Clinical care of an older man was appropriate but he was not given important information about his condition

What happened

Mr T was in his late seventies. In 2008 he had a large heart attack and was taken to hospital. Doctors started treatment for his heart attack and booked him for a diagnostic test called an angiogram. The test did not take place because Mr T developed diarrhoea and because he later discharged himself from the hospital against the advice of his doctors. Over the following months, Mr T was booked two more times to have an angiogram, but on each occasion he cancelled the test.

In 2009 Mr T was referred by his GP to the hospital with symptoms of itching, weight loss and loss of appetite. Doctors investigated Mr T's symptoms and inserted a stent, an expandable tube, into the common bile duct (a part of his digestive system). They planned to repeat the procedure and replace the stent two months later. However, Mr T was given a patient information leaflet that said the stent could 'remain in place permanently'. And Mr T therefore wrote to his doctors to say that he did not want to undergo the repeat procedure.

In late 2010 Mr T started having abdominal discomfort and his GP referred him back to the hospital. An appointment was made for Mr T, but he cancelled this. Mr T was referred again by his GP to the hospital in 2011 and a scan showed multiple liver abscesses and multiple lesions on his spleen. Mr T was admitted to hospital and treatment and investigations were started. He was later transferred to another hospital, run by a different trust, but he died.

What we found

We partly upheld this complaint. After Mr T's heart attack in 2008, his doctors had acted in line with recognised standards and good practice. They had also taken reasonable decisions about his further care and treatment, given that Mr T seemed reluctant to undergo the investigations and treatment they planned for him.

In spring 2009 doctors had assessed Mr T's condition in line with the General Medical Council's Good Medical Practice and investigated his symptoms in line with guidance by the British Society of Gastroenterologists. Doctors had acted in line with established good practice and made decisions about Mr T's further care and treatment that were based on all relevant considerations. However, the patient information leaflet Mr T was given in 2009 was wrong. The stent could not be left in place permanently, but needed to be replaced every three to six months. And when Mr T wrote to his doctors about this, they did not correct his understanding or tell him about the risks if the stent was not changed or removed.

Due to these failings in communication, Mr T was denied the opportunity to make a fully informed choice and to receive care and treatment that might have saved his life.

Mrs T's distress at her husband's death was worsened by the uncertainty of never knowing whether Mr T might have survived if doctors had given him all the information he needed to know about his stent.

Putting it right

The Trust apologised to Mrs T and paid her £750 as an acknowledgement of the added distress she had been caused. It also put together an action plan that showed learning from its mistakes so they would not be repeated. This included changes to the patient information leaflet.