Royal Devon University Healthcare NHS Foundation Trust

7. Mr G complains about the care and treatment provided to his father, Mr Y, by Royal Devon University Healthcare NHS Foundation Trust (the Trust) between January and June 2023. Specifically, he raises concerns about:

• the Trust’s inaccurate reporting of an outsourced CT scan in January 2023, including whether the reporting radiologist had appropriate subspecialty expertise • clinical decisionmaking on 10 May 2023, including Mr Y’s deterioration should have prompted a CT scan at that point.

8. Mr G believes an error in the reporting of the January CT scan delayed his father’s diagnosis of gastric cancer. He considers outsourcing and the reporting radiologist’s specialism has contributed to this error.

9. He feels if the cancer had been identified correctly in January, it would have been detected at an earlier, potentially treatable stage.

10. Mr G accepts by the time of the May appointment the cancer was already incurable, and the overall outcome would not have changed. However, he believes earlier imaging on 10 May could have avoided further invasive tests and supported earlier palliative planning, allowing for a more dignified and less distressing final phase of life.

11. He says the failings have caused him distress and a loss of confidence in the Trust’s clinical processes.

12. Mr G is seeking service improvements in radiology reporting including around the outsourcing of scans, ensuring future Mr Ys receive timely, specialist-informed reviews. He wants the Trust to reflect on the clinical decision-making involved and consider departmental learning or support, so future patients receive appropriate care.

13. Mr G has concerns about the care provided to his father, who had a history of follicular lymphoma (a slow-growing type of blood cancer affecting the immune system). In January 2023, his father underwent a CT scan to monitor his condition. The scan was outsourced and reported as showing stable disease. The Trust received and accepted this report as accurate.

14. On 2 May 2023, his father attended the Trust’s emergency department (ED) with symptoms including a change in bowel habit, abdominal and back pain, and weight loss. An urgent appointment was arranged with a consultant surgeon, which took place on 10 May.

15. The consultant surgeon contacted radiology, who confirmed a CT scan had been performed in January and advised no further imaging was required. The records do not show the January images were reviewed again at this point, and the advice was based on the existing report.

16. A stool sample had been taken on 3 May, and haematology had arranged a colonoscopy (a procedure where a doctor uses a thin, flexible tube with a camera to look in the bottom and large intestine).

17. The consultant surgeon arranged an oesophagogastroduodenoscopy (OGD, a procedure where a doctor uses a thin, flexible tube with a camera to look in the mouth, stomach and small intestine).

18. The OGD was performed on 24 May, and biopsies were taken from the stomach. At that point, concerns were raised about possible recurrence of lymphoma, and advice was sought from the consultant surgeon regarding further imaging.

19. A CT scan was carried out on 5 June, and an addendum report later identified progression of the soft tissue at the site of the lymphoma from the scan in January. Biopsies from the OGD confirmed stomach cancer. Mr G’s father attended ED on 18 June unable to eat for 48 hours due to nausea and chronic back pain. On 20 June, Mr G’s father sadly died.

Inaccurate reporting of the CT scan

24. Mr G says the January 2023 CT scan was incorrectly reported. He believes the reporting radiologist failed to identify significant abnormalities, including progression of lymphoma and possible early signs of gastric cancer. He also questions whether the radiologist had the appropriate subspecialty expertise to report a lymphomasurveillance scan, and whether outsourcing contributed to the error.

25. The Trust said the January scan was outsourced for reporting, which is standard practice for nonurgent imaging. The reporting radiologist concluded there was stable disease. The Trust acknowledged it was possible the radiologist compared the January scan only with itself rather than with the 2020 scan, which may explain why progression was not identified.

26. The Trust said if the scan had been correctly reported as showing gastric thickening and progressive retroperitoneal disease (growth of lymphoma in the deep abdominal tissues behind the stomach and intestines), this would have triggered a twoweekwait OGD. It said the diagnosis would likely have been made in February rather than June.

27. The Trust noted there was no evidence the cancer had spread to the liver in January and the cancer was ‘possibly’ curable at that stage, although this was uncertain and may have been affected by Mr Y’s ongoing lymphoma and radiotherapy. Even if curative treatment was not possible, the Trust said earlier diagnosis would have allowed earlier palliative therapy and avoided a fourmonth delay in knowing the diagnosis.

28. The January 2023 CT scan was performed for routine lymphoma surveillance. The report described stable appearances, but the clinical information on the request was incomplete. The report was acknowledged by the referrer around one month later. Subsequent investigations in May and June identified gastric cancer and progression of lymphoma.

29. Our radiology adviser said the most likely explanation for the missed findings in was the radiologist failed to compare the January scan with the 2020 imaging. Standard practice requires reviewing both previous reports and previous images, as set out in the RCR standards for reporting.

30. We can see from the records the clinical information on the January scan request was incomplete, with the text stopping mid-sentence. This suggests either missing pages or incomplete information was provided to the reporter.

31. While this does not excuse the reporting error, it may indicate shared responsibility for the context in which the scan was interpreted. The 2020 scan showed a small amount of residual retroperitoneal tissue, which had grown significantly by 2023. Missing the stomach cancer may be understandable, as CT is not the most sensitive test for early gastric cancer, but missing the progression of lymphoma was not.

32. Our radiology adviser said if the correct comparison scan had been used, the progression of lymphoma should reasonably have been identified. This would likely have prompted further investigation of Mr Y’s symptoms, even if the gastric cancer itself was not detected at that stage. This is consistent with the Trust’s position that correct reporting would have triggered a two-week wait OGD.

33. The incomplete information may have contributed to the context in which the scan was interpreted, but responsibility for the missed progression remains with the failure to review the 2020 imaging. If the reporter had not received the full referral, they should have highlighted this.

34. The evidence indicates the January 2023 CT scan was incorrectly reported. The radiologist appears not to have compared the scan with the 2020 imaging, which would have shown clear progression of lymphoma. This fell below expected standards of radiological practice, and we consider this a failing.

35. We consider the impact of this failing later in our report.

36. We recognise how troubling it must have been for Mr G to learn that important findings were missed on the January scan, particularly given his understanding of how such imaging should be interpreted and the processes that should support accurate reporting. We appreciate the impact this had on the family’s ability to understand the progression of Mr Y’s illness and hope our report provides some reassurance that treatment options were not affected by the error.

37. Mr G also questioned the expertise of the reporting radiologist. Our radiology adviser said it is common for general radiologists to report scans outside their subspecialty. Most hospitals do not have haematology radiologists, and the reporting radiologist confirmed they routinely report on this type of scan. This is consistent with the RCR teleradiology standards, which state radiologists should report on what they usually handle in their NHS practice. We hope this provides some reassurance to Mr G.

Clinical decision making on 10 May 2023

38. Mr G says the consultant surgeon who reviewed his father on 10 May 2023 should have recognised how unwell he was and arranged further imaging, including a repeat CT scan, rather than relying on the January 2023 report. He also says the consultant surgeon stated they had spoken with radiology and been advised a further CT scan was not required, but this conversation was not documented in the records.

39. Mr G found the absence of this documentation troubling, as advice which directly influences clinical decisions should be recorded.

40. The Trust said the consultant surgeon acted appropriately based on the information available at the time, including the January 2023 CT report, which described stable disease. It said the consultant surgeon sought radiology advice, was told a further CT scan was not required, and therefore arranged an urgent OGD and relied on the colonoscopy already requested by haematology. The Trust said Mr Y did not appear to require emergency admission on 10 May and the investigations were arranged within expected NHS timeframes.

41. The records confirm Mr Y was reviewed in clinic on 10 May by a consultant surgeon, who documented ongoing symptoms of abdominal pain, change in bowel habit and weight loss. The consultant surgeon contacted radiology, who advised a CT scan had been performed in January and no further imaging was required at that point. The records do not show the January images were reviewed again.

42. The consultant surgeon arranged an urgent OGD and noted a colonoscopy had already been requested. The OGD was performed on 24 May. A CT scan on 5 June then identified progression of lymphoma and gastric cancer.

43. We considered this issue with the help of our surgical and radiology advisers.

44. The January reporting error likely gave the consultant surgeon false reassurance on 10 May. Based on the information available at the time, the consultant surgeon’s plan was appropriate. There are no specific guidelines dictating the order of investigations in this scenario, and clinicians must use their judgement to decide the most efficient route to diagnosis. The decision to request an urgent OGD before repeating the CT scan was reasonable.

45. Our surgical adviser explains Mr Y was clearly unwell, but there were no indications in the records he required emergency admission from clinic. The urgent outpatient investigations arranged were appropriate, and the timeframes in which they occurred were consistent with current NHS capacity.

46. On documentation, our surgical adviser said GMC guidance requires clinicians to document advice received from other specialties. Ideally, the radiology advice should have been recorded.

47. Our radiology adviser said the January scan did show recurrent lymphoma, but this was missed by the outsourced reporter. They said the stomach cancer was unlikely to have been visible at that stage. By May, Mr Y almost certainly had two separate cancers, and even if the lymphoma recurrence had been recognised earlier, this would not necessarily have removed the need for the OGD arranged on 10 May.

48. The advice given to the consultant surgeon, that no repeat CT was required, was based on the incorrect January report but was understandable from the radiologist’s perspective at the time.

49. Our radiology adviser also noted when outsourced reporting is used, clinicians should be encouraged to request an inhouse review if symptoms persist or new concerns arise.

50. All three of our clinical advisers explained even if a CT scan had been repeated on or shortly after 10 May, this would not have removed the need for an OGD. CT imaging cannot diagnose gastric cancer, and the abnormality seen on the June scan would still have required a biopsy to confirm the diagnosis. Performing a CT scan first would not have accelerated the pathway, as the OGD would still have been required.

51. Our clinical advisers also explained Mr Y’s symptoms involved both upper and lower gastrointestinal systems. A colonoscopy alone would not have identified a gastric cancer, as it examines only the large bowel. An OGD was required to examine the stomach and obtain biopsies.

52. Earlier imaging in May might have brought forward palliativecare referral by a short period, but it is unlikely this would have changed treatment intent or prognosis. In the circumstances, we do not think symptomdriven palliative care would have started significantly earlier, and Mr Y’s deterioration would likely have been similar.

53. The evidence shows the consultant surgeon relied on the January 2023 CT report, which incorrectly described stable disease. This provided false reassurance and likely influenced the decision not to request a repeat CT scan. The consultant surgeon sought advice from radiology, arranged an urgent OGD, and noted the existing colonoscopy request. These actions were consistent with the information available at the time and with expected clinical practice. The records do not indicate Mr Y required emergency admission on 10 May.

54. Documentation of the radiology advice was incomplete, which does not meet GMC expectations for recording clinical decision making. We understand why Mr G found the absence of this record troubling, particularly when the advice directly influenced the plan of care. On the balance of the evidence, we do not consider the consultant surgeon’s overall clinical decision making on 10 May to be a failing.

55. We acknowledge Mr G’s concerns about the consultant surgeon’s judgement on 10 May, including his view his father’s frailty and symptoms warranted a more urgent investigative approach. We also understand why he was troubled by the absence of a record of the radiology advice, particularly given his professional background and his expectation that such discussions should be documented.

56. While we have not found the clinical decision making on 10 May to be a failing, we recognise these issues have caused Mr G to question the process that led to the decisions made that day.

Impact

57. We find the January 2023 CT scan was incorrectly reported. This was a failing and resulted in a four‑month delay in identifying the progression of lymphoma and the presence of gastric cancer.

58. Our oncology adviser explained although this delay meant the diagnosis was made later, the available evidence indicates it did not change Mr Y’s overall prognosis or the treatment options that would realistically have been available to him.

59. On the balance of probabilities, the gastric cancer was already at least stage two in January 2023. Mr Y’s frailty, previous heart attack, and ongoing lymphoma meant major stomach surgery or aggressive chemotherapy was unlikely to have been offered even if the cancer had been identified at that time.

60. Even if chemotherapy or immunotherapy had been attempted earlier, our oncology adviser said it would probably not have prevented the spread to the liver that was evident by June, when the cancer was confirmed to be stage four and incurable. The deterioration Mr Y experienced in June was therefore likely to have occurred regardless of when the diagnosis was made.

61. Our oncology adviser also said when cancersurveillance imaging is outsourced, it is good practice for the resulting scans to be reviewed by the relevant multidisciplinary team (MDT) to ensure appropriate clinical oversight. The records show the January 2023 scan was not reviewed by any MDT until June, when the discrepancy was first recognised at the Gastroenterology MDT following identification of the gastric cancer. There is no evidence it was reviewed by the haematology MDT as part of routine lymphoma surveillance.

62. Had an MDT review taken place in January, whether by the haematology MDT for lymphoma surveillance or another appropriate specialty team, it is more likely than not the gastric thickening and progression of lymphoma would have been identified earlier. While this would not have changed Mr Y’s prognosis, it may have reduced the delay in diagnosis and the uncertainty experienced by Mr Y and his family.

63. Earlier clarity about the cancer’s progression could have brought forward conversations about prognosis, goals of care, and the support available. Our oncology adviser explained while palliative‑care involvement is often triggered by symptoms, clearer understanding of the underlying cause can prompt earlier planning.

64. On the balance of probabilities, we consider earlier recognition of the cancer would have enabled Mr Y and his family to prepare emotionally and practically for the final phase of life. It may also have allowed palliative‑care services to be involved sooner, supporting a more coordinated and comfortable end‑of‑life experience.

65. Mr G told us he believes earlier palliative involvement could have prevented his father spending his final hours on an ED trolley. We cannot say this with certainty, but we consider earlier planning could reasonably have reduced the distress experienced in his father’s final days.

66. Our radiology adviser also highlighted that when outsourced reporting is used, Trusts should have clear processes to ensure surveillance scans are reviewed by the appropriate MDT and that clinicians can request an inhouse review if symptoms persist or new concerns arise. These safeguards may help prevent similar situations in future and support more timely recognition of disease progression.

67. We have considered what action the Trust has already taken to address the failing and improve its services.

68. The reporting error was identified by a radiologist at a multidisciplinary team (MDT) meeting, noting the January report did not match the clinical picture. This prompted a formal discrepancy review within the radiology department.

69. The Trust raised an incident report on its Datix system and requested a re-review of the January imaging. An arbitrating radiologist compared the 2023 and 2020 scans and confirmed the original reporter had mistakenly compared the January scan with itself.

70. The outsourced reporting radiologist was asked to explain the error and subsequently issued an addendum acknowledging the misinterpretation. These steps are consistent with the RCR REALM guidance, which requires investigation, peer review, and documented learning following a reporting discrepancy.

71. While actions were taken at the time to review and correct the discrepancy, it is not clear what action has been taken to prevent a similar situation in future. We do not know what action was taken in respect of the incomplete referral, and the failure to highlight this by the outsourced radiologist.

72. The Trust did not acknowledge the impact the delay had on Mr Y and his family, including the loss of opportunity to prepare for the final phase of life and the distress experienced in his final days. This remains an outstanding injustice.

1. We have carefully reviewed Mr G’s complaint about the care and treatment provided to his father, Mr Y, by Royal Devon University Healthcare NHS Foundation Trust between January and June 2023.

2. We understand how deeply personal and difficult it must have been for Mr G to raise these concerns during such a challenging time, and we appreciate his determination in seeking answers and improvements.

3. We found failings in the reporting of the January 2023 CT scan. This error contributed to a delay in recognising Mr Y’s disease progression. While this did not alter Mr Y’s overall prognosis or treatment options, it caused unnecessary uncertainty and distress for him and his family during an already difficult time. Earlier recognition may have allowed Mr Y and his family to prepare more fully, both emotionally and practically, for the final phases of his illness.

4. The Trust has acknowledged the reporting error and taken steps to investigate it internally. However, it has not fully reflected on the impact this had on Mr Y and his family, nor has it outlined what it will do to prevent similar issues in future.

5. We partly uphold this complaint, recognising the emotional impact and lost opportunity for earlier planning, even though the clinical outcome was not affected.

6. We are making recommendations to address the failings we have identified and to improve the service and experience of future patients and their families

73. We make recommendations in line with our Principles for Remedy, which are reflected in the NHS Complaint Standards. These say organisations should identify instances where things have gone wrong, take responsibility for these, and find ways to put things right for those involved. They should learn from complaints to improve services.

74. We have identified failings in relation to: • the incorrect reporting of the January 2023 CT scan • incomplete referral information and the failure of the outsourced radiologist to highlight this • the absence of a mechanism to ensure outsourced surveillance scans are reviewed by the appropriate MDT • incomplete documentation of interspecialty advice on 10 May.

75. We consider these failings led to uncertainty and distress for Mr Y and his family, including the lost opportunity to prepare for the final phase of life.

76. With that in mind, we recommend following this final report the Trust explains what action it will take, or has taken, to address these failings by 18 September 2026. This should be provided in the form of an action plan, which should be shared with us, Mr G, and the Care Quality Commission.

77. The Trust should send us evidence it has completed all of the recommendations we have made. We will check the action plan includes the reason for each failing (where possible), what the organisation does or will do differently in future, who is responsible for each action, the timescale for completion, and how it will be monitored.

78. We would like to express our thanks to Mr G for his cooperation and determination throughout this investigation. We recognise the emotional strength it has taken to raise these important concerns while navigating the profound loss of his father. His perseverance has been instrumental in helping us identify key failings. By highlighting these issues, Mr G has contributed to meaningful recommendations aimed at improving processes and care, ensuring other families may never have to face similar difficulties.