Misdiagnosis prevented appropriate care

What happened

Mr P was in his seventies when he first went into hospital in spring 2013 with shortness of breath and chest pain. He had a scan to investigate a possible diagnosis of cancer, and doctors thought that the scan results confirmed this. After a review at a multidisciplinary meeting, clinicians decided he did not have cancer but had a pulmonary embolism (a blood clot in the lung) and started Mr P on anticoagulant medication to thin his blood. This diagnosis was right.

Mr P went back into hospital in early summer 2013 with shortness of breath. Trust staff diagnosed pulmonary fibrosis (a chronic condition that causes scarring of the lung and breathlessness). This diagnosis was wrong, Mr P had a pulmonary embolism.

Mr P went back into hospital later that month and again the next month at the request of the community respiratory nurse and the community heart disease nurse. They were worried about Mr P's shortness of breath and low blood pressure. Mr P died in hospital just over a week after this admission.

What we found

The radiology adviser we consulted felt that the initial scan showed a pulmonary embolism: a large blood clot. He did not find anything to raise a strong suspicion of cancer.

It is established good practice for a medical team to check scans and form a diagnosis. There is no evidence that this happened before the scan was reviewed at a multidisciplinary team meeting. Even though pulmonary embolism was mentioned on Mr P's admission documentation and clearly showed on the scan, and there was no obvious sign of malignancy, staff accepted the initial reading of cancer without question. Mr P's pulmonary embolism was then untreated for seven days. There was no evidence that staff considered the cause of Mr P's symptoms, or planned how they would manage his care. This was a serious failing in his medical care.

Mr P's diagnosis of pulmonary fibrosis at his second hospital admission was apparently made on the basis of the scan taken earlier. There was no evidence to explain this diagnosis, which was incorrect. The diagnosis of pulmonary fibrosis was not only wrong, it also discouraged doctors from seeking other explanations for his ongoing and deteriorating symptoms. This was a serious failing in Mr P's medical care.

From this time until Mr P's death, there was no evidence that his pulmonary embolism, a blood clot on his lungs that persisted despite anticoagulation treatment, was adequately investigated, correctly diagnosed or properly managed. These were serious shortcomings by the Trust.

There were also failings in discharge decisions and the Trust's communication with Mr P's family. In addition, the community respiratory nurse got involved in Mr P's care very late.

Although there were serious failings in the standard of care and treatment the Trust gave Mr P, we thought it unlikely that, given his age and symptoms, different treatment would have altered the outcome. However, the substandard treatment given to Mr P meant that his family were not adequately supported during his illness and understandably lost confidence in his care.

There were shortcomings in how the Trust started a palliative care pathway for Mr P. This meant that Mr P and his family did not have the opportunity to come to terms with his condition and prepare for his death in the way he would have wanted. This compounded their grief.

Putting it right

The Trust agreed to apologise to Mrs L for the failings we found. It paid her £1,750 compensation and agreed to explain what it has done, or plans to do, to address its shortcomings.