Poor cancer treatment did not lead to patient's death

What happened

The Trust treated Mrs L for a bowel obstruction in spring 2007 and found she had bowel cancer. She developed other medical problems and the cancer spread throughout her body. Mrs L died in summer 2008.

Dr L complained to the Trust in spring 2010 about various aspects of his wife's treatment. The Trust responded in early 2011 having spoken to 13 medical staff. Dr L submitted a follow–up complaint and met with the Trust. It provided a second and final response in early 2012.

Dr L then wanted an independent opinion on his complaint as he said he had no faith in the Trust and believed the treatment it provided had led to his wife's death. The Trust referred Dr L to the NHS Litigation Authority (NHS LA) as Dr L implied that he may take legal action. The NHS LA obtained a medico–legal opinion and Dr L commissioned his own medico–legal report. Dr L was dissatisfied with the NHS LA's report and so he came to us.

What we found

We partly upheld this case. There were no failings in some aspects of Mrs L's treatment. However, we did find the following failings by the Trust: a lack of supervision after her operation which contributed to a delay in treating a leak where sections of her colon had been re–joined; doctors should have carried out a biopsy on her sternum (breastbone) rather than on her vertebra; failure to respond to Mrs L's kidney problems; poor communication about chemotherapy treatment; two incorrect discharges; poor record keeping; and a delay in handling Dr L's complaints.

As a consequence of these failings, the Trust caused Dr L and Mrs L distress, as they could have chosen palliative care for her and been better prepared for her death. Poor record keeping also meant that we could not respond to parts of Dr L's complaint.

However, in our view Mrs L's death was not preventable. With the benefit of hindsight, it is likely that she had incurable disease at the time of her initial operation in spring 2007. The type and stage of her bowel cancer carries an extremely poor prognosis. Taking this into consideration we did not think that the Trust's failings had led to Mrs L's death, or that her life would have been prolonged had her care been better.

The NHS LA should have handled Dr L's case better and updated him more regularly.

Putting it right

The Trust accepted our recommendations and apologised to Dr L for the failings we identified. It also paid Dr L £3,200 for the distress this caused him and for the poor handling of his complaint.

The NHS LA apologised to Dr L for the delays in handling his case.