A four day delay in a cancer diagnosis, and Trust ignores independent review

What happened

Mrs A was admitted to hospital in early 2013 after suffering a stroke. While she was an inpatient, she developed abdominal pains which were initially thought to be related to acid reflux. Her appetite reduced during her stay and she continued to suffer with pain in her abdomen and back. Mrs A was discharged eight weeks later.

Mrs A remained unwell after her discharge and was readmitted to hospital with jaundice in spring 2013. Following a number of tests, Mrs A had a CT scan which revealed that she had pancreatic cancer. Mrs A died shortly afterwards.

What we found

Our investigation highlighted a number of shortcomings and failings in the way that Mrs A was treated both during her first and second admission. We cannot say it is more likely than not that her cancer would have been diagnosed during the first admission had the tests been carried out, but we can definitively say that she should have been diagnosed at least four days earlier, during her second admission. Regardless of this, more tests should have been completed and there should have been better communication between the multidisciplinary teams (MDT).

The Trust's failings are likely to have resulted in unnecessary discomfort for Mrs M and it denied her family an opportunity to better prepare for her death.

We were disappointed that the Trust did not choose to alter its view following receipt of the independent opinion, which clearly conflicted with the opinions of its own staff, and those expressed during local resolution.

We partly upheld this complaint.

Putting it right

The Trust acknowledged the service failure we identified, and apologised for the injustice that Mrs A's family have suffered as a result.

We recommended the Trust produce an action plan to show how it will learn from this complaint and make sure that others do not suffer in the future. In particular it must ensure it reflects on the quality of the handover of clinical information and communication between the MDT; reviews policies and procedures regarding scans; and considers how complaint handling can be improved in the future.