A hospital’s failure to diagnose a woman’s cancer denied her precious time with her family, England’s Health Ombudsman has found.
The Parliamentary and Health Service Ombudsman (PHSO) is urging hospitals to improve processes to avoid delays in diagnosis.
A woman underwent a CT scan at University Hospitals of Leicester NHS Trust towards the end of November 2017 to investigate a potential liver problem.
While nothing significant was found on her liver, the scan revealed a nodule – a small dense area - and a possible pulmonary embolism on her left lung.
In December, the woman was referred to a clinic to treat the pulmonary embolism. The consultant at the clinic wrote to her GP asking she be referred for another CT scan three months later to investigate the nodule. This was not done and a review in mid-April 2018 revealed the follow-up scan had not been carried out.
An urgent CT scan towards the end of May 2018 revealed the woman had lung cancer, of which she died aged 81 in February 2019.
The woman’s daughter, from Oakham in Rutland, brought her complaint to PHSO.
The Ombudsman found the woman should have been diagnosed with lung cancer in December 2017, around six months earlier.
The Trust should not have passed the matter back to the woman’s GP and did not appropriately follow up the lung nodule’s finding.
Though PHSO cannot say exactly what would have happened, there is evidence the woman may have lived longer if the diagnosis had been made sooner, and this uncertainty about how much longer her mother might have lived has caused her daughter distress.
The Trust had already apologised to the woman, acknowledged its failings and taken action to avoid a reoccurrence for other patients.
However, PHSO recommended the Trust pay the woman £3,300 for the distress it caused. The Trust has complied with this recommendation.
The woman’s daughter, 64, who wishes to remain anonymous, said:
“Right from the diagnosis we were questioning why the scan hadn’t been followed up. It delayed my mum’s treatment for six months, which could have made a difference to how long she lived.
“There were things mum wanted to do that were not ticked off her bucket list because she was too ill or the end came up sooner than we thought. It was so upsetting.
“Time was taken away where we could have spent more quality time together. It wouldn’t have been years I don’t think, but who knows.
“Without the Ombudsman I wouldn’t have got where I am today. The advice I got from the Ombudsman was invaluable.
“I can’t express enough my gratitude to the caseworker and all the team for looking into things, not just my case, anybody’s case, because without their help we wouldn’t get anywhere.
“I promised my mum that I would go through with a complaint to find out what went wrong and in my mind, I’ve fulfilled that now for my mum.”
Parliamentary and Health Service Ombudsman Rebecca Hilsenrath said:
“Cancer has or will at some stage of our lives affect almost all of us either by being diagnosed with the disease ourselves or knowing somebody who has. This case had a tragic outcome. Even though the mother’s cancer was terminal at the point she sought medical assistance, the delay in her diagnosis meant important time with her family was lost and this can never be restored.”
Earlier this year, the Ombudsman warned cancer patients could be put at risk because of overstretched and exhausted staff working in a system at breaking point and delays in diagnosis and treatment.
And in 2021, PHSO published a report called Unlocking Solutions in Imaging about recurrent failings in the way X-rays and scans are reported on and followed up across the NHS service.
Rebecca Hilsenrath added:
“We have seen failings in multiple aspects of cancer care in the past. It is important that when mistakes are identified in healthcare, they are acted upon, and improvements made in order to deliver a better service for all. In this case, we welcome an acknowledgement of failings and improvements made by this Trust. A key aspect of our service to the public is about encouraging learning from complaints and we hope this means others will not have to experience the same issues again.”