Mrs N’s story - Care and Compassion

Case studies

Mr & Mrs J's story

Hospital staff at Ealing Hospital NHS Trust left Mr J forgotten in a waiting room, denying him the chance to be with his wife as she died.
Mr D’s story

Royal Bolton Hospital NHS Foundation Trust discharged Mr D with inadequate pain relief, leaving his family to find someone to dispense and administer morphine over a bank holiday weekend.
Mrs R's story

Mrs R’s family were concerned that she would not receive food and drink while in Southampton University Hospitals NHS Trust unless they themselves helped her to eat and drink.
Mrs Y's story

Mrs Y died from peritonitis and a perforated stomach ulcer after her GP Surgery missed opportunities to diagnose that she had an ulcer.
Mrs H’s story

When Mrs H was transferred from Heart of England NHS Foundation Trust to a care home, she arrived bruised, soaked in urine, dishevelled and wearing someone else’s clothes.
Mr C's story

Staff at Oxford Radcliffe Hospitals NHS Trust turned off Mr C’s life support, despite his family’s request that they delay doing so for a short time.
Mr W's story

Mr W’s life was put at risk when Ashford and St Peter's Hospitals NHS Foundation Trust stopped treating him and then discharged him when he was not medically fit.
Mrs G’s story

Mrs G’s doctors at her local surgery failed to review her medication after she left hospital, with serious consequences for her health.
Mr L’s story

The care and treatment that Surrey and Borders Partnership NHS Foundation Trust gave Mr L contributed to a loss of his dignity and compromised his ability to survive pneumonia.
Mrs N’s story

While doctors at Northern Lincolnshire and Goole Hospitals NHS Foundation Trust diagnosed Mrs N’s lung cancer, they neglected to address the severe pain that she was suffering.

The Story
What our investigation found
What happened next

The story

In October 2007 Mrs N was provisionally diagnosed with lung cancer by her GP. She went to Scunthorpe General Hospital (part of Northern Lincolnshire and Goole Hospitals NHS Foundation Trust – the Foundation Trust) for tests to confirm the diagnosis. The results were inconclusive and a biopsy was carried out. When Mrs N next saw her Consultant, he said it was very likely that she had lung cancer, but further tests were needed to confirm this. Mrs N underwent tests at Castle Hill Hospital (part of Hull and East Yorkshire Hospitals NHS Trust) where a scan showed that the cancer had spread to her chest and spine.

While waiting for the results of the Scunthorpe General Hospital tests, Mrs N began to suffer from severe pain. Her daughter told us that because her mother had not been given a diagnosis, she was not given adequate pain relief. The lack of a diagnosis also prevented Mrs N claiming full attendance allowance – something that would have helped the family to care for her. The Christmas period was a particularly distressing time for everyone, as Mrs N’s family witnessed her suffering without being able to help. Another daughter, who spent a large part of each day caring for Mrs N, became ill herself as a result of the distress.

In January 2008 Mrs N attended Scunthorpe General Hospital for the test results. A different Consultant confirmed that she had lung cancer, but that the particular type of cancer could not be identified. He told Mrs N that there had probably been enough evidence from the first tests to diagnose inoperable lung cancer.

A few days later Mrs N — who described herself as ‘disorientated and in extreme pain’ at the time — was admitted to Scunthorpe General Hospital to control her increasing pain. A pain management plan was drawn up specifying that Mrs N should receive medication on an ‘as required’ basis, but it was five days before she received adequate pain relief. Mrs N said that she was in ‘unbearable pain’. On one occasion Mrs N had asked for pain relief, only to be told that she had already taken it. However, when the Macmillan Nurse checked the drugs chart, that was not the case. As her daughter observed ‘our mother continued to suffer for too long’.

Mrs N was then moved to a different hospital for radiotherapy treatment, but was still unaware that the cancer had spread to her spine. She was transferred back to Scunthorpe General Hospital and then discharged home. Mrs N complained to the Foundation Trust about several issues including poor communications between the departments and hospitals caring for her, and delays receiving test results. She queried if some of the tests (which she found distressing) had actually been necessary. She sought ‘some reassurance that everything possible will be done to stop anyone else experiencing the problems I have experienced’.

In March 2008 Mrs N had an MRI scan. Only then did she learn that the cancer had spread to her spine. She died the following month, aged 82. Seven months after Mrs N’s death, the Foundation Trust sent their full response to her daughters. During the local resolution process, the Foundation Trust acknowledged failings in Mrs N’s care, offered their apologies and described actions they had taken to improve their practices. However, Mrs N’s daughters escalated matters to the Ombudsman, seeking a more detailed response and apologies.

What our investigation found

The Foundation Trust should have concluded in October 2007 that it was likely that Mrs N had inoperable lung cancer. Instead, they focused on obtaining a full diagnosis and neglected to manage her pain. Both this and delays in scheduling investigations and reporting the results contributed to Mrs N not being treated for her symptoms within two months of her referral (in line with Department of Health guidance). The delayed diagnosis also meant that Mrs N was ineligible for full attendance allowance, which could have helped the family to care for her, until January 2008.

Although a pain management plan was in place for Mrs N, nurses seemed unaware of her specific pain management requirements. That was not in accordance with the Nursing and Midwifery Council’s guidelines. The lack of adequate pain relief greatly distressed Mrs N and her family. Mrs N should also have been told that the cancer had spread to her spine before the MRI scan. The Foundation Trust delayed unnecessarily providing a full response to Mrs N’s complaint. The fact that she did not receive the response before she died compounded the family’s distress.

We upheld the complaint about the Northern Lincolnshire and Goole Hospitals NHS Foundation Trust.

For their part, Hull and East Yorkshire Hospitals NHS Trust communicated poorly with Mrs N about the investigations at Castle Hill Hospital and contributed to the delay in her receiving the results. We did not uphold the complaint about them, however, as these shortcomings added little to the delay in treating Mrs N’s cancer and the Trust had already apologised for them.

What happened next

Northern Lincolnshire and Goole Hospitals NHS Foundation Trust apologised to Mrs N’s daughter and paid her compensation of £2,000. They also drew up further plans to improve their service, by taking such steps as arranging training for ward staff in pain and symptom control; improving systems for scheduling investigations and reporting the results; and planning to appoint an additional lung cancer nurse.