Cancer patient got lost in the system

What happened

Mr S went to A&E as he had blood in his urine. He was sent to a urology clinic for tests. At the clinic, a scan showed he had a mass on his left kidney. Mr S was not told about this but was sent for an urgent CT scan, which took place shortly afterwards. A follow‑up appointment was not made for Mr S at that time, and, unaware of any problems, Mr S went on holiday.

The printed report of Mr S's CT scan went astray and did not reach his consultant urologist. As no follow‑up appointment had been made, no one was prompted to either chase the CT scan results or review them on the Trust's patient information system.

When he returned from holiday Mr S contacted the hospital for his results, but was told he was not on the system. It was only after repeated attempts that he finally got a message to his consultant urologist, who tracked down the CT scan report and arranged to see Mr S urgently. By the time the consultant urologist saw Mr S and told him of the scan's findings, it was almost two months since the scan was performed.

Mr S had his kidney removed two months later, but a follow‑up scan taken the next year showed that his cancer had spread to his lungs. Despite chemotherapy, Mr S died a little under a year later.

What we found

There were unnecessary delays in diagnosing Mr S's cancer and in arranging surgery to remove his kidney. Mr S had 'fallen off' the cancer pathway.

However, even if Mr S had received more urgent treatment, it would not have extended or saved his life. There were no failings in how the possibility of recurrent cancer was investigated.

The Trust's complaint responses were generally to a good standard, but there were excessive delays.

Putting it right

The Trust apologised to Mr S's family and paid them £1,000 compensation.

It agreed to prepare an action plan to show what it has done and plans to do, to prevent the failings happening again.