Guy's and St Thomas' NHS Foundation Trust

4. Miss V complains about the care she received from Guy's and St Thomas' NHS Foundation Trust, which was responsible for her transplant care until early 2024. She complains that the Trust:

• failed to investigate urinary and gynaecological symptoms she reported in 2022 • failed to detect a bladder tumour that was visible on an MRI scan in August 2023.

5. She was diagnosed with bladder cancer in March 2024, following an MRI arranged by a different Trust.

6. Miss V believes that if the Trust had acted sooner, her cancer may have been diagnosed earlier. She says this could have avoided the need for full bladder removal or reduced the severity of long-term complications.

7. Miss V is seeking:

• clear explanations for the missed diagnosis • service improvements to prevent similar issues for others • a financial remedy, if we consider one appropriate.

8. Miss V has a complex medical history. She had acute myeloid leukaemia (a type of blood cancer) as a child and later had a heart transplant. The Trust took over her transplant care in 2018.

9. In January 2022, Miss V told the transplant team she was passing urine more often than usual. In October 2022, she told the team about abnormal vaginal bleeding. Her GP was also involved in investigating her gynaecological symptoms.

10. In July 2023, the transplant team noted new prominent veins around Miss V’s abdomen and hip. It arranged an MRI scan of her abdomen and pelvis to investigate these. The Trust carried out the scan in August 2023, but the report did not identify a bladder mass.

11. In March 2024, an MRI scan arranged by another hospital identified a bladder tumour. The Trust later reviewed its August 2023 MRI and confirmed the tumour had been present on the scan but had not been identified at the time.

Failed to investigate urinary symptoms she reported in 2022

15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation got something wrong and whether this caused an injustice. We do this by comparing what should have happened with what did happen.

16. Miss V says the Trust did not properly investigate urinary symptoms she reported in 2022. She believes that if the Trust had investigated these symptoms further, it may have found her bladder cancer sooner and she may have avoided long-term complications she has experienced.

17. The GMC guidance says doctors should adequately assess a patient's condition, taking account of their medical history and symptoms. It also says they should promptly arrange suitable investigations or treatment where necessary and refer a patient to another suitably qualified practitioner when this serves the patient's needs.

18. In January 2022, Miss V told the transplant team she was passing urine more often than usual. The Trust sent a urine sample for testing. The results did not show an infection or blood in her urine. Miss V did not report any urinary symptoms after this point.

19. Our cardiology adviser explained that testing Miss V's urine was a reasonable response to the symptoms she reported at that time.

20. We consider the Trust acted in line with the GMC guidance because it investigated her urinary symptoms. As the results were negative, and she did not report any further urinary symptoms, it was appropriate that no further investigations were conducted.

21. We have therefore seen no indications of a failing in how the Trust investigated her urinary frequency in January 2022.

Failed to investigate gynaecological symptoms she reported in 2022

22. Miss V says the Trust did not properly investigate gynaecological symptoms she reported in 2022. She believes that if the Trust had investigated these symptoms further, it may have found her bladder cancer sooner and she may have avoided long-term complications she has experienced.

23. In September 2022, Miss V saw her GP after experiencing abnormal vaginal bleeding. She told her GP that she had recently had three periods close together within two weeks, and these periods were heavy with some clots. She said that she had previously had six weeks without a period prior to this. Her GP arranged blood tests and an ultrasound scan. The blood tests were normal.

24. Miss V told the transplant team about the bleeding during a video appointment in October 2022. The records say the bleeding and discharge had lasted for a week and had stopped around two weeks before the appointment. Miss V also told the Trust that her GP had arranged blood tests and an ultrasound.

25. The GMC guidance says doctors should adequately assess a patient's condition, taking account of their medical history and symptoms, and they should promptly arrange suitable investigations or treatment where necessary. It also says that doctors should contribute to the continuity and coordination of care between healthcare providers.

26. As Miss V's GP was already investigating these symptoms, Miss V had already had suitable investigations arranged. Therefore, we do not consider the Trust needed to repeat the same investigations.

27. In line with the GMC guidance on continuity and coordination of care, the Trust wrote to the GP and asked to be sent the results from the ultrasound. This shows the transplant team intended to consider the outcome to ensure Miss V was receiving the correct care depending on the results.

28. The Trust did not receive the ultrasound result and did not follow this up. Also, when Miss V spoke to the Trust briefly in April 2023, after she missed a scheduled telephone appointment, the Trust did not ask Miss V about the ultrasound result.

29. Our cardiology adviser explained that chasing the ultrasound result was particularly important because the transplant team should have been aware of Miss V's previous cancer and the increased risk of cancer associated with immunosuppression following a transplant.

30. We consider that to ensure continuity of care, the Trust should have followed up the ultrasound result after specifically asking to see it. Its failure to do so was not in line with the GMC guidance and is an indication of a failing. We have therefore considered what difference this made to Miss V's care.

31. The GP received the ultrasound result on 18 October 2022. The scan was reported as normal. On 7 November, the GP sent Miss V a message telling her the result was normal. Therefore, if the Trust had chased the result as it should have done, it would have received a reassuring result.

32. The records also show Miss V had been referred by her GP to gynaecology, for an unrelated issue, and had an appointment in February 2023, which she did not attend. The gynaecology service wrote to her GP in March saying it had discharged her but that she could be referred again if she still needed to be seen.

33. Our cardiology adviser explained that if the ultrasound was normal and Miss V was not continuing to report symptoms, no further action was required, and routine follow-up would have been appropriate.

34. We have carefully considered the records for the period after October 2022. They do not show Miss V reporting further abnormal vaginal bleeding to the Trust or her GP. We recognise this does not necessarily mean she was no longer experiencing symptoms. It means the information available to the clinicians caring for her did not indicate that the bleeding was continuing.

35. As Miss V missed her follow up telephone appointment in April, a face-to-face appointment was arranged for July 2023. During this appointment the Trust noted prominent veins around Miss V's abdomen and hip. They discussed this with a radiologist and arranged an MRI of her abdomen and pelvis to investigate the cause. We will address the reporting of this scan below.

36. We recognise Miss V believes her symptoms should have led the Trust to investigate cancer sooner. We also recognise how difficult it must be for her to know, following her later diagnosis, that the tumour was already present at this time.

37. Whilst we have seen an indication of a failing with the Trust not chasing the ultrasound result, if it had done this, it would have been reassured by the normal result. Miss V did not report any further abnormal vaginal bleeding, and alongside that normal result, would not have indicated that the Trust needed to take different action before the new concern arose in July 2023.

38. We therefore have not seen an indication of a failing with the Trust’s assessment of Miss V’s gynaecological issues, and we cannot say that the Trust's failure to follow up the ultrasound result caused a delay in diagnosing Miss V's bladder cancer or the impact she has described.

Failed to detect a bladder tumour that was visible on an MRI scan in August 2023

39. In July 2023, clinicians at the Trust noted new prominent veins around Miss V's abdomen and left hip. They discussed this with a radiologist and arranged an MRI scan of her abdomen and pelvis to investigate the cause.

40. The MRI was carried out on 14 August 2023. The clinical information provided to the radiologist explained that Miss V had developed new varicose veins around her lower abdomen and left hip. The scan was therefore primarily looking for a vascular cause.

41. The radiologist reported an obstruction of veins in Miss V's pelvis and upper leg. The report did not identify a bladder mass.

42. In March 2024, an MRI arranged by another Trust to investigate the cause of hip pain identified a bladder tumour. The Trust subsequently reviewed the August 2023 MRI and accepted that the tumour had been present on that scan but had not been identified at the time.

43. Miss V believes the Trust should have identified the tumour in August 2023. She says this delayed her diagnosis by more than seven months and believes an earlier diagnosis may have resulted in less invasive treatment and fewer long-term complications.

44. The RCR guidance says radiologists should look at the whole scan, not just the part related to the main clinical question. It also says they should focus on important findings, explain any relevant unexpected (incidental) findings, and avoid including irrelevant details that could distract from the main message or lead to unnecessary tests.

45. We asked our radiology adviser to review the August 2023 scan and say whether the bladder tumour should reasonably have been identified at the time. They explained there were several factors which made this particularly difficult.

46. They said the tumour did not have the usual appearance of a bladder tumour. It arose from the bladder wall rather than its inner lining and was next to the bowel, meaning it could have been mistaken for surrounding structures. They also said Miss V was unusually young to have this type of bladder tumour. In addition, artefact (distortions or anomalies in imaging scans that do not represent real anatomical structures) on some of the MRI images partly obscured the mass.

47. Our radiology adviser also explained that the MRI had been requested to investigate a vascular problem following Miss V's transplant care. The clinical information provided with the request referred to the new abdominal and hip veins and did not suggest a suspected bladder tumour.

48. They explained that, with hindsight and knowledge of Miss V's later diagnosis, the mass can be identified on the August 2023 MRI. However, reviewing a scan retrospectively with knowledge of the diagnosis is different from interpreting it at the time. They considered that a reasonable number of radiologists, including radiologists experienced in cancer imaging, could also have missed this unusual mass.

49. We recognise how difficult it must be for Miss V to know that the tumour was present in August 2023 and in hindsight could be seen on the scan. Our role is to consider whether it should reasonably have been identified based on the information available and the circumstances at the time, rather than whether it can be identified with hindsight.

50. Having considered the imaging, the circumstances in which the scan was requested, and our independent radiology advice, we consider the Trust’s reporting of the scan was in line with the RCR guidance and we do not consider it a failing that the Trust did not identify the bladder tumour on the August 2023 MRI scan.

51. The Trust has since reviewed the scan through its Radiology Education and Learning Meeting so that learning could be shared. Our radiology adviser explained that this is consistent with the expectation that clinicians reflect on their practice and learn from cases where abnormalities have potentially been missed.

52. We therefore will not consider this part of Miss V's complaint further.

53. We understand why Miss V feels that the Trust should have diagnosed her cancer earlier. We appreciate that this has been a difficult time for her. We appreciate that this may not have been the decision she was expecting, but we thank her for bringing her complaint to our attention.

1. We have carefully considered Miss V complaint about the Trust. We recognise how difficult it must be for her to know that the bladder tumour was present before it was diagnosed in March 2024, and the distress this has caused her.

2. After reviewing the available records, relevant guidance and independent clinical advice, we have seen an indication of a failing in the Trust not following up an ultrasound result it had requested from the GP. We have not seen an indication that this failing caused a delay in Miss V’s cancer diagnosis.

3. We have seen no indication of failings in the Trust’s investigation of Miss V’s urinary symptoms or in its failure to identify the bladder tumour on the August 2023 MRI scan. We will therefore not be taking any further action on this complaint.