Case study 1: Failing to inform a patient that his cancer had spread
What happened
Mr O visited his GP with abdominal pain and unexplained rapid weight loss. Blood tests suggested cancer, and he was referred to the hospital for further tests and scans. Biopsies confirmed he had colorectal cancer, and a CT scan showed the cancer had spread to his liver.Despite attempts to treat Mr O, he was eventually admitted to hospital and his cancer was diagnosed as terminal. Mr O was discharged home for end of life care and died a week later.
What we found
We found that the Trust failed to clearly and promptly inform Mr O that the cancer had spread to his liver and was terminal. This poor communication led to Mr O accidentally finding out that his cancer had spread.
Mr O visited his GP to get help with managing his pain while waiting for cancer treatment. Records showed that the GP knew Mr O had secondary liver cancer, as the Trust had already shared results from earlier tests with them.
During the appointment, the GP made a comment that assumed Mr O already knew the cancer had spread. This caused confusion and distress for Mr O and his wife. It was only when they asked for clarification that Mr O found out the cancer had spread to his liver, which the Trust had not told them about.
The Trust knew the cancer had spread weeks earlier but delayed informing Mr O, meaning he only found out because the GP unintentionally disclosed it. Hospital records confirmed that the Trust did not tell Mr O directly until a month after the tests had identified the spread of the cancer. This delay denied Mr O additional time to prepare for the end of his life.