Patient may have lived longer or in less discomfort but for missed opportunities

What happened

Mrs R's GP referred her to a gastroenterologist to investigate symptoms suggesting bowel cancer. Mrs R had a number of tests in mid–2011, including a CT scan of her chest, abdomen and pelvis. The gastroenterologist concluded there was no sign of cancer.

In late 2011 Mrs R went to the emergency department at her local hospital with pain associated with a urinary stone. Doctors arranged a CT scan of Mrs R's kidneys, ureters (the tubes that carry urine from the kidneys to the bladder), and bladder. This showed a possible small stone in Mrs R's ureter, and an abnormality in the bowel, but the bowel abnormality was not identified.

Over the next seven months Mrs R repeatedly visited her GP and the emergency department with various symptoms. She also had a number of urological investigations and treatments. In July 2012 urologists referred her for another CT scan of her abdomen and pelvis. This showed bowel cancer. Mrs R was subsequently twice admitted to the hospital's cancer ward. However, she suffered a perforated bowel on her second admission, and sadly died.

What we found

We partly upheld this complaint. The GP Practice had provided appropriate care and treatment and had responded reasonably to the complaint.

The care and treatment provided for Mrs R on the cancer ward was mostly appropriate, and where there had been shortcomings, the Trust had responded appropriately. However, there was service failure in that the Trust should have arranged further investigations to exclude the possibility of cancer in mid?2011, and identified and acted on an abnormality on a CT scan in late 2011, but did not do so. Mrs R may have lived longer, or in less discomfort but for those missed opportunities to further investigate her symptoms. This caused her Family uncertainty and distress. There were some shortcomings in the Trust's complaint responses, but we decided these did not amount to maladministration.

Putting it right

The Trust agreed to apologise to Mrs R's daughters, and it paid them £1,000 (to be shared equally between them). It also prepared an action plan setting out what it had done/ would do to learn the lessons from this complaint.