Delay in diagnosis of rare syndrome in older woman

What happened

Mrs B had treatment for an aggressive form of breast cancer and following remission began to deteriorate rapidly. After the eventual diagnosis of a rare syndrome she died. Her daughters complained about: the lack of information provided to their mother about her cancer and treatments; lack of investigation following remission when their mother began to deteriorate and was admitted to hospital; delay in getting their mother to an acute hospital for investigations, diagnosis and treatment; poor care in two of the hospitals she stayed in during this time; lack of diagnosis of reoccurring cancer and subsequent poor complaint handling when both daughters made complaints in their own right. The daughters felt that if their mother had been diagnosed earlier, she could have received treatment and might not have died when she did.

What we found

There were failings in the way that the Trust responded to complaints about: information provided to Mrs B about her initial diagnosis; delays in arranging an MRI scan; monitoring of nursing care to ensure improvements; poor communication about discharge; and the provision of incontinence products.

We consider that, as a result of this, there is no documentation to support the doctor's assertion that Mrs B and her family were fully informed about her initial diagnosis and treatments available. There were some delays in arranging an MRI scan and there is a lack of reassurance that monitoring is in place for the actions taken to improve matters as a result of this complaint.

However, given her rapid deterioration and condition, the outcome for this patient would not have been changed by the failings found and delay in diagnosis.

Putting it right

The Trust has acknowledged the failings identified and has apologised, paid £500 to each of the complainants for distress, and completed an action plan dealing with the failings found.