Trust failed to inform man his cancer was terminal, Ombudsman finds

The Parliamentary and Health Service Ombudsman has found serious failings at Royal Cornwall Hospitals NHS Trust (the Trust) following the death of a man whose cancer was misdiagnosed, and who was not informed that his condition was terminal.

The man, Mr W, was referred to the Trust for a chest X-ray in March 2015, after suffering from pneumonia. A separate company, 4Ways Healthcare, was employed by the Trust to report on the X-ray. They suggested that he may have had an aneurysm.

With his symptoms not improving, Mr W was referred again for a CT scan in April. The Trust found that the original X-ray had been reported incorrectly by 4Ways Healthcare. The results from the new scan suggested Mr W may instead be suffering from lung cancer and further tests confirmed this.

The Trust was aware by this point that Mr W’s cancer was inoperable, but they did not inform him of this. He began chemotherapy and radiotherapy.

A further CT scan taken in late October showed that Mr W’s cancer had spread to other parts of his body, including his brain. He was admitted to hospital but later discharged. On 14 November, Mr W came back to hospital as his condition had worsened at home. Sadly, he died later that day.

The Ombudsman investigated the case after Mr W’s wife made a complaint.  They concluded that there was no evidence the Trust had informed Mr W of his prognosis. As such, he lost the opportunity to make a fully informed decision on his choice of treatment. Mr W did not get the time he should have to come to terms with his condition and get his affairs in order. His son also lost the opportunity to see his father before he died.

The Ombudsman also found that the misreported X-ray resulted in Mr W’s lung cancer diagnosis being delayed. Had the X-ray been reported correctly, the Trust could have started carrying out further tests, and Mr W could have started palliative treatment sooner. The Trust should have explained the error in reporting the X-ray to Mr W. They failed to do this, resulting in his family finding out of the error themselves after he had passed. The Ombudsman found that these failings amounted to a serious injustice to Mr W and his family.

Rob Behrens, Parliamentary and Health Service Ombudsman, said:

‘Mr W passed away having been unable to make an informed choice about his treatment. His family were not given the opportunity to properly say goodbye to him. The failings in this case were avoidable and caused huge emotional distress. They must not be repeated.’

Bernadette George, Director of Integrated Governance for Royal Cornwall Hospitals Trust said:

‘This is a very sad set of circumstances, where we let both the patient and their family down with our lack of openness and poor communication. We are extremely sorry for this and the additional distress it caused.

‘The review of this case has led to changes in the way we handle any situation where a misdiagnosis comes to light and as our recent work with the Care Quality Commission has confirmed, we are now making sure that we fulfil all of our Duty of Candour responsibilities. We now have an integrated Specialist Palliative and End of Life Care Team for patients and their families to ensure there is appropriate support and clear communication between everyone involved in a person’s care.’

What happens next?

The Ombudsman’s investigation highlighted the urgent need for the Trust to develop an action plan to address its failings and explain what it will do differently in the future. In addition to sending this plan to the Care Quality Commission, it should also reach an agreement with 4Ways Healthcare as to how in the future both organisations will communicate appropriately with patients whose care they are both involved in.

The Trust has written to Mrs W to apologise for the impact their failures have had.

Read the case summary.