12. Miss C complains the Trust failed to act on abnormal chest X-rays from July 2014 and May 2015. She says this caused a delay in diagnosis which in turn led to the disease progressing and her father’s death.
13. The GMC’s Good Medical Practice sets out the responsibilities of a doctor. It says doctors must contribute to the safe transfer of patients. This means doctors must ‘share all relevant information with colleagues involved in your patient’s care within and outside the team… [and] check, where practical, that a named clinician or team has taken over responsibility when your [the doctor’s] role in providing a patient’s care has ended’.
14. We understand the Trust has a system setting out responsibility for patient care. A patient is admitted from the Emergency Department to hospital under the care of a doctor. Responsibility for reviewing investigations (such as X-rays) passes from the Emergency Department to the doctor. Our clinical adviser said this is a relatively common system.
15. When Mr C was seen in July 2014, the Emergency Department requested a chest X-ray. He was then admitted under the medical team. In line with the GMC guidance, the Emergency Department should have notified the medical team that a chest X- ray had been requested or undertaken. In line with the Trust’s own system, after Mr C was admitted under the medical team, the responsibility for reviewing the results of the chest X ray passed to them. There is no evidence that the chest X ray, or the report, were ever reviewed.
16. In May 2015, a chest X-ray was again requested by the Emergency Department. Mr C was then admitted under the medical team. Again, the responsibility for reviewing the results of the chest X-ray passed to the medical team following Mr C’s admission. On this occasion, the X ray report was sent to the Emergency Department, who noted on the report ‘patient admitted under medics’. The Trust took no further action despite the report noting a ‘clinically important radiological finding’.
17. We have found the Trust failed to act in line with the GMC guidance and its own system. On two occasions, nobody took responsibility for reviewing the X-ray image or the report. This is a serious failing. Our clinical adviser said there is an obvious abnormality visible on both the X-ray images. This had been identified by the Trust on both X-ray reports.
18. The GMC’s Good Medical Practice says doctors must provide a good standard of practice and care. It says if doctors assess, diagnose or treat a patient, they must ‘adequately assess the patient’s condition… promptly provide or arrange suitable advice, investigations or treatment where necessary [and] refer a patient to another practitioner when this serves the patient’s needs’.
19. If the Trust had reviewed the X-ray images or the reports, it should have taken action in response to the abnormality. Our clinical adviser said this could have been in the form of a repeat chest X-ray six to eight weeks later (to check that the abnormality noted was not an infection), or a CT scan and referral to the cancer team. Because the Trust did not review the X-ray images or report, it did not take the action it should.
20. Our clinical adviser said on the balance of probabilities, had either of the X-rays been reviewed, lung cancer would have been diagnosed. There was a clear abnormality visible on the image and it had been noted on the report. Additionally, in 2015, the Trust noted the abnormality had progressed since 2014. Because the Trust failed to act on the abnormality, no action was taken. We have gone on to consider the impact of this.
21. In 2014, the chest X-ray report described the tumour as being 2.5cm by 1.3cm. Based on the information available, our clinical adviser said it was likely this was stage one cancer. There was a small tumour which was wholly within the lung, and which had not spread any further. (Cancer Research UK (CRUK) describes stage one cancer as being small (less than 4cm) which has not spread to the lymph nodes or other distant organs.)
22. The 2015 chest X-ray report does not provide a measurement of the tumour, but it is noted to be larger than it had been in 2014. Our clinical adviser said it is not possible to be very accurate in terms of measurement, but the X-ray does show a slightly larger mass. Our clinical adviser said the lung cancer could still have been at stage one, but that is it possible it had started to spread to local lymph nodes. If it had done, then it would have become a more advanced stage of the disease, a stage two cancer. (CRUK describes stage two lung cancer as being up to 5cm, and if lymph nodes are involved, they are close to the affected lung.)
23. We cannot rule out that Mr C had stage two cancer in 2014 or 2015. As no further investigations were undertaken at these points we have limited information available to help us understand the status of his cancer. For example, we do not know whether the cancer had spread to the lymph nodes, making it a stage 2 cancer, in 2014 or by 2015.
24. We do know that in 2014 the tumour appears to be less than 4cm, which is suggestive of a stage one cancer. In addition, our clinical adviser noted Mr C lived for several years after the first X-ray. This would have been unlikely if the cancer had already spread outside of the lungs in 2014. Our adviser said if this were the case Mr C would have presented with symptoms of metatastic cancer much sooner than 2017. The average survival for an individual with stage four lung cancer is less than one year. (CRUK describes stage four lung cancer as having spread. It can involve both lungs, the covering of the lungs or heart, or the fluid around the lungs can contain cancer. The cancer can spread to the lymph nodes or other organs, such as the liver or brain. It can also spread to several areas in one or more organs). By the time Mr C was eventually diagnosed in 2017, his cancer was stage four, as it had spread from his lung to his brain.
25. The World Health Organisation (WHO) has a performance classification which gives a score to indicate the overall health of a patient. By the time Mr C was seen at the Trust in 2017, he had developed brain metastases. His performance score was three, because he was symptomatic and in a chair or in bed for greater than 50 percent of the day, but he was not bedridden. The classification scores patients from 0 (able to carry out all normal activity without restriction) to 4 (completely disabled; cannot carry out any self-care; totally confined to bed or chair (https://www.nice.org.uk/guidance/ta121/chapter/Appendix-C-WHO-performance-status-classification)
26. In 2014, when the abnormality was first seen on the X-ray, Mr C was noted by the Trust to be mobile and independent. Based on this, his WHO performance score was likely to have been one. This is because he was restricted in strenuous activity but ambulatory and able to carry out light work. In 2015, when the abnormality was seen to be progressing, he was noted by the Trust to be ‘normally well’ and was independently mobile and self caring. Again, his WHO performance score was likely to have been one, or possibly two (ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours).
27. Based on this, our clinical adviser said it is more likely than not that if Mr C had been diagnosed in 2014 or 2015, he would have been offered radical treatment – either surgery or high dose radiotherapy. On the balance of probabilities, Mr C would likely have survived had he received this radical treatment in 2014 or 2015. This is because survival rates (at both one year and five years after diagnosis) are much better when the cancer is diagnosed at an early stage (stage one or two). When Mr C was diagnosed in 2017, he had stage four lung cancer and radical treatment was no longer an option.
28. In summary, the Trust undertook two chest X-rays in 2014 and 2015 which showed abnormalities. We have found the Trust failed to take responsibility for reviewing these X-rays, which was not in line with the GMC guidance or the Trust’s own system. We have found that, on the balance of probabilities, had this not occurred Mr C’s cancer would have been diagnosed at an earlier stage. Had he been diagnosed in 2014 or 2015, based on his health at that time, it is more likely than not that he would have been given radical treatment which would have meant he survived. We have found that, on the balance of probabilities, Mr C’s death was avoidable. Miss C has understandably found her father’s death distressing. This distress has been compounded by her feeling he deserved better treatment. Miss C has told us how she has struggled to grieve knowing her father’s death could have been avoided, and we can understand why this would be the case.
29. Following Mr C’s diagnosis in 2017, the Trust completed a Serious Incident report. This identified that the Trust had taken no action following the two abnormal chest X-rays and that the Trust had missed the lung cancer diagnosis. It said this had delayed the lung cancer diagnosis by three years, leading to metastatic spread and a catastrophic impact on Mr C.
30. The Trust found the root cause of the failure to identify the abnormality in 2014 was an outdated paper reports system. It said there was no evidence to suggest the report had ever reached the requesting physician. The Trust said in 2014 and 2015, there was a failure of the responsible physician to review the chest X-ray. Additionally, in 2015, the requesting physician failed to notify the responsible physician of the abnormal chest X-ray. The author of the Serious Incident report also said ‘I suspect changing the mind-set and working practice of the accident and emergency department when it comes to actioning these reports will not be possible. A different system for alerting serious chest X-ray reports is required’.
31. The Trust recommended the introduction of a ‘failsafe’ pathway for inpatients. This proposed that if a pulmonary mass was detected on an X-ray, a code would be included in the report. This would automatically generate an alert for the lung multidisciplinary team (MDT), which would be reviewed on a weekly basis. The lung MDT would contact the requesting physician to ensure they are aware of the report. It was recommended the pathway be implemented for a trial period, and an audit be undertaken three months after implementation.
32. We have considered whether the actions of the Trust are in line with our Principles of Good Administration and our Principles for Remedy. Both Principles say organisations should seek continuous improvement. Our Principles of Good Administration say organisations should ensure lessons are learnt from complaints and complaints should be used to improve services and performance. Organisations should review policies and procedures to ensure they are effective. Our Principles for Remedy say organisations should use the lessons learnt to ensure that poor service is not repeated.
33. We asked the Trust for evidence it had implemented the recommendation made in its Serious Incident report. The Trust confirmed that it had implemented a ‘failsafe’ pathway, but that it had not trialled or audited the pathway as it had said it would.
34. We asked our clinical adviser whether the actions taken by the Trust would be sufficient to prevent a similar failing from occurring in the future. Our adviser said the system the Trust had introduced reflects the pathway that had been suggested in the Serious Incident report. The pathway is broadly in line with the Standards for interpretation and reporting of imaging investigations guidance from the Royal College of Radiologists. This says radiologists should be ensuring failsafe mechanisms are present where necessary.
35. However, the Trust did not trial the pathway prior to fully implementing it, and it has not undertaken an audit. Our adviser said that a Serious Incident report should have been shared with the CCG (who should be supervising the delivery of the action plan).
36. We have found the Trust has not acted in line with Our Principles. While the Trust has implemented a new pathway, it has not reviewed (in the absence of a trial prior to implementation) or audited the pathway, despite over two and a half years having passed since the Trust completed its Serious Incident Investigation. It is not possible to reach a view as to whether the new pathway is working as anticipated and whether it has ensured the failings we have identified (and which the Trust identified in its Serious Incident report) have not been repeated nor continue to present risks to ongoing patient care.
37. We have also considered the individual remedy provided to Miss C, to address the injustice she has suffered. Our Principles of Good Administration say organisations should be ‘open and accountable’ by taking responsibility for the actions of their staff. Our Principles for Remedy say organisations should ‘get it right’ by acknowledging poor service that has led to injustice and should be ‘customer focused’ by apologising for and explaining poor service. Organisations should ‘put things right’ by returning the complainant to the position they would have been if the poor service had not occurred and if this is not possible, compensating the complainant appropriately.
38. We have seen that the Trust has acknowledged it did not review the X-rays and it has apologised that this occurred. The Trust’s Serious Incident report acknowledged Mr C’s cancer progressed from a likely curable lung cancer to terminal lung cancer by the time it was diagnosed. This is not addressed in the Trust’s response to Miss C’s complaint. The Trust apologised for the experience Miss C described in her complaint and the concern this caused. It said that it regretted the delivery of its services fell below expectations and it apologised. We cannot see that the Trust has apologised to Miss C for causing Mr C’s avoidable death.
39. The Trust has apologised for the actions of its staff, so has acted in line with our Principles of Good Administration. However, it is of concern that the Trust’s Serious Incident report noted ‘I suspect changing the mind-set and working practice of the accident and emergency department when it comes to actioning these reports will not be possible. A different system for alerting serious chest X-ray reports is required’. This does not suggest that the Trust’s clinicians have properly reflected on the impact their actions had on Mr C and Miss C.
40. The Trust is unable to put Miss C in the position she and her father would have been in had the failings we have identified not occurred. In line with our Principles for Remedy, the Trust should have considered compensating Miss C. It did not do so while responding to the complaint. Prior to our investigation, we asked Miss C what she wanted to achieve if we were to uphold her complaint. She told us she would like a park bench in memory of her father. In light of the failings the Trust identified in its Serious Incident report, we asked the Trust to consider this request. The Trust considered the request and decided it did not wish to provide this remedy.
41. In summary, we have found the Trust has not acted in line with our Principles of Good Administration or Our Principles for Remedy. While it has taken some steps to achieve continuous improvement, it has failed to complete this and failed to do what it said it would do. It has acknowledged the failings that occurred, but it has not apologised for the impact and it has failed to put things right for Miss C.
42. We have decided to uphold this part of Miss C’s complaint. We have made recommendations to remedy the injustice caused by the failings. These are set out below.
43. Miss C also complains about how the Trust handled her complaint. She says the responses were delayed and did not answer her questions. Miss C says she has been caused additional distress by the handling of her complaint.
44. The NHS Complaints Regulations say that after completing the investigation, an organisation must send the complainant a response in writing. This should show the complaint that has been considered and the conclusions reached. If an organisation does not send a response within six months of receiving the complaint, it should notify the complainant in writing and explain why.
45. Our Principles of Good Complainant Handling say organisations should be customer focused. This means they should have clear and simple procedures and should ensure complainants can easily access the service dealing with complaints, informing complainants about advice and advocacy services where appropriate. Organisations should also put things right by acknowledging mistakes and apologising where appropriate. They should provide prompt, appropriate and proportionate remedies, considering all the relevant factors of the case when offering remedies.
46. Miss C complained to the Trust in March 2018. She set out her concerns and asked the Trust to carry out an investigation and provide a response in accordance with the NHS Complaints Procedure. The Trust acknowledged this letter on 13 April. It offered to meet Miss C to discuss the findings of the Serious Incident report and we understand this meeting took place in May. The Trust took no further action in response to the complaint until Miss C contacted it in April 2019 to chase a response to the complaint. The Trust provided a written response in June 2019.
47. When we considered whether we could investigate Miss C’s complaint, we asked both Miss C and the Trust what was happening between May 2018 and April 2019. Miss C told us that she had met with the Trust to discuss the Serious Incident report, but that this had not addressed her concerns and she had expected a response to her complaint. She said she was not familiar with the complaints process so had not known how long it would take the Trust to respond. She also told us how she had not felt supported in making a complaint and how she thought she would have benefited from having an advocate to help support and guide her through the process. The Trust told us it had presumed that discussing the Serious Incident report had addressed Miss C’s concerns and it had not thought a written response was required.
48. We have found the Trust failed to act in line with the NHS Complaint Regulations. It did not provide a written response to the complaint in a timely manner. While we think it is positive that the Trust met with Miss C to discuss the findings of the Serious Incident report, this does not in itself mean the Trust had addressed Miss C’s concerns. If the Trust was going to act outside of the NHS Complaints Regulations, it should have made more of an effort to ensure Miss C’s concerns had been addressed and that she was not expecting a response to be provided.
49. We have also found the Trust failed to act in line with our Principles of Good Complaint Handling. The Trust did not make clear to Miss C how it was handling her complaint and it did not provide her with details about advocacy services to help her navigate the complaints system. The Trust has also failed to provide a prompt, appropriate and proportionate remedy to address the injustice Miss C has suffered, both when it responded to the complaint and when we asked it to specifically consider this.
50. Miss C has told us the handling of her complaint caused her additional distress at an already difficult time. We can see how the delay in resolving her concerns would compounded the distress she has experienced following her father’s avoidable death. The Trust’s further refusal to provide a remedy to the complaint has exacerbated this distress.
51. We have decided to uphold this part of Miss C’s complaint. We have made recommendations to remedy the injustice caused by the failings. These are set out below.