Trust gave good clinical care to cancer patient, but poor record keeping left family with unanswered questions

Summary 1104 |

Mr P complained that his wife was not given appropriate treatment following breast cancer in 2009. The cancer returned in 2014 and spread to her lungs. Mrs P died and Mr P felt if his wife had been given appropriate treatment in 2009, and if the cancer had been diagnosed sooner in 2014, his wife may have survived or had lived longer.

What happened

Mrs P had a mastectomy in 2009. The Trust offered her follow-up hormonal treatment and chemotherapy to reduce the chances of the cancer returning. Mrs P declined the further treatment as she wished to have children and the treatment would delay her ability to do this.

Mrs P was diagnosed with cancer of her other breast in 2012. This was successfully treated. As this was a different type of cancer, follow-up treatment would not have been beneficial.

In 2014, Mrs P attended hospital with difficulty breathing. She had fluid on her lungs. She was diagnosed with cancer which was most likely to be linked to her breast cancer in 2009 returning. Unfortunately Mrs P was too ill to start chemotherapy at that time and she died the following month.

What we found

We partly upheld this complaint. The Trust offered Mrs P appropriate follow-up treatment after her mastectomy in 2009. It was recorded that she declined treatment as she was keen to become pregnant as soon as possible. The records were not detailed enough to establish whether a full discussion took place with Mrs P about the consequences of not having the follow-up treatment. On the balance of probabilities, we considered a discussion did take place: it would have been difficult to discuss the treatment options with Mrs P without reference to why this was recommended or what the consequences would be if she did not have treatment.

However, the lack of records left Mr P not knowing exactly what was discussed or whether his wife had all the information she needed to make an informed decision to decline further treatment. This caused him considerable distress.

We found no failings in the clinical care provided to Mrs P in 2009, 2012 or 2014. Her treatment was timely and appropriate.

Putting it right

The Trust acknowledged the failings we identified and apologised to Mr P for the impact these had on him. It also took steps to learn from this complaint and improve its service.

Health or Parliamentary
Organisations we investigated

Ashford and St Peter's Hospitals NHS Foundation Trust



Complainants' concerns ?

Did not keep proper records or audit trail



Recommendation to learn lessons or draw up an action plan