Case study 3: Missed opportunities to keep a family informed about their mother’s condition
What happened
Mrs B was admitted to hospital with a suspected urinary tract infection, alongside weight loss and reduced appetite. A CT scan the following day showed enlarged lymph nodes and signs that cancer had spread to her abdomen and liver.
Further tests and a multidisciplinary team review were recommended. Mrs B’s condition deteriorated rapidly. She was moved to end of life care about three weeks after admission and died the next day.
What we found
We found failings in how information was shared with Mrs B and her family. This caused the family distress and affected their ability to understand what was happening and to make plans.
Despite the Trust’s complaint responses claiming Mrs B had been informed about her diagnosis, we found no evidence in the medical records that a doctor had told her about her possible diagnosis after the CT scan, or that her family had been made aware.
The first clear recorded discussion of a possible cancer diagnosis did not happen untilalmost two weeks after the first scan results were available. The Trust missed numerous opportunities to share information with Mrs B’s family and keep them informed of the likely diagnosis and prognosis.
Mrs B’s daughter and her family assumed it was something minor from which Mrs B would recover. She said they felt let down by the fact that the Trust knew what was happening but they did not.