Barts Health NHS Trust

4. Mr B complains the Trust missed opportunities to diagnose his father, Mr L’s lung cancer relapse between May 2023 and January 2024. He specifically says it did not carry out the correct diagnostic tests and failed to promptly act on the results of the biopsies it carried out during this timeframe.

5. Mr B says this led to a delay in diagnosing his father’s relapse which meant when a diagnosis was made, nothing could be done for him. He says he suffered terribly and died earlier than he should have done. He also says it had a devastating impact on their family and his father missed out on spending his final months at home and meeting his grandchild. Mr B wants an acknowledgement, apology and service improvements.

6. Mr L had a history of Multiple Sclerosis (MS), which is a long-lasting disease where the body's immune system attacks the brain and spinal cord. In 2018 the Trust diagnosed him with lung cancer in his left lung which had spread to his spine.

7. It provided him with cancer treatment which included a combination of chemotherapy, immunotherapy and surgery. Mr L only completed two cycles of immunotherapy as he had a severe reaction to it. Mr L also paid for private cancer treatment in 2018 before transferring his care back to the Trust in 2019. The Trust provided him with further cancer treatment to kill remaining cancer cells and lower the chance of cancer recurrence.

8. Once it completed his treatment the Trust considered Mr L to be in remission, which means a temporary or permanent lessening of disease symptoms. The Trust closely monitored Mr L, and its lung oncology team carried out regular scans.

9. In 2021 and 2022 the Trust carried out several spinal surgeries for Mr L, which included inserting metal, to stabilise his spine. In January 2023 the Trust carried out a scan of Mr L’s chest and abdomen. It indicated no worsening or improvement compared to previous scans.

10. It carried out a further scan in May and noted suspicious changes which suggested cancer recurrence in the upper part of Mr L’s left lung.

11. Between June and December, the Trust discussed Mr L at several multi-disciplinary team meetings (MDT) and carried out several investigations. An MDT meeting is where a group of different medical experts such as surgeons, oncologists, radiologists, and specialist nurses meet to review a patient's test results and agree a plan for patients.

12. It did not find any evidence to confirm cancer recurrence or cancer spread in this period. Alongside these investigations, Mr L presented to the Trust’s emergency department (ED) in July and it admitted him with a suspected fracture in the metal work in his spine. It carried out further surgery on his spine in August.

13. In January 2024 it carried out further investigations which confirmed a recurrence of cancer in Mr L’s left lung. The Trust provided him with his first cycle of immunotherapy in early February. In early March it identified Mr L’s cancer had spread to his brain. It provided him with two further cycles of immunotherapy in March and April. He sadly died in mid-April. Mr L remained an inpatient at the Trust between July 2023 and April 2024.

16. Mr B says the Trust missed opportunities to diagnose his father’s lung cancer relapse between May 2023 and January 2024. He specifically says it did not carry out the correct diagnostic tests and failed to promptly act on the results of the biopsies it carried out during this timeframe. He says the delayed diagnosis meant his father suffered and he died sooner than he should have done. We are sorry to hear about the devastating impact Mr L’s death has had on his family.

17. NICE guidance says choose investigations that give the most information about diagnosis and staging with the least risk to the person.

18. In early May 2023, the Trust began investigating a possible recurrence of Mr L’s lung cancer after a contrast computed tomography (CT) scan of his chest, abdomen and pelvis showed suspicious findings in his left lung. A contrast CT scan is an X‑ray test that uses a special dye to make blood vessels, organs and abnormal areas, such as tumours or infections, show up more clearly.

19. NICE guidance says people known or suspected to have lung cancer should be offered a contrast CT scan of the chest, including views of the liver, adrenal glands and lower neck, to help confirm the diagnosis and assess how far the disease has spread.

20. Given Mr L’s history of lung cancer, the Trust’s decision to use a contrast CT scan to monitor him for recurrence in early May appears to be in line with this guidance. It does not appear this contrast CT scan included his lower neck as NICE recommends. However, the Trust carried out a further scan in June which covered his whole body including his neck. We have explained this in more detail below.

21. The Trust discussed his case at an MDT meeting in mid‑May and decided to carry out a positron emission tomography (PET) CT scan to clarify what treatment, if any, was required. The Trust performed the PET‑CT scan in mid‑June.

22. A PET‑CT scan is a combined imaging test. The PET part shows how cells and tissues are working, and the CT part shows the physical structure of the body. Together, they help doctors see both the size and position of any abnormal areas and how active they are. The scan showed a new mass in the upper part of Mr L’s left lung and suspicious activity in the lymph nodes in his neck.

23. The Trust’s decision to use a PET‑CT at this stage appears consistent with the NICE guidance to confirm any abnormal changes outside the area covered by the CT scan and plan any potential treatment.

24. At a further MDT in late June 2023, the Trust discussed the findings from the PET-CT scan and planned an EBUS (endobronchial ultrasound‑guided needle biopsy) to obtain tissue samples to test for cancer. It carried out the EBUS in early July. An EBUS is a minimally invasive procedure where a thin tube with a camera and an ultrasound probe is passed down the windpipe to take tissue samples from nearby lymph nodes or abnormal areas. The samples the Trust obtained during Mr L’s EBUS did not show any evidence of cancer.

25. NICE guidance says EBUS should be offered to obtain samples from abnormal areas. The decision to use EBUS in this situation appears in line with the guidance to gain more information for a potential diagnosis.

26. A few days after the EBUS in early July, the Trust admitted Mr L with a suspected fracture of his spinal metalwork. It carried out a contrast CT scan of his spine, which showed signs of infection around the metalwork. The Trust prescribed antibiotics for this. The scan also incidentally showed the mass in his lung had grown compared with images from May. We recognise this was a worrying time for Mr L.

27. Later in July, the Trust’s oncology team informed Mr L the EBUS samples did not show cancer. They explained that further diagnostic tests were needed but, given the negative findings so far, they recommended waiting until he had recovered from his spinal infection before doing more invasive investigations.

28. It is important to note the Trust treated Mr L for sepsis at this time, which is a life-threatening medical emergency which happens when the body has an extreme reaction to an infection. It also treated him for a chronic bone infection in his spine. This required a prolonged course of strong antibiotics and spinal surgery to treat his spinal infection and the problems with his metalwork. The surgery resulted in partial loss of movement in his lower body. Our adviser explains for these reasons he was not well enough to have further investigations for possible cancer recurrence at this time.

29. After his spinal surgery in late August, the Trust carried out another CT scan in early September. This scan showed a mild change in the mass in his left lung. At an MDT meeting later in September, the Trust decided to proceed with a CT‑guided biopsy and performed this towards the end of September.

30. A CT‑guided (image‑guided) biopsy is a procedure where doctors use CT scan images to guide a fine needle through the chest wall into an abnormal area in the lung to obtain tissue samples. This helps them confirm a diagnosis and plan the most appropriate treatment. The biopsy samples taken in late September showed no evidence of cancer.

31. NICE guidance says a CT‑guided biopsy should be offered when the abnormality is in the outer part of the lung, which is where the mass was in Mr L’s lung, to help plan the most appropriate treatment. The Trust’s use of CT‑guided biopsy at this stage therefore appears consistent with the guidance, to further inform its suspicion of cancer despite previous negative test results.

32. The oncology team discussed the results with Mr L at the end of October. They explained there was no evidence of cancer and planned his next surveillance CT scan for the following month.

33. Our adviser explains the Trust’s plan was reasonable at this point given there was no definite evidence of recurrent cancer and he still needed treatment for his chronic spinal infection whilst undergoing rehabilitation.

34. The Trust carried out a follow‑up contrast CT scan at the end of November. This scan showed further growth in the lung mass. It discussed Mr L again at an MDT in mid‑December and decided to carry out a further biopsy. The Trust completed a second CT‑guided biopsy about a week later. The tissue samples, again, showed no evidence of cancer.

35. The Trust held another MDT in early January 2024 and arranged a repeat PET‑CT scan, which it carried out about a week later. This PET‑CT scan showed active disease in the area of the lung mass. Two days after the scan, the Trust performed another CT‑guided biopsy. This biopsy confirmed recurrence of cancer in Mr L’s left lung. We recognise how upsetting this must have been for Mr L and his family, particularly given the previous negative results.

36. Mr L had a long and complex cancer history, complicated by ongoing infection. Our adviser says even when the Trust confirmed Mr L’s cancer recurrence it was still treating him for a chronic infection and he had a reduced performance status. Performance status is a score (usually from one to four) used by doctors to measure how well a patient can perform daily activities and care for themselves.

37. The Trust recorded Mr L’s performance status as three in July 2023, and it does not appear this improved throughout his admission. A performance status score of three indicates someone is confined to a bed or chair for more than half the day. Our adviser explains this along with his ongoing infection, put him at high risk of complications of treatment throughout his admission.

38. Based on the evidence, the Trust’s actions overall appear to be in line with relevant NICE guidance, from when it suspected a possible recurrence of lung cancer in May 2023. We can see the Trust arranged a contrast CT scan, followed by a PET‑CT scan and then an EBUS biopsy, all of which NICE recommends. Although the May contrast CT scan does not appear to have included Mr L’s lower neck, we can see the PET-CT scan included his neck and the Trust took tissue samples from the abnormal area in his neck during the EBUS in July. Therefore, this limitation does not appear to have impacted his overall diagnosis or treatment.

39. The NICE guidance does not specifically set out the timeframes for investigations or what to do if there remains a suspicion of cancer despite negative biopsy results. However, when the initial tests did not show cancer, the Trust balanced the need for further investigations against Mr L’s significant clinical problems, including sepsis and a serious spinal infection, for which he required urgent treatment, prolonged antibiotics and major surgery.

40. The Trust continued to be concerned about possible cancer recurrence. Therefore, as his condition allowed, the Trust continued to investigate the suspicious lung mass with repeat CT scans, CT‑guided biopsies and a further PET‑CT scan, all of which are consistent with NICE guidance on investigating suspected lung cancer and planning treatment. Based on the evidence we have seen, it does not appear the Trust carried out incorrect diagnostic tests when investigating the suspicious area in Mr L’s lung.

41. It confirmed Mr L’s recurrence of cancer in January 2024. The Trust carried out several earlier biopsies which did not confirm evidence of cancer. Given his complex cancer history, ongoing infection and reduced performance status, the Trust appears to have carefully considered which investigations to do and when, to maximise information and minimise risk to Mr L. Which is in line with NICE guidance. For these reasons, we do not consider the Trust unreasonably delayed acting on the results of his biopsies or missed earlier chances to diagnose the relapse.

42. In reaching this decision, we are in no way underestimating the impact Mr L’s death had on Mr B or their family. We are sorry we cannot take further action on his complaint and acknowledge how disappointing this will be for him.