Decision Report 201203891

Summary

Mrs C had a history of myeloma (a type of cancer arising from plasma cells found in the bone marrow). She began to suffer from sickness and diarrhoea and arrangements were made for her to have a gastroscopy (a medical procedure during which a thin, flexible tube called an endoscope is used to look inside the stomach) and a colonoscopy (an examination of the lining of the bowel using a long flexible tube-like camera). Before these could be done, Mrs C's condition deteriorated and she had to attend a hospital accident and emergency department (A&E). She was told that her problems could be related to her myeloma. Blood tests and an x-ray were arranged and steps were taken to hydrate her (give her more fluids).

Mrs C had the gastroscopy two days later and a hiatus hernia (a protrusion of part of the stomach) was discovered which could be controlled by medication. The colonoscopy, however, could not take place as Mrs C was feeling unwell. She attended A&E again a few days later, as her legs were swollen, and was admitted to hospital. Five days later, the hospital contacted her husband (Mr C) to tell him that doctors had found a tumour in Mrs C's bowel and that it had ruptured. Mrs C died the following week.

Mr C complained that staff failed to carry out appropriate investigations in order to arrive at an accurate diagnosis for his wife. We found that there were some failures in the care and treatment provided. In particular, there was a failure to adequately assess some of Mrs C's symptoms; to perform examinations; and to consider her blood tests in sufficient detail. Although there were only a few days for a diagnosis to be made, we found that the hospital had missed opportunities. They initially considered that she might have infectious diarrhoea, possible clostridium difficile (a type of bacterial infection that can affect the digestive system) or that there might be a cardiac cause. These were excluded and doctors concluded that it was likely she had a new acute illness. However, the blood test results did not fit with diagnosis of new acute illness, but suggested a significant period of illness, iron deficiency and malnutrition. Mrs C was already having her bowel investigated for an alternative diagnosis of iron deficiency anaemia, which was unrelated to her myeloma. We found that a more balanced view of Mrs C's symptoms, clinical signs, and blood results would have considered chronic bowel disease, including malignancy, at least as likely as acute diarrhoea and vomiting caused by infection. We found that the level of care provided to Mrs C was below acceptable standards.

Recommendations

We recommended that the board:

• consider holding a significant event analysis in order to reflect and learn from this case; and
• issue a written apology to Mr C for their failure to adequately examine Mrs C and assess her symptoms and blood tests and for the delay in making an accurate diagnosis.