Organisation we investigated: Royal Cornwall Hospitals NHS Trust
Date investigation closed: 25 February 2019
The complaint
Mrs W complained about failings in communication between Royal Cornwall Hospitals Trust and her late husband, Mr W, while he was a patient there.
She said that her husband was not informed that an initial X-ray had been misreported and that he was left in unreasonable pain until the misdiagnosis was corrected. She also said that the Trust had failed to explain that his lung cancer was incurable.
This meant that Mr W was unable to make an informed decision about his choice of treatment, and he and his family were not given time to put his affairs in order. Mrs W said they were also left without being able to say goodbye properly.
Background
Mr W was referred to the Trust for a chest X-ray on 27 March 2015 after suffering from pneumonia. A separate company, 4Ways Healthcare, reported the X-ray and suggested that Mr W may have had an aneurysm.
Mr W’s GP prescribed painkillers in line with this diagnosis. However, symptoms did not improve so Mr W was referred to the Trust again for a CT scan on 16 April.
On 29 April, his GP contacted the Trust to follow up and they found that the X-ray had been reported incorrectly. The results from the CT scan suggested lung cancer. Further tests confirmed this.
The Trust was aware at this point that Mr W’s cancer was inoperable.
Mr W began chemotherapy and radiotherapy. However, a further CT scan taken on 30 October showed the cancer had spread and he was admitted to hospital.
He was discharged on 10 November but readmitted on 14 November, as he had significantly deteriorated at home. Sadly, he died later that day.
What we found
We partly upheld this complaint. We did not find that Mr W’s GP had acted improperly in managing pain relief. The GP believed Mr W had an aneurysm and started him on lower scale pain relief with the intention of moving him up as the pain progressed.
We did find, however, that the misreported X-ray resulted in Mr W’s lung cancer diagnosis being delayed. Had the X-ray been reported correctly, the Trust could have started carrying out further tests and Mr W could have started palliative treatment sooner.
The Trust should have explained the error in reporting the X-ray to Mr W. They failed to do this, resulting in his family finding out the error after he had died.
We also found there was no evidence the Trust had informed Mr W of his prognosis. As such, he lost the opportunity to make a fully informed decision regarding choice of treatment.
Mr W did not get the time he should have to come to terms with his condition and make appropriate arrangements. His son lost the opportunity to see his father before he died. These failings amounted to a serious injustice to Mr W and his family.
Putting it right
The Trust has apologised to Mrs W and agreed to our recommendations, which are as follows:
- The Trust should agree with 4Ways Healthcare how both organisations will meet duty of candour requirements for patients in their joint care.
- They should develop an action plan to address their failure to make Mr W aware of his prognosis and that he was in palliative care.
The action plan should identify the reasons for the failings and explain:
- the learning the Trust has taken from these issues
- what it will do differently in the future
- who is responsible and timescales for each action
- how it will monitor implementation.
The plan should also assure us that no other patients at the Trust are in the same situation as Mr W. That is to say, an error has been made with an X-ray reported by 4Ways that the patient has not been made aware of.