North Bristol NHS Trust

6. Mr D complains the Trust: • did not give chemotherapy within three months of the first operation in May 2022. He says the impact of this was a reduction in his life expectancy.

• did not take action in line with guidance on scans taken in March to September 2024. He says the impact of this was a reduction in his life expectancy.

• moved Mr D by hoist on 13 December 2023, too soon after his operation and in a way that was not in line with guidance. He says the impact of this is an inoperable fistula.

7. Mr D says as a result of what happened his life has been shortened. He says the fistula means that he is housebound, in pain everyday, and experiences embarrassment because of the impact of the fistula. He is no longer able to enjoy activities with his family.

8. The outcomes he seeks are an acknowledgment of failings, service improvements and a financial remedy.

9. Mr D was diagnosed with rectal cancer in June 2021. He had a course of chemoradiotherapy that completed in August. He developed COVID-19 in November, with a three month pause to allow for recovery, after which he had imaging to re-stage his cancer.

10. On 1 February 2022 the colorectal cancer multidisciplinary team (MDT) discussed Mr D’s case, recommending he be seen in clinic to discuss surgery. At the appointment on 14 March, the consultant colorectal surgeon wrote that Mr D’s preference was for chemotherapy alone without further intervention. The surgeon noted their concern that Mr D’s tumour behaviour was not in keeping with other patients who followed that approach. The surgeon wrote of the management plan, should chemoradiotherapy alone prove not therapeutic, and surgery be required.

11. The MDT discussed Mr D’s case again on 19 April, and on 5 May the same surgeon wrote to the MDT following its review of updated imaging. The letter notes Mr D had no complete response following chemoradiotherapy and had resisted surgical intervention for almost one year. The surgeon confirmed happiness to proceed with surgery. On 13 May the surgeon wrote to Mr D’s GP, having met with Mr D to discuss and agree upon surgery.

12. Mr D was admitted on 18 May for an elective total pelvic exenteration (a major surgery that removes many of the organs inside the pelvis). A CT scan was taken on 26 July and at a colorectal surgery clinic follow-up appointment on 27 July the documented plan was for nurse-led surveillance for the next five years. The letter notes: ‘With respect to any further oncological treatment at this, given the fact that we have given you chemoradiotherapy in advance, post operative medical oncology is not to considered of additional benefit’.

13. Records show Mr D was seen in the clinic on 29 November when the urological consultant notes problems with the urostomy (a surgical opening in the abdomen knowing as a stoma, to allow urine to exit the body). This was noted as being very retracted and stenotic (narrowed) at the opening in the skin, suggesting consideration for a stomal revision surgery.

14. Mr D was seen by the consultant colorectal surgeon on 2 December who noted revision surgery was not without risk and the abdomen may settle. They planned for a CT scan to understand the abdominal wall and quality of the bowel behind the conduit. This scan went ahead in December 2022.

15. A CT scan taken on 14 May 2023 was reported noting comparison with the previous scan of December 2022. The May 2023 report notes: ‘No mass lesions suggestive for local recurrence’ and concludes: ‘No recurrent or metastatic malignant disease’ (malignancy meaning cancer, and metastatic meaning having spread).

16. Mr D was seen in the colorectal clinic on 9 June, where blood tests were noted as encouraging and the plan was for review in six months with surveillance colonoscopy (a flexible tube with a camera, inserted to enable visualisation of the colon and rectum).

17. On 19 August Mr D attended the Trust presenting with vomiting, constipation and abdominal distension. A CT scan was taken and compared with the May 2023 CT, and reported: ‘no soft tissue mass to suggest recurrent disease’.

18. A review of images at the colorectal MDT on 12 September raised concern of a left-sided pelvic recurrence. The MDT advised both MRI and PET scans to confirm the MDT discussion. An MRI scan was taken on 28 September, reporting a malignant mass, concluding local recurrence of the rectal cancer. A whole-body PET scan was taken on 2 October and reported a highly active mass, characteristic of recurrent tumour.

19. The images were reviewed at the colorectal MDT on 17 October confirming recurrence of the cancer. The MDT plan was for Mr D to be seen in clinic, to consider the possibility of chemotherapy and if surgery would be possible. The images were also reviewed at the urology MDT on 1 November, when a plan was made to proceed with excision and refashioning of the conduit.

20. On 9 November 2023 an addendum was added to the May 2023 CT report, noting a progression of the thickening of a specific area seen, suggesting, suggesting progressive disease.

21. Mr D was seen in the colorectal surgery clinic on 23 November where surgery and its risks were discussed, and that radiotherapy or chemotherapy were not possible or done for any form of curative intent. The clinic letter said radiology colleagues had reviewed the imaging and on review, this disease had been present in the scan taken in May 2023. It said in some situations where a tumour has an appearance of adjacent bowel it can be difficult to determine the difference between them. The surgeon planned to discuss with urological, orthopaedic and vascular colleagues with a plan to proceed with surgery.

22. CT scans of Mr D’s chest and of his thorax, abdomen and pelvis were taken on 29 November and an MRI was taken on 1 December. Images were reviewed at the colorectal MDT on 5 December. The record states the 29 November CT showed a left pelvic mass with suspicion of adjacent bone invasion, and the MRI taken on 1 December showed progressive disease with pelvic bony invasion.

23. Mr D was admitted on 7 December for surgery the following day, undergoing a resection of his recurrent cancer into the left pubic bone, ileal conduit and small bowel. Post-surgery Mr D was admitted to the intensive care unit (ICU), where he stayed from 8 to 20 December.

24. On 13 December Mr D was mobilised using a hoist, transferring him from bed to a chair and back again. He was seen after by the colorectal surgery team who noted the stoma looked healthy and pink and his abdomen was soft. On 14 December a CT scan showed a large haematoma (collection of blood) in the pelvic region with no signs of active bleeding. On 15 December the vascular surgery MDT discussed the images, noting a substantial gas filled haematoma that was not drainable percutaneously (through the skin).

25. On 17 December physiotherapists noted confirmation from the doctor that Mr D could weight bear, and on 20 December at another physiotherapy session, it is noted Mr D was transferred out from and back to bed.

26. On 20 December Mr D was transferred from the ICU onto a ward. At the ward round on 24 December, it is noted the wound ‘looks clear & stitches intact’. When a physiotherapist attended, they discussed exercises with Mr D and noted he was pleased to learn nurses could assist in sitting him out over the coming days.

27. At the ward round on 25 December the consultant notes there being succus entericus (intestinal fluid) in the midline wound, with a large volume of bowel content removed. The consultant first documents the impression of a high output fistula (an abnormal connection between two parts of the body that do not normally connect). A CT scan taken on 4 January 2024 confirmed a single fistula tract at the site of the midline surgical wound.

28. Images were reviewed at the colorectal MDT on 9 January where it was confirmed the margins following surgery were clear (indicating all cancerous tissue was removed) and Mr D was for follow-up only. Mr D remained an inpatient through to 7 June 2024, having what appears to have been a complicated post-surgical course, including issues with pelvic collections, thrombus (blood clots), a fistula, having total parenteral nutrition (all nutrition delivered via a feeding tube) for six months and needing prolonged bedrest.

29. After discharge Mr D had a whole-body PET scan on 17 June and a CT scan on 19 June both of which reported no convincing evidence or features to suggest local recurrence or recurrent metastatic disease. Mr D next had a CT scan on 21 August solely focusing on an ongoing area of pelvic collection. He had an MRI on 23 August which reported a 15mm nodule which was ‘highly suspicious for recurrence’.

30. MDT review of the images on 3 September advised a further MRI scan which was taken on 18 October, reporting a small, stable nodule that remained suspicious for recurrence. Further scans were taken including an MRI of the spine on 3 November.

31. On 31 December Mr D was seen by the consultant clinical oncologist who formally documented two areas of cancer recurrence, one within the abdomen and one on the left pelvic side wall. The oncologist documented three treatment choices whilst explaining this would not be curative and would be given to control the disease.

32. Mr D opted to have radiotherapy and the necessary arrangements were made. In the clinic letter, the oncologist wrote: ‘in hindsight he has likely had recurrence for at least eight or nine months probably in both sides’.

33. Mr D raised his complaint to the Trust. Remaining unhappy with the responses received, he asked us to investigate.

Chemotherapy 37. Mr D complains the Trust did not give him chemotherapy within three months of his first operation in May 2022. He says having understood from coverage he saw reported by the BBC, this is best practice for cancer patients.

38. Before his first operation in May 2022, Mr D received a course of chemoradiotherapy (chemotherapy and radiotherapy combined). He then had rectal surgery for a cancer classified as T3NxMO (disease that has grown through the muscle of the rectum to surrounding fat but has not spread to other organs).

39. Our oncology adviser confirms this was the appropriate treatment, in line with National Institute of Health and Care Excellence (NICE) guidance on colorectal cancer. This guidance says:

‘1.3.5 Offer preoperative radiotherapy or chemoradiotherapy to people with rectal cancer that is cT1-T2, cN1-N2, M0, or cT3-T4, any cN, M0.

1.3.6 Offer surgery to people with rectal cancer (cT1-T2, cN1-N2, M0, or cT3-T4, any cN, M0) who have a resectable tumour.’

and:

‘Adjuvant chemotherapy (chemotherapy after surgery) is not indicated in this situation, as per NICE guidance above, paragraph 1.3.15, for patients who have received neoadjuvant chemotherapy (chemotherapy before surgery).’

40. We hope to assure Mr D the treatment provided by the Trust was appropriate for his cancer classification, and as per NICE guidance, there was no clinical indication for chemotherapy after his surgery. We do not find evidence of any service failure here.

41. We know Mr D is concerned about this as he considers chemotherapy following surgery could have avoided the subsequent metastases in his pelvic region and the further cancer recurrence below his diaphragm, which has reduced his life expectancy. We asked our surgery adviser about this and share their following comments in the hope of providing further assurance to Mr D on this matter.

42. Our surgery adviser said rectal cancers that are locally advanced, as Mr D’s was, are quite complex. They explain the most important factor for survival is to achieve clear margins on surgical removal of the cancer. Records show this was achieved at Mr D’s first surgery. Records also show that he had cancer within the lymph nodes around the rectal wall/tumour at original staging. Our surgery adviser says after Mr D’s pre-surgical chemoradiotherapy these lymph nodes were sterilised, indicating the cancer had been removed from those areas.

43. Records show Mr D therefore achieved no cancer within those lymph nodes and clear histological margins following surgery, presenting the best possible chance for retaining a disease-free state. He very sadly still suffered recurrence, which our surgery adviser says indicates the highly aggressive nature of his particular type of cancer.

Scans 44. Mr D complains the Trust did not take action in line with guidance on scans taken between March and September 2024. He says at an oncology outpatient appointment in December 2024, he was advised of two areas of recurrence of likely eight- or nine-months’ duration. Mr D says the intra-abdominal mass seen on scans in late 2024 had appeared in earlier scans yet was not acted upon.

45. To first address Mr D’s specific complaint, our surgery and oncology advisers confirm that records show the Trust did act appropriately in response to the imaging reports provided across the period in question.

46. Our surgery adviser explains there is no national guidance that stipulates what should happen or in what timeframe in this circumstance, as it is ultimately dependent on the content of the reports and whether they warrant alternative or additional action. They advise that the following content from General Medical Council (GMC) ‘Good Medical Practice’ guidance would apply and was met in Mr D’s case:

‘15. You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: • Adequately assess the patent’s conditions…. Where necessary, examine the patient • Promptly provide or arrange suitable advice, investigations or treatment where necessary • Refer a patient to another practitioner when this serves the patient’s needs.’

47. In considering the period in question, Mr D remained an inpatient up to early June, meaning he continued to receive acute inpatient care between the CT scans taken from March to early June. Records show these scans were requested to monitor the pelvic collection that developed around the resection bed. Our surgery and oncology advisers both confirm that none of the four CT reports in this period noted anything concerning to have indicated any additional clinical need or action, nor any concern of cancer recurrence.

48. Shortly following discharge Mr D had a PET scan on 17 June and just one month later, a CT on 19 July. The PET was requested to assess if Mr D’s previous sepsis of unknown origin may have been cardiac in origin, and the CT was requested as a further check of the pelvic collection at the resection bed. Neither report was requested due to any sinister or concerning signs or symptoms related to cancer.

49. Both reports state there is no convincing evidence or features to suggest locoregional recurrence or recurrent, metastatic disease. Our surgery and oncology advisers again both confirm that as such, there was nothing reported to have suggested any need for additional or alternative clinical action.

50. It was due to Mr D’s further hospital attendances in August with pain and a discharging wound, that more scans were taken. Our surgery adviser confirms the Trust’s action was appropriate and in line with the GMC guidance outlined earlier, in conducting more scans to further investigate Mr D’s presenting symptoms. The requests for both CT on 21 August and MRI on 23 August were timely, and both surgery and oncology advisers again confirm the CT report did not note anything remarkable to have warranted additional or alternative action.

51. It was the report of the MRI on 23 August that first identified concern, reporting a 15mm nodule ‘highly suspicious for recurrence’. Due to this being reported, in line with GMC guidance the next appropriate clinical step was for MDT involvement, to consider this scan, to compare with previous scans and to determine the next steps.

52. This action was taken, as the MDT met on 3 September, when a further CT went ahead. The MDT compared the MRI with the multiple previous CTs and PET scans and determined a clinical plan. Our surgery and oncology advisers confirm this was reasonable and timely.

53. The MDT concluded there was a suspicion of a small focus of recurrence in the left lower pelvis. They suggested a further MRI in six-to-eight-weeks’ time, to assess if this progressed prior to commencing palliative treatment, with consideration for radiotherapy once pelvic sepsis was suitably controlled and recurrence confirmed.

54. Our surgery adviser explains this was again the appropriate action, to further investigate to confirm the current suspicions of recurrence. Some time is needed between these investigations to provide a reasonable comparator. Our surgery adviser says a six-to-eight-week follow-up was not unreasonable to accommodate for this, in line with GMC guidance.

55. The follow-up MRI was performed eight weeks later, on 18 October, in line with the MDT’s plan and enabling comparison to the previous MRI. This reported a stable small nodule in the left hemipelvis which remained suspicious for recurrence. Further investigations took place to enable a confirmed diagnosis, as outlined in the clinic letter of 31 December, which confirmed two areas of recurrence.

56. Our surgery adviser is satisfied that the evidence shows regular monitoring and appropriate action taken in a timely manner as required at each step, determined by each of the reports’ findings. Our oncology adviser also found nothing to indicate any service failure with the Trust’s action in response to those reported scans.

57. That said, we note the consultant’s statement in December that with hindsight, Mr D likely had recurrence for at least eight or nine months. Whilst we do not find evidence of any service failure in the actions taken by the Trust in response to the imaging reports, we moved on to ask our radiology adviser whether these images were reported in line with the relevant guidelines.

58. Our radiology adviser explains that reporters in the UK are advised by the Royal College of Radiologists’ guidance on interpretation and reporting imaging investigations. This states that:

‘A radiology report should be actionable and prompt appropriate care for the patient. It should answer the clinical question and include a tentative or differential diagnosis when an abnormality is seen and relevant negative observations if pertinent’.

59. Our radiology adviser explains radiology reports should encompass the findings in the current imaging, relate it to the clinical information and provide advice for action or potential diagnoses. Whilst accuracy of findings is understandably desirable, it is not referenced within the guidelines. Our radiology adviser explains this is because it is accepted that human error can occur and that interpretation of findings will differ between radiologists, and sometimes for the same reporter, if different evidence is available at the time of reporting.

60. We therefore do not find evidence of any service failure with the reporting of these images considering what is expected from the guidance. However, we then moved on to ask our radiology adviser whether Mr D’s cancer recurrence was wrongly missed in the reporting of any of these scans, to the extent it would be considered inappropriate to have not been reported sooner.

61. Our radiology adviser reviewed the images and their associated reports for more than the period in question, from January to December 2024. They explain there are two areas of recurrence in question: one in the area of cancer resection in the deep pelvis within/adjacent to the surgical field; another larger metastatic recurrence likely within a lymph node near to the inferior vena cava (the largest vein in the body).

62. Our radiology adviser finds the pelvic recurrence retrospectively visible within the June PET-CT scan as an area of tracer (contrast dye) uptake, but they explain it is small and near to the large pelvic fluid collection which also shows uptake. As such, they explain it is difficult to accurately attribute this to a recurrence. Our radiology adviser finds the same pelvic recurrence invisible on CT as it shares the same density as the surgical scar therefore cannot be distinguished from the surrounding tissue.

63. Considering the evidence, our radiology adviser says the area later known as the pelvic recurrence could potentially have been queried on the PET-CT taken in June but says this would have been a judgement call with a high false-positive rate. From the evidence presented, we cannot say that this not being reported at that time constitutes a service failure.

64. Realistically our radiology adviser says the earliest the pelvic area of recurrence could have been seen to a reasonable extent to be reported was on the August MRI, which is when it was first reported. We therefore do not find evidence of any service failure with the timeliness of the reporting of the pelvic recurrence.

65. For the lymph node recurrence however, our radiology adviser confirms its presence on multiple CT studies prior to the time it was first reported. They find it was first present on the CT taken in April and can be seen as increasing in size on CT images through to December. They confirm the lymph node recurrence also appears, showing uptake, on the PET-CT taken in June. Yet, it was reported for the first time on the PET-CT report in December 2024.

66. Considering the evidence, our radiology adviser considers this was missed, as it was clearly present on multiple studies, demonstrated size change, and is at a common location for metastasis from a colorectal cancer. We do find evidence of a service failure here.

67. In response to Mr D’s complaint, the Trust said this nodule was extremely difficult to appreciate, and having had many radiologists’ conduct a retrospective review, none were able to appreciate this nodule, showing how challenging the interpretation of the scan was. Our radiology adviser explains the nodule in question was small, but not sub-centimetre in size (it was approximately 20 x 10 x 15mm).

68. They explain sometimes there is confusion between collapsed small bowel and solid lesions but said this is clearly not a small bowel loop as it has no continuity with small bowel around it. They appreciate there could have been some confusion as to whether it was related to the ureter or urostomy but the join between the ureter and the urostomy is at least 5cm away from it and it is not related to the ureter.

69. We appreciate that it is easy to see things with retrospect, but given that this nodule was new, over 1cm in size, growing, and in a typical location for metastatic nodes from colorectal cancer, we reasonably consider most radiologists would conclude that this was a miss and should have been reported earlier.

70. We have identified that the lymph node recurrence should have reasonably reported from April 2024. We know that Mr D considers earlier identification, when the tumour was smaller and action at that time, may have improved his chance of recovery and he may have a better life expectancy. We have carefully considered the evidence and the impact of this.

71. Our radiology adviser considers if the nodule/lymph node had been reported in April, it would most likely have been considered non-specific (meaning not indicative of anything immediately suspicious or of concern) as Mr D was acutely unwell with his ongoing postoperative fluid collection. They explain that reactive lymph nodes can increase in size in this context.

72. Our oncology adviser also acknowledges the likely chance of it being reported as non-specific. Our surgery adviser comments similarly, stating that even had this nodule been reported at this earlier time, it would not necessarily have been wrong to have ascribed it to the circumstances of post-surgical recovery.

73. Considering the extensive surgery undertaken in December 2023, our surgery adviser says this would be expected to result in considerable post-operative swelling, haematomas, oedema (build-up of fluid) and more, as the body reacted and recovered. They consider any nodule seen earlier would not unreasonably have been considered the result of this and what was going on in the pelvis at that time.

74. Both our radiology and oncology advisers say had the lymph node/nodule been reported in April as we think it should have, the most likely cause of action would have been arranging follow-up imaging, either a CT or PET-CT.

75. Whichever method of imaging, just as we explained earlier, reasonably there would have been a period of wait as some time is needed between imaging to provide a reasonable comparator. Our oncology adviser explains there are no guidelines that stat how soon the next scan should be. Our lead clinical adviser says the timings of scans and decision on the next steps of a management strategy are things generally decided by a cancer MDT. They explain those MDTs are attended by radiologists, surgeons and oncologists, amongst others, and they discuss between them how best to proceed.

76. Our lead clinical adviser explains there are often differences of opinion, and standards/guidelines do not often lend themselves to individual patient circumstances. Our oncology adviser considers it likely the follow-up scan would have taken place around twelve weeks later, around mid-July, and we do not see anything to suggest this wouldn’t have been timely.

77. Our radiology adviser has seen evidence of this nodule growing in the CT imaging that was taken across this period. We can therefore say with this evidence-base, that a repeat scan in mid-July completed to specifically look at this nodule further, would have shown that it had grown and from this, provided an initial suspicion of recurrence.

78. Instead, this suspicion was first raised one month later, in the MRI report in mid-August. As we have explained earlier and to reiterate here, our oncology, surgery and lead clinical advisers confirm the actions taken from then were appropriate as the further investigations and time they took were necessary to enable a confirmed diagnosis. These investigations and the time they took would still have been needed, even had a mid-July scan been taken focusing on this nodule and reporting a size growth.

79. We therefore think if not for this failing, Mr D’s cancer recurrence would likely have been diagnosed one month sooner than it was. We recognise Mr D’s view on the impact of earlier identification. Sadly, our oncology and lead clinical advisers do not consider an earlier diagnosis of one month here would have been so significant to have had any difference to his prognosis or outcome.

80. Whilst we cannot see that this would have had made any clinical impact, we recognise knowledge of this service failure will likely cause Mr D otherwise avoidable distress. We also recognise he has been caused distress in considering whether this may have had a more significant impact on his outlook.

81. We can see that in response to his complaint, the Trust acknowledged the challenge in interpreting these scans, just as we have acknowledged the extent of what was happening at a time Mr D remained unwell and was recovering from extensive surgery. It sincerely apologised to him for the delay in the diagnosis of his recurrence, acknowledging the significant emotional and physical distress this has caused. The Trust also said the imaging department would take these incidents to their next radiology event and learning meeting, to learn from these reviews.

82. We are encouraged by the response already provided by the Trust. It remains we have set recommendations to ensure the Trust fully recognises what we have found, and to provide assurance of the stated action taken, to remedy the impact.

Physiotherapy 83. Mr D complains the Trust moved him by hoist on 13 December 2023, too soon after his operation and in a way that was not in line with guidance. He says he was moved from bed out to a chair and back again just seven days after major surgery, that being hoisted resulted in him being swung, and he believes the movement was performed by nursing staff who didn’t move him in line with guidance.

84. We hope to assure Mr D we do not find anything documented to suggest the decision to mobilise was too soon or that it was not clinically appropriate. Our physiotherapy adviser explains the timing of the decision to mobilise is a medical one, for the surgical team to have directed, and it is clearly documented to have been a consultant-led decision. Records show Mr D was only mobilised once this consultant-led decision was made.

85. As NHS website guidance about what should happen after surgery explains:

‘The sooner you start to move around, the better. Lying in bed for too long can cause some of your blood to pool in your legs. This puts you at risk of a blood clot.’

86. Information on the Macmillan website specifically about recovering from bowel cancer surgery says:

‘After surgery for bowel cancer, you will be encouraged to start moving around as soon as possible. Even if you have to stay in bed, it is important to do regular leg movements and deep-breathing exercises. A physiotherapist or nurse will explain these to you.

After your operation, a nurse will usually help you to get out of bed or to sit up for a short time. Gradually, you will be able to sit or stand up for longer, and to start walking around the ward.’

87. This aligns with NICE guidance on rehabilitation after critical illness, which states:

‘Rehabilitation should start as early as possible during the critical care stay and continue throughout the recovery pathway.’

88. The guidance specifies that rehabilitation should be individualised and clinically appropriate, and this includes physical rehabilitation:

‘Provide an individualised and structured rehabilitation programme, including physical rehabilitation, tailored to the patient’s needs and clinical condition.’

89. Importantly, this NICE guidance frames rehabilitation decisions around clinical stability rather than diagnosis or surgical status: ‘Decisions about rehabilitation interventions should be based on the patient’s physiological stability and overall clinical condition.’

90. It explicitly supports mobilisation in ICU after major surgery where the patient is deemed clinically stable, and reinforces the importance of early, active rehabilitation:

‘Adults who have had critical illness start an individualised rehabilitation programme as early as possible to minimise complications and support recovery.’

91. Our physiotherapy adviser explains this reflects national expectations to reduce complications such as ICUacquired weakness, functional decline, and prolonged recovery associated with immobility.

92. Considering all the above cited information and guidance, this makes clear the decision to mobilise should account for the patient’s individual circumstances, and mobilisation should commence as soon as the patient is deemed clinically stable and able to tolerate it, even sometimes when still in ICU.

93. Our physiotherapy adviser explains this is because there is a greater risk of problems developing the longer a patient remains bed bound – muscle atrophy, joint stiffness, circulatory issues, skin integrity problems, metabolic changes, for example. They explain the muscular system is impacted the most, that it can only take a few days for muscles to weaken to the extent patients can lose their ability to weight bear. ICU paralysis syndrome can result and can itself lead to further problems and increasing negative outcomes.

94. Mobilisation does not equate to walking, as just moving out from a bed and into a chair can activate the muscles and other bodily systems to promote healing and reduce the risk of problematic issues occurring.

95. Considering the recorded evidence, both our surgery and physiotherapy advisers confirm the decision for Mr D to mobilise on 13 December was clinically appropriate and in line with guidance, and records evidence physiotherapists acted in line with this.

96. In line with the NICE guidance, evidence shows Mr D was clinically stable and suitable to attempt to safely mobilise, which took the form of transferring him into a chair using a hoist. Our surgery adviser explains the use of a hoist is typically the safest and least damaging way of lifting or transferring a patient in this context.

97. The use of hoists was therefore appropriate. The physiotherapist who hoisted Mr D out of bed and into the chair documented the whole process, and our physiotherapy adviser confirms this demonstrates appropriate use of hoists in the transfer. There is no documentation of Mr D’s transfer back to bed and so we are left without evidence of what this involved and what occurred.

98. This should be fully documented and is not. Our physiotherapy adviser explains that unfortunately, this is a common occurrence. It is typically physiotherapists who get the patient out of bed during their attendance, they document their involvement and note as a handover for the healthcare assistant (HCA) or nurse what period of time that patient should sit out and when they should be mobilised back to bed. It is then typically HCA or nursing staff who mobilise patients back to bed, on the physiotherapist’s instruction.

99. Our physiotherapy adviser explains this is not unreasonable and is appropriate for the HCA or nursing team to follow those physiotherapy instructions. Due to this being common practice, HCA and nursing teams are fully versed in the use of hoists to complete such transfers and do so as a routine part of their role.

100. It appears in Mr D’s case, as is often seen, whilst the physiotherapist transferred him to the chair and documented this, the HCA or nursing team did not then document the process of transferring him back. Whilst we can see evidence of appropriate use of hoists and appropriate transfer without any noted problem or concern when being moved to the chair, we are left without evidence of the transfer back to bed, what this involved and what occurred.

101. We do not find evidence of service failure in the process of transfer from the records we have, but we take this opportunity to highlight to the Trust this lack of documentation, resulting in a lack of accountability for what happened on Mr D’s return transfer.

102. That said, our physiotherapy adviser says what would be reasonable to see documented is simply that Mr D was transferred using a hoist with the assistance of two. From his own account, he recalls there were two members of staff who performed this task using a hoist. As such we find assurance in that Mr D’s own recollection supports that hoists were used which was appropriate, by staff members who would routinely undertake this task, and with the expected number of staff involved.

103. Mr D’s concern is that being mobilised too soon and in improper fashion exacerbated his wound which split open on 25 December 2023, leading to the development of an inoperable fistula. We recognise how much of an impact the fistula has had on Mr D and can understand the reasons for his concerns about being mobilised.

104. It remains, we do not find evidence of any service failure with the decision to mobilise and its timeliness, or with the manner of mobilisation performed. In attempts however to further assure Mr D, we share that our physiotherapy adviser explains it is highly unlikely there is any connection between his mobilisation from 13 December and the development of his fistula, identified on 25 December. This is unfortunately a well-known complication of abdominal/bowel surgery, and most likely its cause.

1. We have carefully considered Mr D’s complaint. We do not see any concern with the Trust not providing chemotherapy after Mr D’s surgery in May 2022, or with the timing or manner of him being moved by hoist in December 2023.

2. We also do not see any concern with the Trust’s action in response to imaging reports between March and September 2024. However, we do find the reports missed an earlier identification of the nodule that was later identified as the pelvic recurrence of his cancer.

3. Had this been done, considering the likelihood of what would have been seen and the appropriate next steps required, we think Mr D’s cancer recurrence would have been diagnosed one month sooner than it was. Sadly, we do not consider this period so significant to have had any impact on Mr D’s prognosis or outcome.

4. Yet, we recognise knowledge of our decision of a misreporting and potential earlier diagnosis will cause Mr D otherwise avoidable distress. We partly uphold this complaint and have set recommendations for the Trust to remedy this impact.

5. We know how considerably Mr D and his family have been affected by these events, both at the time, and still to this day. We hope our report fully explains the reasons for our decision and provides Mr D some resolution.

105. We make recommendations in line with our Principles for Remedy, which are reflected in NHS Complaints Standards. These state that where poor service or maladministration has led to an injustice or hardship, the organisation responsible should take steps to put things right.

106. In line with this, we recommend that by 18 August 2026, the Trust should write to Mr D to acknowledge the failing we have identified, as set out specifically at paragraphs 66 and 69 and apologise to him for the impact this caused, as set out specifically at paragraphs 80 and 82.

107. NHS Complaints Standards state that public organisations should look for continuous improvement and use the lessons learnt from complaints to make sure they do not repeat poor service or maladministration.

108. In line with this, we recommend that by 4 September 2026, the Trust should produce an action plan to address the failing we have seen. It should explain what action it will take, or has already taken, to learn from and prevent a repeat of the failing; this can include information on what happened at and what the outcome was from the radiology event and learning meeting. For each action it should state who is responsible for it, give a timescale, and explain how it will monitor this.

109. The Trust should provide a copy of the action plan to Mr D. It should send us a copy of the action plan and the letter it sends to Mr D. It should also send an anonymised copy of our final report and its action plan to the Care Quality Commission (send to safeguarding@cqc.org.uk) and NHS Improvement (send to enquiries@improvement.nhs.uk).