Mr F's son complained about the care his late father received at the Trust. He said the Trust had not diagnosed and treated his father's leukaemia at the earliest opportunity. He said the delay deprived the family of the opportunity to make Mr F's last days more comfortable and they were unaware of how much he was suffering.
Mr F, who was in his late seventies, was seen in an outpatient clinic in summer. Blood test results showed some abnormalities but the results were not referred to a doctor for a clinical opinion, nor were they seen or acted upon by the doctor overseeing Mr F's care. In autumn, Mr F was back in hospital after he had a fall at home. Further blood tests showed that his haemoglobin level was low and his white blood cell count was raised. He was diagnosed with a urinary tract infection and discharged home.
Shortly after this Mr F was readmitted to hospital and become generally unwell and confused. Staff initially suspected that he was suffering from sepsis and treated him with antibiotics. His haemoglobin level was again low and he was given a red blood cell transfusion. Mr F was reviewed by a haematologist, who confirmed that he had leukaemia. His condition deteriorated over the following days until he died.
What we found
Staff missed two opportunities to diagnose Mr F's condition. Had staff reviewed and investigated the summer 2012 blood test results, he would have been diagnosed with myelodysplastic syndrome (a blood disorder that reduces the number of healthy blood cells). A diagnosis of acute myeloid leukaemia could have also been made in light of the autumn 2012 blood test results. This was not diagnosed until later in the month after Mr F had become very unwell. Overall, Mr F's care was not in line with established good practice and the missed opportunities to diagnose his condition sooner were failings.
Mr F had a number of medical conditions and was generally in poor health as a result. Although it is unlikely that an earlier diagnosis would have improved his prognosis, it would have led to offers of supportive care. This would have included transfusion of blood and platelets as required and attempts to treat any infections he developed. Mr F would also have been offered palliative care services, depending on what was available in the area.
We could understand why Mr F's family felt, and will likely continue to feel, distressed that opportunities were lost to make Mr F's last weeks and days more comfortable. Similarly, his family also suffered additional distress because they were not aware of how seriously unwell Mr F was or how poor his prognosis was until the days before he died.
The Trust wrongly sent its final response to Mr F's son's complaint to Mr F's last known address, which by this time had been sold. The Trust dealt with this issue in a reasonable way by apologising to Mr F's son and highlighting the error internally as a data breach. However, we could not see that the Trust had done anything to stop this happening again.
Putting it right
The Trust paid £1,000 to Mr F's son, and prepared an action plan to prevent the failings we identified from happening again.
Colchester Hospital University NHS Foundation Trust
Essex
Came to an unsound decision
Compensation for non-financial loss
Recommendation to learn lessons or draw up an action plan