Decision report 201201251

Summary

Mr C complained on behalf of his late wife (Mrs C) who developed severe abdominal (stomach) pain in November 2011. After initial tests, hospital doctors at first thought Mrs C had a urinary tract infection, then appendicitis. These diagnoses were ruled out after she was transferred to another hospital, where a CT scan (a special scan using a computer to produce an image of the body) showed that Mrs C had a shrunken right kidney. This had been identified the year before in an MRI scan (a scan used to diagnose health conditions that affect organs, tissue and bone), when Mrs C was told that the shrunken kidney was likely congenital (present from birth). The CT scan also showed that bile ducts within her liver were enlarged, but that her liver was functioning normally. Further tests led to a suspected diagnosis of primary sclerosing cholangitis (a disease causing inflammation and obstruction of the bile ducts). Mrs C was later referred to a consultant urologist (a clinician who treats disorders of the urinary tract) who reviewed her CT scan and identified that the abnormalities in her kidneys had in fact progressed since the previous year's scan, and that the shrunken right kidney contained a solid cancerous mass. The cancer later spread into Mrs C's lungs and stomach.

Mr C complained that Mrs C's shrunken kidney had been observed as early as June 2010, but she had repeatedly been assured that this was congenital. He thought that the board's failure to investigate the cause of this had contributed to a delay to the diagnosis of her cancer.

After taking independent advice from a medical adviser, who is a consultant surgeon, we considered the initial investigations into Ms C's abdominal pain, and the working diagnoses, to have been reasonable. Early ultrasound and CT scans highlighted abnormalities in Mrs C's biliary tree (the structures responsible for transporting bile) and it was appropriate for these to be investigated. That said, we were concerned by the apparent lack of consideration of Mrs C's shrunken kidney, and upheld Mr C's complaint that this was not investigated quickly enough. Investigations concentrated on the biliary tree but found no significant abnormalities other than gallstones. Mrs C's pain was located in the area of her shrunken kidney, which was highlighted in June 2010 and showed again in the November 2011 CT scan. It was established in December 2011 that the biliary tree abnormalities were not the source of the pain. We concluded that there was sufficient cause to refer Mrs C to a urologist at an early stage, rather than to concentrate investigations on the biliary tree abnormalities. We did not uphold Mr C's complaints about how details of his wife's condition were explained in a letter to her and about medication prescribed.

Recommendations

We recommended that the board:

• share our findings with the clinical team so that they may consider reviewing how referrals are managed for patients requiring multi-disciplinary investigations.