Royal Surrey NHS Foundation Trust

4. Mrs A complains between late October 2022 and mid February 2023, SASH and the RS Trust failed to identify the spread of cancer to her husband’s lymph nodes and pancreas.

5. She says her husband’s prognosis could have been better and his death may have been prevented had he received an earlier diagnosis and treatment. Mrs A is devastated from the loss of her husband.

6. Mrs A is seeking acknowledgment of failings from the Trusts, an apology, service improvements and financial redress.

7. Mr A had a diagnosis of squamous cell carcinoma (a type of cancer) following a biopsy of lymph nodes in his neck. Clinicians did not know where the cancer had originated, but this type of cancer usually begins in the head and neck area.

8. Mr A was under the care of the oncology team at the RS Trust from early September 2022. Computed tomography (CT) scans, which take detailed images of the body, prior to starting treatment showed the cancer had not spread anywhere else in his body.

9. Doctors at the RS Trust fitted Mr A with a percutaneous endoscopic gastrostomy (PEG), which is a feeding tube, to support his nutrition before starting chemotherapy later in September.

10. Mr A first presented at the Emergency Department (ED) at the RS Trust, with problems linked to his PEG feed in early October 2022, and the RS Trust prescribed antibiotics and discharged him.

11. Later that month, he attended the oncology clinic at the RS Trust, and an X-ray showed he had faecal loading (a build up of faeces). The doctor prescribed laxatives and a suppository to help him empty his bowel and booked a follow up for a week’s time.

12. SASH admitted Mr A the following day with worsening symptoms of constipation, nausea and vomiting from chemoradiotherapy (a combination of chemotherapy and radiotherapy). It discharged him in the first week of November.

13. During his admission, SASH paused Mr A’s feed and supported him with intravenous fluids and medication to prevent nausea. Clinicians restarted the PEG feed once his sickness subsided and then monitored Mr A.

14. On 8 Nov, the RS Trust concluded Mr A’s chemoradiotherapy. It arranged a follow up oncology appointment for 5 December.

15. SASH readmitted Mr A for eleven days in November with pain to his lower left side which radiated to his scrotum, which clinicians attributed to his history of kidney stones. A CT scan did not indicate any new localised spread of cancer.

16. Clinicians readmitted Mr A to SASH between early and mid December, due to him being unable to tolerate his PEG feed, abdominal pain and constipation. Mr A did not attend his oncology review at the RS Trust as it was during the time he was an inpatient at SASH.

17. On 7 December, SASH performed a CT scan. Clinicians identified the kidney stones, but no abnormalities in Mr A’s head, abdomen and pelvis, pancreas, lungs and kidneys.

18. SASH rescanned Mr A the following week with a CT scan id the kidneys, ureters, and bladder to detect stones, obstructions, infections, tumours and other urinary tract conditions. It again showed kidney stones.

19. It performed shockwave lithotripsy (a non-invasive therapy to treat kidney stones) that day and discharged him in mid December.

20. On 20 January 2023 the RS Trust conducted an MRI scan on Mr A’s neck which showed an ‘excellent post treatment response’ with ‘no new lesions’.

21. In late January, SASH fitted a stent to help Mr A’s kidney stone particles pass.

22. On 3 February, SASH admitted Mr A after he presented with severe leg pain, radiating to his groin. He told clinicians it had started ten days earlier, after the operation to fit the stent.

23. SASH scanned Mr’s A leg to check for a deep vein thrombosis, (a blood clot) but clinicians found no evidence of a clot.

24. Clinicians performed a CT scan of Mr A’s kidneys, ureter and blader on 3 February which showed a potential mass in the lymph nodes around Mr A’s pancreas. The CT report noted ‘lesions were not noted in the previous scan dated 14 December 2022’ and recorded the possibility of lymphoma (a type of blood cancer).

25. In mid February, Mr A had a full body PET-CT scan, (a detailed scan to check organs and tissue) which showed a pancreatic mass and a mass of lymph nodes in his left leg.

26. On 8 March, following a biopsy of the abdomen and lymph nodes on 1 March, an RS consultant oncologist reviewed Mr A in clinic and confirmed the cancer had spread.

27. Mr A sadly died at the end of March 2023.

31. Mrs A complains both organisations missed opportunities to identify her husband’s cancer had spread. We understand she has some concerns about the communication between SASH and the RS Trust, which means she feels they were both unaware of the actions of the other organisation.

32. Paragraph 44 of ‘Good medical practice’, sets out what is expected of doctors when treating patients whose care is also oversaw by other organisations. It says-

‘You must contribute to the safe transfer of patients between healthcare providers and between health and social care providers. This means you must:

a share all relevant information with colleagues involved in your patients’ care within and outside the team, including when you hand over care as you go off duty, and when you delegate care or refer patients to other health or social care providers’.

33. Our oncology adviser told us it is the responsibility of the admitting Trust, SASH in this case, to keep the RS Trust updated on Mr A’s condition.

34. Our physician adviser has no concerns about the communication between SASH and the RS Trust. There is evidence SASH kept the RS oncology team updated about Mr A and that communication was prompt, in some cases happened on the same day.

35. It appears the RS oncology team had access to SASH’s medical records in real time and SASH communicated regularly with the relevant team members at the RS Trust.

36. There is also evidence of decision making shared across the palliative care team at SASH and the oncology team at the RS Trust.

37. There is no evidence to suggest SASH failed to follow GMC (44) or keep the RS sufficiently updated on Mr A.

SASH

38. We considered if there was any available evidence to indicate SASH missed an opportunity to identify the spread of Mr A’s cancer earlier than 16 February 2023.

39. ‘Good medical practice’ paragraph 15 says ‘You [doctors] must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:

a adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient b promptly provide or arrange suitable advice, investigations or treatment where necessary c refer a patient to another practitioner when this serves the patient’s needs.’

40. Mr A presented to SASH numerous times between October 2022 and February 2023 with nausea, vomiting, and constipation. In early February, he also reported severe pain in his leg.

41. We can see from Mr A’s records, SASH carried out blood tests and imaging, which we understand from our physician adviser were appropriate based on the symptoms he presented with. As detailed above, the results of the investigations did not show any indication that cancer had spread.

42. When admitted in November, Mr A was also experiencing radiating pain to his scrotum.

SASH performed a CT scan.

43. Our physician adviser again told us these were the appropriate investigations for Mr A’s presenting symptoms. They did not indicate a spread of cancer. Our physician adviser also explained it was reasonable for SASH to attribute the scrotal pain to Mr A’s previously diagnosed kidney stones.

44. SASH also tested Mr A’s blood. Although there are no available blood tests which would have ruled out spread, the c-reactive protein (CRP), which is a type of protein in the blood, blood count and calcium are often elevated if there is cancer spread.

45. Mr A’s blood results did not show any elevated markers indicating no concern about the spread of cancer.

46. SASH admitted Mr A in early December 2022, for the purpose of treating his previously diagnosed kidney stones. During this admission clinicians performed a further CT scan which again showed normal appearances of his gallbladder, pancreas, spleen, adrenal glands and the right kidney.

47. Mr A’s December admissions were unrelated to his ongoing cancer diagnosis and treatment. We understand from our physician adviser that Mr A did not present with any symptoms which would indicate the cancer had spread during this time.

48. The evidence shows SASH considered Mrs A’s history and symptoms and examined him during each admission, in line with GMC guidance (15). We also think the investigations it provided were appropriate, which is supported by our physician adviser’s view. The results did not indicate the cancer had spread.

49. We understand from our oncology adviser Mr A’s disease was very unusual due to how rapidly it spread after the review in January. We recognise it must have been devastating for Mr and Mrs A to learn Mr A’s cancer had spread.

50. The first available evidence in Mr A’s records to indicate the cancer had spread was on 3 February, when he attended SASH with significant leg and groin pain. Mr A’s records show he told clinicians the pain started ten days earlier.

51. SASH arranged a CT scan the same day and identified a mass of lymph nodes which were not present on the scans conducted in December and took a biopsy. We think its prompt action to investigate this in response Mr A’s pain was in line with the above GMC guidance (15).

52. A biopsy later sadly confirmed Mr A’s cancer had spread on 16 February.

53. We cannot see any evidence Mr A’s cancer had spread prior to February 2023 when he attended with new symptoms.

The RS Trust

54. Mrs A believes the oncology department at the RS Trust also missed an opportunity to identify the spread of cancer during its contact with Mr A.

55. The RS Trust oversaw Mr A’s oncology care. We can see from Mr A’s medical records it held weekly oncology reviews whilst it provided chemoradiation (a mix of chemotherapy and radiation which treats cancer) to Mr A. The primary aim of the reviews was to check if Mr A was tolerating treatment.

56. In the reviews, Mr A reported severe constipation after treatment, and later nausea, vomiting and diarrhoea. The RS oncology team identified these symptoms as relating to problems tolerating his PEG feed. Our oncology adviser told us these are normal side effects of a combination of PEG feeding and chemoradiotherapy and did not indicate Mr A’s cancer had spread. They told us it is common for patients who are receiving treatment for head and neck cancers to have similar side effects.

57. We recognise Mr A’s repeated admissions must have been very worrying to both Mr and Mrs A.

58. The records show the RS Trust considered Mr A’s symptoms during its weekly oncology reviews whilst it treated him and he had no symptoms to indicate his cancer had spread.

59. Therefore, from the evidence available to us, we think the RS Trust acted in line with the above GMC guidance (15).

60. Our oncology adviser told us it is usual practice for oncology to review a patient around six weeks after completion of treatment. Mr A finished treatment on 8 November and the RS Trust arranged a follow up appointment with Mr A for early December, which was within the recommended timeframe.

61. However, SASH had already admitted Mr A so the RS Trust’s oncology review could not happen. SASH was responsible for managing Mr A’s acute symptoms during this admission.

62. We know the results of investigations SASH conducted at the time showed no spread of cancer during this period.

63. As above, SASH appropriately communicated with the RS Trust and the RS Trust was able to view Mr A’s records in real time.

64. We can see the RS Trust arranged to review Mr A in mid January, and its investigations also showed Mr A had an excellent response to treatment.

65. We cannot say there was an indicated failing in the way the RS Trust handled Mr A’s post treatment review. It is clear it arranged a review, which could not go ahead due to an admission, and it rearranged it once SASH discharged him.

66. We also think if the RS Trust had reviewed him earlier, it would have been highly unlikely it would have identified any symptoms which needed further investigations, given SASH provided detailed investigations and found no areas of concern.

67. As we have seen no indication of failings, we will take no further action.

68. It is clear from speaking with Mrs A, the loss of Mr A has impacted her greatly. We recognise Mrs A has been through a very difficult and distressing time.

1. We have carefully considered Mrs A’s complaint about the Surrey and Sussex Healthcare NHS Trust (SASH) and Royal Surrey NHS Foundation Trust (the RS Trust).

2. We are very sorry to hear about the sad loss of Mrs A’s husband, Mr A, and of the concerns about his care at what must have been a very difficult and distressing time for Mrs A.

3. We have seen no indication SASH and the RS Trust missed an opportunity to identify Mr A’s cancer had spread before February 2023.