The Parliamentary and Health Service Ombudsman (PHSO) has found serious failings at Warrington and Halton Hospitals NHS Foundation Trust after the death of a man whose cancer surgery was unacceptably delayed.
Mr Denis Harrison, 62 from Warrington, waited six months from being diagnosed with bladder cancer to having surgery. He had been referred to the Trust via the urgent suspected cancer pathway in October 2016. In line with NHS guidance, the Trust should have treated Mr Harrison’s cancer by 11 February 2017. However, he was not operated on until 25 April 2017, by which time the cancer was incurable.
Mr Harrison was also showing signs that the cancer had spread in March 2017, when he went to the hospital with a swollen leg. Despite this, the Trust failed to carry out a scan which would have shown this. The failure meant Mr Harrison’s operation, when it did eventually happen, went ahead unnecessarily as the cancer had already progressed beyond an operable state. Sadly, Mr Harrison passed away on 24 August 2017.
The Ombudsman investigated the case after Mr Harrison’s wife made a complaint. The Ombudsman concluded that the delays in treating Mr Harrison’s cancer amounted to a serious failure, and that the Trust should have taken reasonable steps to provide intervention more quickly. While it is not possible to know whether more timely surgery would have saved Mr Harrison’s life, studies show that delays in treatment are associated with worse survival rates[1].
Rob Behrens, Parliamentary and Health Service Ombudsman, said:
‘The failings in this case caused huge anxiety and distress to Mrs Harrison, who has been left not knowing whether more prompt treatment could have extended her husband’s life.
‘The Trust knew Mr Harrison’s cancer was growing and could be treatable but they failed to act with any urgency and in line with clear NHS guidelines. It is essential they learn from this case.’
Mrs Harrison said:
‘On top of my husband’s diagnosis, the Trust’s delay in arranging an operation caused both of us severe mental anguish.
‘I complained to the Ombudsman because I don’t want anybody else to go through what my husband had to endure. The Trust needs to do more to make sure that this can never happen again.’
The Ombudsman’s investigation highlighted the urgent need for the Trust to learn from their mistakes. In response to recommendations made by the Ombudsman, the Trust has agreed to develop an action plan to address their failings, which will outline what they will do differently in the future.
Kimberley Salmon Jamieson, Chief Nurse at Warrington and Halton NHS Foundation Trust, said:
‘The Trust would like to sincerely apologise to Mr Harrison’s family for the poor care experienced, and we fully acknowledge and accept the findings within the report from the PHSO.
‘The Trust has taken actions following Mr Harrison’s death and as a result of the recommendations within the report. The Trust remains committed to learning and improving our services and we would like to reiterate our sincere condolences to the family for their sad loss.’
The Ombudsman also made clear that this action plan should be shared with the Care Quality Commission alongside its final investigation report.
[1] Waldert M et. Al. A delay in radical nephroureterectomy can lead to upstaging. BJU Int. 2010 March.