King's College Hospital NHS Foundation Trust

4. Mr F and Miss F complain about the care the Trust and the Practice gave their mother, Mrs F, in 2022.

5. They complain the Trust failed to: • arrange investigations on 17 August • carry out a biopsy urgently on 5 September • act on a NEWS score of 6 on 6 October.

6. They complain the Practice failed to: • see Mrs F face to face on 27 July • refer her to a dietician.

7. They say the impact of the Practice not seeing her face to face, and the Trust not carrying out investigations, led to a delay in identifying her cancer. They feel identifying the cancer sooner may have led to more treatment options and she would not have died as soon.

8. They feel if the Trust had taken action on 6 October, she would not have died on this day. They consider if she had seen a dietician, she would have been stronger and been able to fight her cancer.

9. The impact on Mr F and Miss F, is the significant grief at the loss of their mum and feeling the medical system failed her.

10. As an outcome, they are seeking apologies and service improvements.

11. This brief background is only intended to place the key events in context, not provide a full account of everything that happened.

12. Mrs F was in her seventies. She developed a loss of appetite and weight loss in July 2022.

13. In August, she attended the Trust with chest pain and had a CT scan showing a spread of cancer to her liver, but it was unclear where it had started from.

14. She had two further hospital admissions in September and October. Her condition deteriorated and she sadly died on 6 October.

The Trust

17 August 18. On 17 August 2022, Mr F took his mother to an appointment at a gastroenterology clinic at the Trust. Her GP had referred her due to weight loss, not eating, upper abdominal pain, constipation and anaemia.

19. Mr F told us his mother had lost a significant amount of weight quickly and was eating very little, only a few teaspoons of food per day.

20. Mrs F’s medical records show the Trust acknowledged her weight loss due to her eating less. The nurse specialist documented her loss of appetite and weight were due to a recent course of antibiotics for a cough.

21. They noted she had constipation with these antibiotics, but it had improved with laxative use. Mrs F said her anaemia was long standing and she had recently started iron supplements. They noted most of her symptoms seemed to be related to the recent antibiotic course.

22. The Trust noted she had a recent negative FIT test. This is a test that looks for blood in the stool. Our surgical adviser explained a negative test makes the likelihood of bowel cancer low and is reassuring.

23. NICE guidance says unexplained weight loss can be caused by several different types of cancer. In general, it signposts the need for a FIT test or a two week wait referral at a hospital if the weight loss is unexplained.

24. Our surgical adviser explained the Trust looked at each individual symptom Mrs F presented with and found a valid explanation for each. Therefore, her symptoms were not unexplained, and it would be reasonable to offer a watch and wait approach.

25. The nurse specialist documented the possibility of carrying out an endoscopy (camera test) and a CT scan but that the family would prefer a conservative approach. We understand from Mr F that he felt investigations should have taken place, so there seems to be a discrepancy of accounts on this day.

26. The Trust safety netted and explained it would investigate further if Mrs F’s weight loss continued and so became unexplained, which would be in keeping with the NICE guidance.

27. Having considered the available evidence, we find Mrs F’s weight loss was not unexplained, and so she did not need further investigations in line with NICE guidance on this day. We have found no failing here.

5 September 28. An MDT (multi-disciplinary team) meeting took place to discuss Mrs F on 5 September. The clinicians reviewed her CT scan and blood tests and planned to perform an urgent liver biopsy.

29. Mrs F attended a clinic appointment with the surgical team on 7 September in which they explained this plan.

30. The Trust admitted Mrs F to hospital on 20 September with abdominal pain, and doctors performed a biopsy two days later. Mr and Miss F feel staff should have performed this earlier as it was needed urgently.

31. The NHS constitution says there should be a maximum of 62 days from a referral for suspected cancer to first treatment. Our surgical adviser explained first treatments can also include a decision to provide supportive care rather than active treatment.

32. Mrs F’s cancer pathway started on 30 August when she had a CT scan showing liver metastases, so she should have received treatment by 31 October. Our surgical adviser explained there is no set guidance on how soon a biopsy should take place, but as it was 23 days into this pathway, it was within the overall pathway guidance.

33. Taking the above into consideration, we find the Trust acted in line with the NHS constitution in providing a liver biopsy on 22 September. We have found no failing here.

6 October 34. The Trust readmitted Mrs F on 3 October with worsening swelling of her abdomen and legs. Staff gave her antibiotics and pain relief, but her condition worsened.

35. On 6 October, at 6.41am Mrs F’s NEWS score was 6. At this time, Mrs F’s rate of breathing was high, and her temperature and blood pressure were low.

36. In line with the RCP guidance, a NEWS score of 5 or more should trigger a nurse to immediately inform the medical team caring for the patient and request urgent assessment by a clinician. This did not happen. We find the Trust failed to act in line with guidance on this day and we note the Trust has acknowledged this.

37. Mr and Miss F feel if nurses had informed the medical team, staff could have taken action to prevent their mother’s death.

38. Our surgical adviser explained Mrs F had deteriorated very rapidly between her CT scans of 30 August and 21 September. She had worsening metastases on her second scan. In October, she had jaundice (yellowing of the eyes due to liver damage). They explained her condition was rapidly progressing and it is likely she would have needed supportive care to keep her comfortable.

39. Our surgical adviser explained Mrs F’s worsening NEWS score on 6 October reflected her worsening condition. Her blood pressure and breathing rate could have been managed with fluids and oxygen, but there was no further intervention that would have been appropriate at this time.

40. They explained the failure by the Trust to escalate her care to a clinician, led to a missed opportunity for a medical review to note she was approaching the end of her life and keep her comfortable. This review could have meant steps would be taken to notify her family, arrange a side room and to prepare them for what was happening.

41. As an outcome for their complaint, Mr and Miss F are seeking apologies and service improvements. In its complaint response, the Trust acknowledged its failing and apologised. In response to this complaint, it has put in place a new process in which the nurse in charge checks observations for any signs of deterioration. The Trust is auditing this, to ensure it is standard practice.

42. Our complaint standards say that public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service. We find the Trust has acted in line with this in learning from Mr and Miss F’s complaint and there is no further action it needs to take.

The Practice

27 July 43. Mr and Miss F told us they were concerned the Practice diagnosed their mother with a chest infection over the phone. They felt this did not take into consideration her full symptoms and so was a missed opportunity to carry out tests earlier.

44. Mrs F’s medical records show she had a cough for three weeks, with no fever or difficulty breathing. The notes document she had no weight loss. The GP took a history and noted she had no worrying features. The Practice treated her for a chest infection and safety netted that she should return if her symptoms worsened, or she had poor oral intake.

45. GMC guidance says doctors must adequately assess a patient’s condition and their history, examining the patient where necessary.

46. Our GP adviser told us the documented assessment of Mrs F on this day showed they took a reasonable history, ensured there were no concerning features and appropriately prescribed antibiotics. They explained there was no reason to bring Mrs F in for an examination, and they safety netted to ensure she returned if she worsened.

47. Taking this into consideration, we find the Practice acted in line with GMC guidance on this day, and there was no indication Mrs F needed to be seen face to face. We have found no failing here.

Dietician referral 48. Mr F told us his mother was losing weight quickly and was only eating a few teaspoons of food. He explained he told the Practice of this multiple times, and his concerns grew as time went on. He says he requested a dietician referral and oral nutritional supplements (ONS) between late July and September.

49. The Practice signposted us to its local guidance on how it manages nutrition (SELIMOC guidance). This guidance says when a patient presents with weight loss, clinicians need to complete a MUST checklist. A MUST (Malnutrition Universal Screening Tool) uses a scoring system to identify adults at risk of malnutrition or obesity. It uses patients’ BMI, recent weight loss measurements and the effect of acute illness to calculate this. A score of 0 is low risk, 1 is medium risk and 2 is high risk.

50. This guidance says if a patient needs oral nutritional support (a score of 1 or 2), clinicians should provide advice on food first and nourishing drinks. They can suggest over the counter products. If a patient is high risk, they should refer them to a dietician. They can only prescribe ONS on the advice of a dietician.

51. The first reference to weight loss in Mrs F’s records is 3 August. On this day, the Practice referred her to the Trust for investigation.

52. On 18 August, Mr F requested supplements from the Practice as his mother had a reduced appetite. The GP calculated her MUST score which was 0. The GP explained that Mrs F did not meet criteria for a dietician referral. They advised Mr F to buy ONS over the counter.

53. There was not a documented weight in Mrs F’s records on this day. A score of 0 would indicate a weight loss of less than 5%, and a score of 1 would include weight loss of 5-10%. Our GP adviser explained Mrs F’s history did not imply a weight loss of more than 10%, and we note when she was later referred, it was 4.35%. Therefore, her score would have been either 0 or 1. If her score was 1, the Practice had already provided ONS advice in line with guidance on this score.

54. On 2 September, Mr F spoke to the Practice and asked for a prescription of ONS as his mother was losing weight. The Practice noted she had lost half a stone over one to two weeks, and she was under investigation for her liver metastases. She now met criteria for a dietician referral and so the Practice completed this. It explained it could not prescribe ONS without a dietician advice as per the SELIMOC guidance. It did provide advice on over the counter ONS and eating fortifying food.

55. On 14 September, the dietician accepted the referral and planned to book Mrs F into the next clinic. On 28 September, Mrs F was still awaiting her dietician review, but had been prescribed ONS while in hospital, so the Practice agreed to prescribe some until she was seen.

56. Taking the above into consideration, we find the Practice acted in line with guidance in managing Mrs F’s nutrition. It calculated a MUST score and provided advice on nutritional supplements that she could buy over the counter. When she met the criteria, it referred her to a dietician. We do not find a failing in the Practice’s actions.

57. We hope Mr and Miss F can be reassured that we find the Trust and Practice acted in line with guidance. On the occasion the Trust acted outside of guidance, we find it has done enough to put this right.

1. We thank Mr and Miss F for bringing their complaint to us. We were sorry to hear of the distress that they have been through. We extend our sincere condolences on the loss of their mother, Mrs F. We acknowledge this has been a very difficult time for them.

2. We have found the Trust acted in line with guidance in arranging investigations and carrying out a biopsy for Mrs F. We have found it failed to act on her raised NEWS score (a measure of how unwell a patient is by measuring their observations), but this did not lead to her death. We have found it has done enough to put things right.

3. We have found the Practice has acted in line with guidance. Therefore, we do not uphold this complaint.