Trust delayed making cancer diagnosis for over 12 months

What happened

Mr S had an excess of fluid in his lungs, so the Trust referred him for a biopsy (a small surgical procedure to take a sample). The results of this were negative and several subsequent scans and tests showed no evidence of cancer. Mr S then developed a painful lump on his back and doctors took a biopsy of this. Unfortunately a machine error at the Trust meant that the biopsy sample was unusable. However, the two consultants involved in his care decided to not take another biopsy of the lump, and assured Mr S it was more than likely a build–up of scar tissue.

The lump remained painful and Mr S developed chest pain. He went to A&E and then was admitted to hospital as an emergency patient. He had a CT scan which showed he had mesothelioma (asbestos–related cancer). Mr S died one month later.

Mrs S said the Trust knew that her husband may have been exposed to asbestos, which increased his risk of developing mesothelioma. She knew that her husband's cancer could not have been cured, but said that if the Trust had done more investigations, her husband could have had earlier treatment which may have reduced his suffering in the final 12 months of his life. She said she and her family suffered a great deal of upset and heartache because of this.

What we found

The initial biopsy test has a well–known 10% risk of giving a false positive result, and the consultant who did the biopsy said at that time that mesothelioma could develop. However, doctors did not discuss this with Mr and Mrs S before his eventual diagnosis.

Our investigation showed that from the time the painful lump developed, Mr S showed clinical signs that should have alerted clinicians to doing more tests. While it was unfortunate that the biopsy sample had been lost, the Trust should have done another biopsy on Mr S. Had it done so, it is likely it that doctors would have found the cancer.

Overall the Trust's care and treatment of Mr S was not in line with established good practice. Had the Trust acted in line with national guidance, it could have diagnosed his mesothelioma 12 to 16 months earlier. This would have given Mr S the opportunity to have treatment and psychological and palliative support. However, it is unlikely that if the diagnosis had been made earlier it would have altered the outcome for Mr S.

Putting it right

The Trust accepted our recommendations and sent Mrs S a letter to acknowledge the failings we found and apologised for the impact of these. The Trust also paid her £2,500 to acknowledge the psychological impact and lack of support it had provided for her because of the delayed diagnosis. It also paid over £8,000 to Mr S's estate to recompense the Industrial Injuries Disablement Benefit he would have otherwise received.

We recommended that the Trust produce an action plan as evidence that it will make sure a delayed diagnosis will not happen again. We also recommended that the Trust shares information about its failures with relevant staff across the Trust, and keeps patients fully informed about their condition and treatment.