rate. It added that new treatments for breast cancer are regularly explored and therefore as time passes, survival rates improve.

29. The Trust also added the prognosis was given in good faith, with the experience of the doctor involved and their knowledge of how cancer treatment is continually researched and being improved for better outcomes for patients.

30. Our adviser explained giving a definite prognosis is difficult because people respond to treatment in different ways and it is only with retrospect that we can say whether a prediction was accurate or not.

31. Macmillan’s information guide notes a prognosis is only an estimate of what might happen based on the information at the time and that prognoses are given based on studies available at the time. It also notes cancer survival rates can change over time.

32. GMC guidance says doctors should give information in a way patients can understand and explain uncertainties about their prognosis.

33. We acknowledge Mrs N sadly did not live for five to ten years as suggested during this appointment. However, it is important to note that it is very difficult to give an exact prognosis as survival rates vary based on individual factors, treatment someone may be on and progression of other illnesses which may affect someone’s overall health. We have also seen the doctor explained they ‘did not know’, which indicates they were not able to give a definitive prognosis at that stage.

34. We have also noted that at this time, whilst a CT scan did show probable spread of the cancer to the bones, it had not been confirmed at the time of this appointment. Mrs N’s confirmed diagnosis was breast cancer.

35. We have found the doctor gave the information about the prognosis based on the studies which were taking place at the time, and the confirmed diagnosis. The prognosis was reasonable and the information was given in a way that Mrs N could understand, with the caveat that the doctor could not give a definite timeframe. It is our view the doctor was not unrealistic when giving the prognosis.

36. We acknowledge it was difficult for Mrs N’s family to see her deteriorate quicker than they expected, and we are sorry to hear they felt unable to prepare for her death. We hope our explanation can provide reassurance that giving a definite prognosis is very difficult and in this case was realistic at the time.

Information given about Mrs N’s lungs being clear

37. Ms Q says her mother was told her lungs were clear during the same appointment in October 2019. She says Mrs N’s lungs were not clear at this stage.

38. During the appointment a doctor discussed potential spread of the cancer. Mrs N had a CT scan before this appointment which reported ‘multiple sub 5mm pulmonary and pleuro-parenchymal nodules’. These nodules are areas of abnormal growth on the lungs and often do not cause symptoms. Pulmonary nodules are commonly found on scans and can be caused by infections, scarring and cancer. They can also sometimes be harmless and do not always indicate cancer.

39. At the time of this appointment the radiology team had reported the nodules as ‘equivocal’, which means uncertain, ambiguous or open to interpretation and the nodules could be ‘followed up on subsequent examinations’.

40. A further scan took place on 11 January 2020 which noted the lung nodules had reduced.

41. We have not seen evidence the doctor specifically discussed the lung nodules during this appointment.

42. As we mentioned earlier, GMC guidance says doctors should give information in a way patients can understand.

43. Our adviser explained clinician needs to condense, interpret and relay clinical information to patients. They added it is not always possible to give detailed information of results of all investigations that have been carried out. They explained in this case, the doctor needed to give information about the significant diagnosis of cancer and at this stage the nodules in the lungs were equivocal and therefore may not have been necessary to discuss at that point.

44. Our adviser also told us information about the lung nodules would have not likely altered the overall plan of treatment at the time.

45. We have considered the importance of the information Mrs N was given during this appointment regarding the cancer diagnosis, which naturally will have been significant news for her and her family. In addition, we have thought about the fact that the lung nodules reduced in size by January 2020, indicating they may not have been cancerous.

46. It is our view the information given to Mrs N during this appointment was focused on the cancer diagnosis. This was reasonable, and in line with GMC guidance, as it was the most important issue at that time. We have not found the Trust failed, when not explaining details of the lung nodules at this time, as the cause of them was uncertain and it is unlikely the plan of treatment would have changed had this been discussed.

47. We realise it was worrying for Mrs Q to know her mother had nodules on her lungs that were not discussed during this appointment. However, we hope to reassure her we have seen evidence the Trust focussed on the correct issues and tried to give only necessary information that had an impact on Mrs N’s immediate care plan.

Information about a malignant pleural and likely malignant pericardial effusion

48. Ms Q complains her mother was not told she had developed malignant pleural and likely malignant pericardial effusion during an appointment in January 2020. She also says her mother was not given enough information about these conditions and was given incorrect information about what caused them.

49. Mrs N was seen again at the Trust on 30 January 2020 where she was told recent scans had shown progression of her cancer to her bones. A recent CT scan also showed Mrs N had a new, small pleural and pericardial effusion.

50. A pleural effusion is a condition where fluid has built up in the area between the lungs and chest wall. A pericardial effusion means fluid has accumulated in the area around the heart. Both conditions can be caused by infections, heart failure and cancer.

51. The audio recording of this appointment shows the doctor explained there was some fluid at the bottom of Mrs N’s lung and close to the heart. The doctor went on to say this could have been caused by chemotherapy and added it was ‘not impossible’ the fluid could have been caused by cancer cells.

52. The doctor told us at the time of the appointment the effusions were very small and they were not the main focus of the appointment or requiring treatment at that point. The doctor also highlighted Mrs N had his contact details and he could be contacted at any time for more advice or for if she was concerned her symptoms became worse.

53. We recognise the doctor’s comments, however we have not seen any evidence that during the appointment Mrs N was given more information about these conditions or what signs to look out for if her symptoms worsened.

54. The records show the pleural effusion was most likely malignant at this stage, however the pericardial effusion was of an uncertain origin. It is important to note that although the malignant nature of the effusion was thought to be likely, it had not been confirmed.

55. The records also show both the pleural effusion and pericardial effusion had ‘resolved’ by 2 July 2020.

56. GMC guidance says doctors should give patients information about their conditions.

57. We have seen Mrs N spoke to the breast care nurses seven days after this appointment about new medication and her overall condition. We can also see she had an appointment booked with the oncology team for four weeks after this appointment, which would have enabled her to ask any follow up questions about her conditions.

58. The Trust gave Mrs N information about the fluid on her lungs and heart and explained potential causes of this, but it did not give her information about what to do if her symptoms got worse. As Mrs N did not have the information she needed, this discussion was not in line with GMC guidance.

59. We have considered the impact of this. Both conditions had resolved by July 2020. Therefore, we cannot see the lack of information about what to do if symptoms worsened had a negative clinical impact on Mrs N. It also did not change the care she received. We hope this reassures Ms Q.

Communication with Mrs N’s private respiratory consultant

60. Ms Q says the oncology consultant at the Trust did not pass on information about her mothers’ history of pleuro-parenchymal nodules or the malignant pleural effusion during a conversation on 28 May 2021.

61. Mrs N sought an opinion from a private respiratory consultant on 4 May 2021 after suffering with continued breathlessness. She saw the consultant on 7, 14 and 28 May 2021.

62. On 28 May 2021, the private respiratory consultant called the oncologist at the Trust who was treating Mrs N to discuss her condition and treatment.

63. The oncologist at the Trust told us the private respiratory consultant called late in the evening, and they did not have access to Mrs N’s medical records at that time. They also explained they were unaware Mrs N had been seeing a private respiratory consultant.

64. The private respiratory consultant sent a letter to the Trust on 28 May requesting a discussion with the Trust’s oncologists. This supports the view the Trust were unaware Mrs N had seen a private respiratory consultant until this stage.

65. GMC guidance says doctors should ensure any information that is communicated about a patient is accurate.

66. We are unable to say for certain what was discussed during the phone call and whether information about Mrs N’s history was passed on. However, we think it is likely that the phone call was unplanned and unexpected.

67. Our adviser explained that passing on information from memory without medical notes available carries a risk.

68. Considering the oncologist at the Trust received an unexpected phone call and did not have access to Mrs N’s medical records at that moment, we do not think the Trust failed to pass on all of the information about Mrs N’s history or conditions at that time. We are satisfied the Trust acted in line with GMC guidance.

69. We have seen a request was sent by the private consultant for a more detailed discussion, and more information could have been given at that time. Mrs N sadly died before the discussion took place.

70. We know this was an extremely difficult time for Ms Q and her family. We hope to reassure Ms Q we have seen the Trust acted within the relevant guidance when giving information to Mrs N, and where information was missed, it did not have a clinical impact on her mother.

1. We thank Ms Q for telling us about her complaint. We know this was an extremely difficult time for her. We partly uphold this complaint.

2. We found the prognosis given to Ms Q’s mother, Mrs N in October 2019 was reasonable and given based on information available at the time. We acknowledge it is very difficult to give an exact prognosis.

3. We also found the Trust gave appropriate information to Mrs N during an appointment in January 2020. Whilst the Trust did not mention the recent finding of lung nodules, at this stage they were not a significant finding.

4. We found the Trust failed to give detailed information about the pleural and pericardial effusions during the same appointment, and it did not give information about what to do if these conditions worsened. We have not found this had an impact on Mrs N’s clinical care, as the effusions resolved a few months later.

5. We do not know what was said during a call in May 2020 between a doctor at the Trust and a private clinician. However, the call was unplanned and we would not expect the doctor at the Trust to give detailed information about Mrs N’s condition or her history during this type of call.

6. We have not made any recommendations for action by the Trust, as we have not found the failings we identified led to an injustice for Mrs N or her family.