Organisation we investigated: Lancashire Teaching Hospitals NHS Foundation Trust, (Royal Preston Hospital)
Date investigation closed: September 2022
The complaint
Mr D complained about the care and treatment of his wife at the Royal Preston Hospital when she was diagnosed with having a brain tumour. He said he and his wife were told that the tumour was not growing and was concerned it was not being properly monitored. He also complained the Trust was not open and transparent in the handling of his complaint about his wife’s care and treatment, and was given clinically contradictory and inaccurate responses about what happened.
Background
Mrs D was referred to the Trust in 2010 after experiencing headaches and focal seizures, which affect one side of the brain. MRI scans showed she likely had a brain tumour. She had another scan in January 2011 and saw the consultant neurosurgeon in February. He advised a repeat scan in three months. Up until late 2014, Mrs D attended the hospital for regular scans and was advised that the tumour was not growing, or only growing very slightly.
Following a scan in November 2014, Mrs D was informed she would need treatment and her case was referred to a multidisciplinary team (MDT). In January 2015 she was referred to a different consultant neurosurgeon.
The neurosurgeon and MDT recommended her for surgery. She had a pre-operative scan and brain surgery in May 2015. Four days later, she had a stroke and sadly died. Mr D had concerns about the management of his wife’s tumour, so he requested a copy of her clinical records and submitted a complaint to the Trust in May 2016.
Our findings
We found that there was a delay of three years before Mrs D was offered surgery to treat her brain tumour. We saw evidence that Mrs D’s tumour grew from 2011 to 2014 and despite undergoing scans throughout this period, surgery was not recommended to her until December 2014. We also found that, contrary to NICE guidelines, the Trust failed to refer her case to the MDT in 2011. Without the delay to surgery, the tumour would have been smaller and the operation easier to carry out. This means it is more likely than not that Mrs D would have survived had she been operated on earlier.
We also found failings in the Trust’s handling of Mr D’s complaint. There were contradictions in the written responses by the Trust and inaccuracies in the Trust’s account of Mrs D’s care and treatment. These problems compounded Mr D’s distress when he was struggling to come to terms with his wife’s death.
Our recommendations
We recommend that the Trust:
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apologise for its failings and the significant distress these have caused Mr D and his family,
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develop an action plan to address the failings summarised in the report. This should identify specific reasons for the failings, the learning taken from them, and what it will do differently in the future,
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pay Mr D £15,000 in recognition of the significant distress he experienced because of the Trust’s failings in his wife’s care and handling of his complaint.