University Hospitals of North Midlands NHS Trust

3. Mrs E complains about aspects of the care and treatment clinicians at two of the Trust’s hospitals gave to her father between 11 March 2022 and 14 January 2023. She specifically complains about:

• how doctors investigated and treated her father’s cancer between March and September 2022.

• a decision to discharge her father from hospital on 29 November 2022 soon after surgery and when he had not had a bowel movement • how doctors investigated and treated her father’s cancer at outpatient appointments in December 2022 • whether clinicians delayed recognising her father’s perforated bowel on 10 January 2023 • a decision not to provide active treatment for her father towards the end of his life and she says the family’s views were not considered.

4. Mrs E believes her father’s death could have been avoided. She says he, and his family, experienced significant distress because of these incidents.

5. Mrs E wants the Trust to acknowledge its failings and recognise and apologise for the full impact they had. She wants to ensure there is learning from her complaint. She also seeks a financial remedy.

6. On 25 March 2022 a consultant urological surgeon from the Trust wrote to Mr S. This was about a recent CT scan which showed an abnormality in the caecum (which connects the small and large bowels). The surgeon made a referral to the colorectal team for their opinion about whether further investigations were needed.

7. Mr S attended an appointment with a consultant vascular surgeon at Hospital A on 28 March 2022. The consultant noted a recent diagnosis of an abdominal aortic aneurysm (AAA). This is an abnormal swelling in the main artery (the aorta) which supplies blood to the lower part of the body. If an AAA ruptures this can cause severe bleeding and death. The consultant noted Mr S was very active and denied any pain. The consultant arranged further tests and follow up.

8. Mr S attended the cardiology department at Hospital B. An advanced nurse practitioner reviewed him and noted he had first degree heart block (a mild delay in the electrical signals of the heart). They planned further tests to see whether or not Mr S should have a pacemaker. A further appointment was planned for when the results were available.

9. On 7 April 2022 Mr S attended an appointment with Mr R (Consultant Colorectal Surgeon) at Hospital A. Mr R carried out an assessment to see whether Mr S could have surgery for the AAA. He noted there was also an abnormality associated with the appendix and that its removal had been suggested. Mr R concluded that the safest plan would be to repeat a scan in three months in view of the cardiology issues.

10. Mr S attended an appointment at Hospital A with a consultant urological surgeon on 6 May 2022. They noted he was already under the care of colorectal and vascular surgeons and was awaiting surgery for a pacemaker. They decided no further urology involvement was needed.

11. On 24 June 2022 Mr S saw Mr W (Consultant Vascular Surgeon) at Hospital A. Mr W noted the AAA was more complex than expected. He noted the colorectal team was awaiting the outcome of further investigations before deciding whether to remove the appendix. He decided to put treatment of the AAA on hold for ‘a couple of months’ until the heart and appendix investigations had taken place.

12. Mr S had a repeat CT scan of his abdomen and pelvis on 7 July 2022. The radiology report for this was completed on 22 August. It showed a mass in the area of the caecum, which suggested cancer.

13. Mr S attended the cardiology clinic at Hospital B on 19 July 2022. A consultant cardiologist said there was nothing more that cardiologists could do. A pacemaker would be considered if Mr S started to experience unexplained dizzy spells or blackouts.

14. On 9 September 2022 Mr S saw Mr W again. Mr W was concerned about increased thickening around the appendix and the base of the caecum as seen on the repeat CT scan. Mr W understood Mr S was to be seen by the colorectal team and so treatment of the AAA would wait until that review had taken place.

15. On 16 September 2022 Mr S attended a consultation with Mr R. It was Mr R’s view that the appendix needed to be removed, but this would depend on how Mr W wanted to manage the AAA. Mr R and Mr W discussed the options for Mr S, who attended his next appointment with Mr W on 14 October.

16. At this point the plan was to repair the AAA and follow this with bowel surgery in a combined procedure. Mr W explained to Mr S that this increased the risk of the procedure. He planned to arrange a date for surgery in consultation with Mr R.

17. Mr W carried out surgery for Mr S at Hospital B on 24 November 2022 with Mr R in attendance. The AAA was not repaired. Instead, the surgery involved removing multiple lesions from the small and large bowels, which showed more extensive disease than expected. Doctors considered he recovered well from the procedure they discharged him on 29 November.

18. On 8 December 2022 Mr S attended a review appointment with Mr R. At this point the results of biopsies on tissue removed during the surgery were unavailable. Mr R noted Mr S was recovering well and explained there would be further contact once the results had been reviewed.

19. Mr S attended another appointment with Mr R on 29 December 2022. Mr R explained the biopsy results confirmed Mr S had a rare and aggressive form of bowel cancer. He noted that Mr S had been referred for chemotherapy.

20. Mr S had a CT scan on 5 January 2023 which showed no evidence of a bowel obstruction. It did show an increased number of abnormalities in the lining of the abdominal cavity. The scan suggested progression of the cancer.

21. On 10 January 2023 Mr S attended the emergency department at Hospital B by ambulance. He had not been able to open his bowels since the surgery and his abdomen was swollen. Doctors admitted Mr S to the hospital. They believed the progression of the cancer was obstructing the bowels. Surgeons considered it would not be the best decision to operate again, and they recommended palliative care to help keep Mr S comfortable.

22. The palliative care team assessed Mr S on 11 January 2023 and considered he was approaching the end of his life. Sadly, he died on 14 January. His cause of death was a bowel obstruction caused by peritoneal carcinomatosis (meaning cancer cells had spread to the lining of the abdominal cavity) due to signet ring cell adenocarcinoma (a rare and aggressive form of cancer).

23. Mrs E first complained to the Trust in July 2023 and attended a meeting with staff from the Trust in October 2023. Over the following two years the Trust sent Mrs E three written responses to her complaint. She remained dissatisfied so she complained to us.

Investigation and treatment between March and September 2022

27. Mrs E complains about the time it took doctors to investigate and treat her father’s cancer following the review of a CT scan in March 2022. She says no treatment was offered and he had to wait for a second scan in July. She says the results of this scan were not reported until 22 August and not communicated to her father until 16 September. She believes her father should have had chemotherapy in July. She also says he should have had a colonoscopy in September.

28. Good Medical Practice says doctors must provide a good standard of care. This includes carrying out adequate assessments, taking account of the patient’s history and examining them if necessary. Doctors should also arrange timely treatment and appropriate investigations or referrals if needed.

29. The Reporting Guidelines were published after the events in 2022. The Clinical Adviser told us its contents were already being followed in practice by doctors working in the NHS at the time. The Reporting Guidelines says no examination should take longer than four weeks to be reported. The aim was to ensure turnaround times should be less than two weeks in the future.

30. The Clinical Adviser told us a colorectal surgeon saw Mr S promptly within two weeks of the initial referral from a urologist on 25 March 2022. At that point the surgeon decided to arrange a repeat scan in three months. This was because Mr S was being investigated for other conditions including an AAA and heart block. This was a good standard of care in line with Good Medical Practice. There was no delay during this initial period.

31. Mrs E is right to highlight there was a delay between the second scan on 7 July 2022, the reporting of the scan on 22 August and the surgeon telling Mr S about it on 16 September. The scan should have been reported on within four weeks as explained in the Reporting Guidelines. This delay fell below the relevant standard.

32. In its complaint responses the Trust accepted that it took too long for radiology to report on the scan results from 7 July 2022. It apologised to Mrs E. It said the volume of cases to report and staffing levels in radiology meant there was a backlog. The Trust explained how it had put measures place to ensure this is not repeated. This has involved outsourcing some reporting to external companies.

33. The Clinical Adviser also told us it was appropriate for the colorectal surgeons not to carry out a colonoscopy in September 2022. They said the CT scan had already shown progression of the cancer and the decision for surgery had already been made. A colonoscopy would have been unnecessary and would have delayed surgery further.

34. We find the reporting delay was a failing. In all other respects we consider doctors followed the relevant standards relating to the care and treatment Mr S had between March and September 2022.

35. The Clinical Adviser told us the delay in reporting the scan results was unlikely to have had an impact on Mr S’ illness. If the surgery had gone ahead in July or August it is likely the findings would have been the same and the cancer would not have been removed. Unfortunately, the type of cancer Mr S had has a poor prognosis with low survival rates. His death would not have been avoidable, and his quality of life would likely have been the same. We recognise it has been distressing for Mrs E to find out about the reporting delay. We hope she is reassured we have seen no evidence to suggest this issue had any impact on her father’s illness.

Discharge from hospital

36. Mrs E recalled that she and her mother attended Hospital B on 29 November 2022 to visit her father. They found he was preparing to go home. Mrs E said the plan had been for doctors to discharge her father only after he had a bowel movement. This did not happen. She says he did not have a bowel movement for the following six weeks.

37. The Clinical Adviser told us it is a clinical decision whether someone is considered fit to be discharged from hospital. It is dependent on several factors. In this case clinicians would have wanted to be assured that Mr S was comfortable, eating, drinking, had normal observations and had support at home. Good Medical Practice says doctors must base any treatment on the patient’s needs and priorities using their clinical judgment.

38. Nursing records indicate that Mr S needed minimal assistance with daily activities at home and that Mrs E would provide additional support if needed. The medical records for 29 November 2022 show doctors considered Mr S was well, passed wind, had no new concerns and was ‘medically fit for discharge.’ Patients are not expected to remain in hospital if this would not be of benefit to them.

39. The Clinical Adviser told us it was not essential for Mr S to have a bowel movement before leaving hospital providing he was passing wind. The records clearly show he could pass wind on 28 and 29 November 2022.

40. We find there was no need for Mr S to remain in Hospital B on 29 November 2022. We can see no evidence the decision to discharge him was inappropriate. Doctors followed Good Medical Practice based on the evidence we have seen.

Investigation and treatment in December 2022

41. Mrs E says doctors at outpatient appointments in December 2022 failed to consider her father’s symptoms and did not examine him. She says he was given dietary advice to address constipation. She believes her father had a bowel obstruction that doctors failed to investigate.

42. This relates to specifically to two outpatient consultations Mr R had with Mr S on 8 and 29 December 2022. Mr R should have followed Good Medical Practice at those consultations.

43. On 8 December 2022 Mr R documented that he discussed findings from the recent surgery with Mr S and his daughter. He explained how there were multiple areas of abnormality affecting the bowel and samples had been taken for analysis. Mr R was awaiting the results of these biopsies. Mr R noted Mr S was recovering well from surgery and planned to review him again once the results were available and following a discussion with his colleagues.

44. On 29 December 2022 Mr R noted he had seen Mr S in clinic. He said test results confirmed Mr S had a signet ring carcinoma. Mr R said she had referred him for chemotherapy.

45. There is no evidence in the clinical records to suggest Mr R examined Mr S. Neither is there evidence in the records that Mr S was experiencing constipation or that clinicians gave dietary advice. During the complaints process Mr R was unable to recall any details of conversations because of the time that had passed. We have no reason to doubt Mrs E’s recollections about what happened at the consultations.

46. Based on the clinical evidence available the Clinical Adviser told us there was no delay in Mr R arranging investigations at this point. There is no evidence to suggest urgent treatment was needed at the time of the consultations. We find Mr R did not fall below the standard expected, Good Medical Practice, in December 2022. We can only recognise Mrs E disagrees with this.

10 January 2023

47. Mrs E believes her father’s bowel perforated on 10 January 2023 and this caused his death.

48. Doctors should have followed Good Medical Practice when Mr S arrived at Hospital B on 10 January 2023. They should have carried out adequate assessments and promptly arranged any necessary investigations and treatment.

49. Mr S attended the emergency department on 10 January 2023. Clinicians noted he had not been able to eat or drink for the last day, and his abdomen had become more swollen.

50. The Clinical Adviser told us the CT scan on 11 January 2023 showed Mr S’ cancer had grown when compared to the scan from July 2022. This resulted in a large bowel obstruction. The Clinical Adviser said doctors would not be expected to arrange a CT scan because a patient had not opened their bowels. But, when Mr S attended he described having abdominal pain and swelling for one day. This prompted the scan that then took place. We have seen no evidence that Mr S had a perforated bowel when he arrived at Hospital B.

51. We find doctors carried out appropriate assessments, investigations and treatment on 10 January 2023. They followed Good Medical Practice.

End of life decisions

52. Mrs E recalled that, on 11 January 2023, a doctor told her that her father was not strong enough to have further surgery. She says the doctor told them he could arrange palliative care to ensure her father was comfortable. She says the family felt rushed and reluctantly agreed with the doctors. Mrs E believes active treatment should have continued and the family’s views about this were dismissed.

53. The Clinical Adviser told us decisions about when to stop active treatment are matters of clinical judgment. But doctors should also follow the End of Life Guideline. This notes it is widely agreed that high-quality treatment and care towards the end of life includes palliative care that focuses on managing pain and other distressing symptoms.

54. The End of Life Guideline explains that when a patient can make decisions themselves the doctor should assess the patient’s condition and involve them in that assessment. They should use their specialist knowledge, experience and clinical judgment and take account of the patient’s views and understanding of their condition. Doctors may recommend a particular option which they believe to be best for the patient but must not put pressure on patients to accept their advice. If the doctor still considers that treatment would not serve the patient’s needs they must not provide it.

55. The End of Life Guideline also says that when a patient lacks capacity to make decisions doctors are responsible for deciding which course of action would be of overall benefit to the patient. Doctors must consult with those close to the patient before taking decisions.

56. On 11 January 2023 Mr S lacked capacity to make decisions about his care and treatment. He was confused and unable to follow the conversation. But he did express the view that he would not like another operation. A doctor had a discussion with Mrs E. They noted Mrs E was upset ‘but realised that likely not best decision to go for surgery.’

57. The same doctor also documented a later discussion with Mr S’ wife and daughters. They noted other doctors were present. The doctors explained that Mr S’ condition was unlikely to be helped by surgery. They planned to arrange palliative care to ensure Mr S was as comfortable as possible.

58. The Clinical Adviser said Mr S was very unwell at this stage. They said it was appropriate to stop active treatment because of the bowel obstruction, the aggressiveness of the cancer and his sudden deterioration.

59. We find the doctors followed the End of Life Guideline. They made a decision based on the overall benefit to Mr S. They clearly had discussions with the family and took their views into account. But the medical decision was appropriate. We recognise how difficult this must have been for the family to accept. We have seen no evidence of any failings in this respect.

Conclusion

60. We have seen no evidence of failings relating to Mr S’ care and treatment, with one exception. This relates to a delay in reporting scan results.

61. We are satisfied the Trust has already accepted its failings relating to the delay in reporting the scan from 7 July 2022. It has apologised to Mrs E and shown it has made improvements to services since the events. We cannot see that this had any impact on Mr S’ health. While we can see this has been a source of distress for Mrs E we do not consider a financial remedy would be proportionate in these circumstances.

62. We do not uphold Mrs E’s complaint.

1. Mrs E complains about how healthcare professionals from the Trust treated her father, Mr S, in the last year of his life. We can see how devastating these events have been for Mrs E and her family. We offer them our sincere condolences for their loss.

2. We find the clinicians from the Trust generally followed the relevant standards and guidelines in relation to the aspects of Mr S’ care and treatment we have investigated. We have seen evidence of a significant delay in reporting the results of a CT scan. We cannot say this had an impact on Mr S’ health, but we can see this has been upsetting for his family for know about. We are satisfied the Trust has taken appropriate action in response to this failing and we do not intend making any recommendations. We do not uphold Mrs E’s complaint.