Failure to provide appropriate care for a cancer patient who suffered a major fit and died

Mr A was admitted to the Trust. He had a CT scan, which showed a tumour obstructing the bowel, and evidence that the cancer had spread to other organs. Neither he nor his family were told of his diagnosis before he had an urgent colostomy procedure to deal with the blockage in the bowel.

Mr A suffered a major fit some hours after he came out of theatre, which had to be controlled with sedatives. Doctors decided he should not be admitted to intensive care because of his advanced cancer. They suspected that the fit may have been caused by a spread of cancer to the brain, but a CT scan showed no evidence of this. Mr A remained on the ward and doctors did not review the 'Do Not Resuscitate' decision they had made earlier.

Mr A's family then pushed for him to be moved to intensive care and doctors agreed. While the family were waiting for Mr A to be transferred, he was given an injection to reverse the sedation. Shortly afterwards, his oxygen levels began to fall rapidly. He was rushed to intensive care but doctors were unable to resuscitate him and he died.

What we found

The Trust failed to attend to Mr A quickly enough after his fit. Once staff had sedated him, they did not monitor him closely enough or provide active care. Staff should have transferred him to a High Dependency Unit rather than kept him on the ward. When the CT brain scan came back clear, doctors should have actively tried to identify the reason for Mr A's fit, and also reviewed the Do Not Resuscitate decision. A junior doctor administered the injection to reverse the sedation without adequate supervision. The Trust also failed to communicate appropriately with Mr A's family about his diagnosis and his deterioration. It did not carry out a robust complaint investigation and discontinued a Serious Incident Investigation without following up on the areas of concern it had initially identified.

We could not say whether Mr A would have recovered from this episode with the right care, and it was not clear what had caused the fit. However, the Trust's failings deprived Mr A of the opportunity of a better outcome, which might have been possible if it had properly managed his care.

Putting it right

The Trust apologised to Mr A's wife and paid her £5,000 in recognition of the distress its failings had caused her. It also drew up an action plan to address the learning points from our investigation and gave an update on its work to restructure its complaints procedures.