Failure of Trust to convert referral to 'urgent' led to delays in diagnosing and treating liver cancer

What happened

Mr B was losing weight and suffered from indigestion, and after an endoscopy was referred by his GP to the Shrewsbury Trust in autumn 2012. The Trust marked the referral as urgent for an appointment within four weeks. Mr B was seen in clinic in winter 2012, where a mass was found in his abdomen and he was referred for an urgent CT scan. The scan was carried out a month later, and Mr B was diagnosed with cancer early in 2013, following a liver biopsy. Mr B was referred to University Hospitals Birmingham. He died in summer 2013.

What we found

The Shrewsbury Trust did not follow National Institute for Health and Care Excellence referral guidelines for suspected cancer when they considered Mr B's referral. This meant that Mr B was not transferred on to the cancer pathway, which would have meant access to early scans and appointments. This delayed multidisciplinary team discussions, oncology referrals, the diagnostic liver biopsy and ultimately the diagnosis and treatment of his liver cancer.

We did not find that Mr B's death could have been avoided, but there was a lost opportunity for his symptoms to be better controlled. This meant he could have tolerated any side effects more easily during the last months of his life. This clearly caused significant distress to both Mr B and Mrs R, his partner.

We did not see any failings by the Birmingham Trust relating to the management of his treatment.

Putting it right

The Trust apologised that Mr B's referral was not converted to a two‑week wait referral. It also completed an action plan to ensure that patients who are not referred under the two‑week wait are put on the cancer pathway at the right time, if this is necessary.