East Lancashire Hospitals NHS Trust

4. Mrs U complains about the care and treatment provided by Trust A. Mrs U says:

• the Trust misdiagnosed her with chronic pancreatitis in 2019 • the Trust failed to communicate the results of a CT scan completed in March 2023 that showed the diagnosis in 2019 was incorrect

5. As a result of the above, Mrs U explains she experienced upheaval in her life due to constant pain and reliance on medication. In managing her diagnosis, she incurred additional costs, such as travel insurance premiums. She says the uncertainty around her diagnosis was extremely stressful.

6. By bringing this complaint to us, Mrs U would like an apology, a financial award equivalent to level 5 of our Severity of Injustice scale and confirmation she does not have chronic pancreatis

9. Mrs U received a diagnosis of chronic pancreatitis in 2020 from Trust B and was prescribed Creon (a pancreatic enzyme replacement medicine) as part of her treatment.

10. She lived with this diagnosis for several years.

11. In 2023, further investigations at Trust A showed no definitive evidence of chronic pancreatitis.

12. Mrs U was not informed of the change in diagnosis until she attended an unrelated medical appointment in September 2023.

13. She raised a complaint with Trust A in April 2024 about the misdiagnosis and the delay in being told her diagnosis had changed.

14. Trust A responded in August 2024, explaining that earlier tests in 2019 and 2020 had supported the original diagnosis. A follow up appointment at Trust A to discuss the 2023 findings had been cancelled due to an emergency and not rebooked because of an administrative error.

15. Mrs U remained unhappy with Trust A’s response and referred the matter to our service in June 2025.

16. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs of service failings or maladministration which the organisation has not put right.

the Trust misdiagnosed her with chronic pancreatitis in 2019 – 2020

17. Mrs U received a diagnosis of chronic pancreatitis in 2020 and in the following years lived with this diagnosis. In 2023 following further tests, Trust A found the original diagnosis was incorrect.

18. We requested copies of the scans that informed the 2020 diagnosis. Trust A was unable to provide these because it did not carry out the tests. We found Trust B carried out Mrs U’s diagnosis and treatment. Trust B provided details of the scans carried out on 18 December 2019.

19. The earliest reference to a chronic pancreatitis diagnosis is in a letter dated 23 January 2020 from a consultant at Trust B with the heading, ‘Diagnosis: Chronic pancreatitis’. The letter refers to an appointment with Mrs U on 17 January 2020 at which a diagnosis of chronic pancreatitis was made.

20. We are confident it was not Trust A who was responsible for the 2019/2020 scans and diagnosis.

21. Mrs U attended an appointment at Trust A to have a CT scan on her gallbladder on 12 March 2023.

22. During that appointment Trust A found there was no longer evidence of Chronic Pancreatitis. An appointment was arranged to discuss these results on 15 June 2023. This was cancelled and was not rearranged until Mrs U had queried when a further appointment would be. As a result a telephone appointment was arranged for 7 September 2023 where Mrs U was informed there was no evidence of Chronic Pancreatitis in her March 2023 scan.

23. Mrs U raised a complaint in which she set out a timeline of events, much of which has been covered above. Within the timeline she confirms the scan and diagnosis was completed at Trust B.

24. In its August 2024 complaint response, Trust A explained the diagnosis had been made based on earlier tests, and in its March 2025 complaint response it stated the initial diagnosis was made at Trust B.

25. GMC guidance outlines that Healthcare professionals are expected to work with information generated by other organisations to ensure continuity of care.

26. The guidance states ‘continuity of care is important… particularly when care is shared between teams… or when patients are transferred between care providers’. This shows an expectation that clinicians should rely on information provided by colleagues in other trusts as part of the continuation of care.

27. The GMC guidance further explains healthcare professionals should ‘share all relevant information about patients… with others involved in their care, within and across teams, as required’. This part of the guidance is designed to ensure that receiving clinicians can safely use the information provided, including an existing diagnosis.

28. The GMC also highlights the importance of accurate recordkeeping, stating clinicians ‘must make sure that formal records of your work… are clear, accurate, contemporaneous and legible’. This requirement ensures records can be safely used by other professionals involved in the patient’s care.

29. The purpose of these standards is to ensure healthcare professionals in receiving organisations can safely rely on the information provided by colleagues, including diagnoses, investigations and treatment decisions.

30. In line with this guidance, it was appropriate for clinicians at Trust A to rely on the diagnosis recorded by Trust B. GMC guidance expects healthcare professionals to use the information shared by colleagues across organisations to support continuity of care.

31. After consideration of the evidence available, Trust A were not responsible for the diagnosis and acted in accordance with GMC guidance when it accepted the diagnosis reached at Trust B. We have seen Trust A did not make the diagnosis, and therefore there are no indications of failings. For this reason, we will take no further action on this part of the complaint.

the Trust failed to communicate the results of a CT scan completed in March 2023 that showed the diagnosis in 2019 was incorrect

32. Trust A arranged for a CT scan for Mrs U which took place on 12 March 2023. It booked a follow up appointment for her on 15 June 2023, approximately three months after the scan date, to discuss the results. This appointment was cancelled to accommodate an emergency.

33. Trust A sent a letter to Mrs U and her GP. Whilst the letter does explain there was nothing worrisome seen on the scans, and the results were reassuring, it did not provide conclusions from the scans undertaken. It said a follow up telephone appointment would be arranged to discuss the results further.

34. Mrs U had an unrelated appointment regarding her Gallbladder at Trust A on 7 September 2023. During this appointment the records show she was told there was no evidence of chronic pancreatitis found in her March 2023 scan.

35. In its complaint response, the Trust confirmed it cancelled the June appointment due to an emergency. It accepted it should have arranged a replacement appointment but failed to do so because of problems with a new electronic system that affected tracking of cancelled appointments. It acknowledged the delay and apologised.

36. Trust A has explained the cancellation itself was unavoidable and not a failing. It explained rebooking the appointment did not happen due to difficulties with the introduction of a new appointment booking system.

37. As a result, Mrs U was not informed of the new diagnosis until September 2023, when it was covered during an appointment about a Gallbladder concern.

38. GMC guidance is clear about how Trust’s should communicate with patients. It states that they must “give patients the information they want or need in a way they can understand”. The guidance also requires clinicians to “share information with patients about the progress of their care”.

39. Ensuring Mrs U was informed of her new diagnosis formed part of Trust A’s responsibility regarding continuity of her care, even when an appointment had to be cancelled for legitimate reasons.

40. While the cancellation of the June 2023 appointment was justified due to an emergency, the Trust should have ensured a replacement appointment was arranged. It acknowledges this did not occur and that this represents a failing.

41. It is worth noting the original appointment was arranged in June 2023, three months after the March scan showing the typical waiting time for an appointment is three months.

42. Based on the timeline of what actually occurred, it is more likely than not that should a new appointment have been made then it would have also been an approximate three month wait time and have fallen around September 2023.

43. Mrs U learned of the diagnosis on 7 September 2023, less than three months after the cancelled June appointment. Although this occurred during an unrelated appointment rather than a rebooked follow up, it reduced the practical impact of the Trust’s failure to arrange a new appointment.

44. While Mrs U understandably felt anxious while waiting for the results, we cannot link any impact from a misdiagnosis between March and September 2023 because she was unaware of the diagnosis during that period.

45. We recognise Mrs U’s frustration with the Trust’s failure to arrange a follow up appointment for this period and understand why this added to her dissatisfaction.

46. In line with our Principles of remedy we consider the Trust’s apology to be sufficient remedy for her complaint. For this reason, we will not be taking any further action on this part of her complaint.

47. We understand how upsetting this experience must have been to Mrs U and we are sorry to hear of the difficulties she experienced while dealing with the Trust.

48. We hope we have been able to explain why we will not be taking this complaint any further. We recognise this conclusion may be difficult for Mrs U, given the emotional impact of this experience.

1. We have carefully considered Mrs U’s complaint about East Lancashire Hospitals NHS Trust (Trust A). Having done so we have not seen any indications of failings in how it dealt Mrs U’s diagnosis of chronic pancreatitis. We found it was not Trust A that undertook the scan or subsequent diagnosis.

2. Whilst we consider there is an indication of a failing by Trust A when it didn’t arrange an appointment with Mrs U to discuss new clinical findings, we think it has already done enough to put right the impact this had on Mrs U.

3. We are sorry to hear about the circumstances of Mrs U’s complaint. We understand the challenges she has faced and her continued struggles in light of the issues experienced. We recognise the strength of feeling and how important it is for her to receive answers regarding her experience.