Royal Cornwall Hospitals NHS Trust

4. Mrs K complains, between November 2020 and April 2023, the Trust did not communicate the results of a CT scan to Mrs U or Mrs U’s registered GP. Mrs K further says the recommendation to refer her mother to a chest physician, following a CT scan on 5 November 2020, was not properly made to Mrs U’s registered GP.

5. Mrs K says the failure to appropriately refer her mother meant Mrs U experienced over two years of untreated declining physical health, prior to her cancer diagnosis April 2023. This impacted her day-to-day life.

6. Mrs K told us the failure meant her mother was unable to commence, potentially life extending, cancer treatment before April 2023. She also says her mother experienced low mental health due to the uncertainty of whether earlier cancer treatment could have been helpful.

7. As an outcome of her complaint Mrs K wants the Trust to answer questions about why an appropriate referral was not made and assurances it has learned from this case to prevent similar events happening to others. Mrs K also seeks financial remedy.

8. Mrs U was referred to the Royal Cornwall Hospitals NHS Trust (the Trust) by her GP in May 2019. This was for a CT scan (computerised tomography scan – a form of X-ray examination) of her chest to investigate recurrent infections and a productive cough. In the referral the GP informed the Clinical Imaging team Mrs U had a history of breast cancer.

9. A CT scan took place on 12 July 2019 and a left lung nodule of uncertain significance was noted. A follow-up CT scan was advised for three months’ time.

10. On 16 October 2019 the follow-up CT scan took place. The CT scan showed the appearance of the left lung nodule had not changed and there was no growth. A further smaller nodule was also seen on this scan and when compared to the July scan this had not changed. A further CT scan was advised to take place in twelve months’ time.

11. On 05 November 2020, 15 months after the last scan, a further CT scan took place. It was noted in the radiology report there had been slight growth in the nodules and a referral to a Chest Physician was recommended.

12. Between the second and third scans Mrs U changed GP practices. Neither the original practice who referred Mrs U for scans or the practice she moved to have records of receiving the report.

13. In April 2023, Mrs U attended a targeted lung cancer screening programme and had a private MRI of her brain at Nuffield Plymouth. The two scans revealed she had metastatic breast cancer (breast cancer that has spread form the breast to other parts of the body) and this had spread to her lungs, lymph nodes, chest wall and brain.

17. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. If what happened fell short of what should have happened, we call this a failing.

18. When we see an indication of a failing we look at whether the failing had a negative impact on the person affected. If we think it has we then explore if the organisation would be willing to take further steps to put this right and resolve the complaint.

Communication to Mrs U

19. Mrs K says the Trust did not communicate the results of the November 2020 CT scan to her mother. She believes the Trust should have contacted her mother to explain the nodules had grown and that it had asked her GP to refer her to a chest physician.

20. The GMC guidance ‘Good medical practice’ requires doctors to share test results with patients in a way they can understand and in a timely manner. The clinician who orders a test is responsible for reviewing, acting upon, and communicating the results and any necessary actions to the patient.

21. We asked our adviser if this was this was appropriate in this case. Our advisor explained there is no requirement for Trust to directly inform patients of scan results as this is the role of the referrer. Our adviser also told us the radiology department is discouraged from directly informing patients of scan results as this should be done by a clinician who can interpret results based on medical knowledge and patient history.

22. We recognise Mrs K’s concerns about this this and understand her mother must have been very upset to discover she had cancer for two years before her April 2022 diagnosis. We consider the Trust did act in line with NHS guidance by completing the requested CT scan and sending the results to the referring GP for further discussion with Mrs U.

Communication to Mrs U’s registered GP

23. Mrs K says the Trust did not communicate the results of the November 2020 CT scan and recommendation her mother was referred to a chest physician to Mrs U’s registered GP.

24. NHS ‘CT scan’ guidance explains that once a CT scan has been done, a radiologist reviews the images. The results then go back to the doctor who requested the CT scan to allow them to discuss with the patient.

25. We asked our advisor if the Trust should have a failsafe to ensure the referrer knew to take action. Our advisor told us when there is a new potential cancer diagnosis there should be a distinct pathway of informing the referrer. Due to the volume growth rate of the nodule between scan dates our advisor told us the nodule would be viewed as high risk. This should result in urgent further workup for definitive management and activate a “unexpected significant finding (USF)” pathway. The pathway is the process those reporting results should follow to alert the referrer of the USF.

26. Our advisor further said there should be a USF alert pathway within the organisation to ensure reports are read and acted upon. This should include strong documentation to record results have been communicated to the referrer.

27. We are unable to see that USF pathway was activated as the report conclusion does not contain appropriate canned text documenting the referrer was notified.

28. In our view the Trust missed an opportunity to ensure Mrs U’s referring GP had received the report, was aware of the significance of the CT scan findings and understood the need to take action. This is not in line with the guidance and there is an indication of a failing.

29. Our Principles for Remedy explain that providing fair and proportionate remedies is an integral part of good complaint handling, and a public body has failed to get things right and this has led to an injustice, it should take steps to put things right.

30. Appropriate remedies can include apologies, remedial action, and financial remedies. In addition to this, public bodies should ensure that all feedback and lessons learnt from complaints contribute to service improvement.

31. We can see the identified failing meant there was a missed opportunity to ensure Mrs U was referred for diagnosis at an earlier point. We discussed this with the Trust to see if it would offer a remedy. Mrs K would like answers to why the claimed failings happened, service improvements and financial remedy.

32. The Trust reviewed the information we provided and has agreed to provide a clear explanation of what happened and why the communication gap occurred. It will also provide assurances of service improvements and will provide a financial remedy to acknowledge the distress and uncertainty experienced.

33. We are satisfied that agreeing to take these steps to put things right is in line with the NHS Complaint Standards with regards to giving a fair and accountable response. For this reason, we will not be taking any further action on Mrs K’s complaint.

34. We hope our thorough consideration reassures Mrs K and her mother’s wider family of the scrutiny we have given their concerns and helps them to move forward.

1. We have carefully considered Mrs K’s complaint about the Royal Cornwall Hospitals NHS Trust (the Trust) and its failure to refer her mother, Mrs U, for further investigation.

2. We are very sorry to hear of Mrs U’s death since this complaint began. We appreciate how difficult this has been for Mrs K, her siblings, stepfather and the wider family. We also acknowledge it must have been very hard to discuss the circumstances of the complaint with us. We are very grateful to Mrs K for the time and effort in bringing this complaint to our attention

3. We have spoken with the Trust and it has agreed it will provide Mrs K with an acknowledgement of the failings identified and assurance improvements have been made to prevent similar events. The Trust has also offered a proportionate financial remedy to acknowledge the distress and uncertainty experienced.