Delay in cancer diagnosis meant a patient's family could not spend time with him at the end of his life

What happened

Mr K was admitted to the Trust after a fall. The Trust carried out a scan of his abdomen and diagnosed a hiatus hernia. It treated Mr K for a chest infection and he went home after rehabilitation.

The Trust readmitted Mr K two months later with a suspected stroke. Tests revealed a very large mass in his abdomen and chest, and doctors diagnosed cancer. The Trust told Mr K's family what it had found a week later but unfortunately Mr K's health deteriorated rapidly and he died.

When the Trust answered the complaint, it did not acknowledge that it could have diagnosed the cancer sooner, it did not recognise the impact of its poor communication and it made no improvements to stop this happening again.

What we found

Trust staff did not properly read a scan and so failed to diagnose Mr K's cancer. Although this did not mean the outcome would have been any different, his family would have had a clearer picture of the prognosis, and Mr K's end‑of‑life experience, and his family's experience of that time, would have been very different.

Poor communication was a factor throughout Mr K's second admission and it affected all of Mr K's end‑of‑life care. It took away the opportunity for him and his family to spend his last few weeks together at home.

Putting it right

The Trust apologised and paid £1,500 in recognition of the distress caused to the family. The Trust agreed to review the work of the doctors who read the scan, and to produce an action plan to identify what led to the failings and what action was needed to stop a recurrence.