Trust did not give patient clear advice to get a referral from her GP

What happened

Mrs J, who was in her seventies, had vaginal bleeding in spring 2012. This was treated at the Trust's gynaecological outpatient clinic. She had another episode of bleeding three months later, in summer 2012. She told staff at the gynaecological outpatient clinic and nurses suggested that she could either go back to the clinic or see her GP if she continued to have problems.

In autumn 2012, Mrs J was still bleeding and a nurse at the clinic advised her to go to her GP. Her GP referred her to a fast–track clinic at the Trust, and in late autumn 2012, Trust staff diagnosed her with endometrial cancer. Unfortunately Mrs J was ill and was unable to have surgery until early 2013, by which time the cancer had spread and could not be treated with surgery.

Mrs J died in mid–2014.

What we found

We partly upheld this complaint. The Trust appropriately treated Mrs J's bleeding in spring 2012. However, when Mrs J continued to report bleeding in summer 2012, nurses should have given Mrs J clear and unequivocal advice that she needed to see her GP. Her care fell below an acceptable standard and was service failure.

We did not find that the Trust should have made a referral for diagnosis in the period between spring and summer 2012. There was then a delay of six weeks, during which time Trust staff could have told Mrs J to see her GP. Mrs J's cancer was still operable at the time of diagnosis in autumn 2012.

The Trust's delay, no matter how short, did not give Mrs J the best possible chance of receiving treatment at the earliest possible stage.

The Trust said it has changed its process to make sure that if a patient presents with vaginal bleeding, staff will give her cream to treat this for two weeks. If the bleeding does not settle, staff will monitor the patient as instructed by a doctor. The Trust said if bleeding continued it would usually carry out an ultrasound scan. We considered that the action the Trust took will strengthen this process. However, the Trust had not acknowledged the impact of its failings.

Putting it right

The Trust had already improved its procedures to prevent a recurrence of the events that led to Mr J's complaint. It wrote to Mr J to apologise for the failings we found.