Decision Report 201300631

Summary

Mrs C, who is an advice worker, complained on behalf of Miss B that the care and treatment provided to her late mother (Mrs A) was unreasonable. Mrs A had been admitted to hospital as an emergency with severe stomach pains and vomiting. She told doctors that she had been having irregular vaginal bleeding for the previous six months. Two days later, she had a major haemorrhage (escape of blood) after which she was scanned and was found to have a pelvic mass. Her care was passed to the gynaecological team and a biopsy (tissue sample) was taken from the inside of her womb before she was discharged from hospital. This showed that Mrs A had developed a high grade and aggressive form of cancer. She was referred to the nearest gynaecological cancer specialist centre and a provisional plan was made to admit her there for an operation. However, Mrs A deteriorated very quickly. She was admitted to hospital again and died there before she could receive the planned treatment.

As part of our investigation we took independent advice from one of our medical advisers. We found that Mrs A had a particularly aggressive form of cancer and there were no undue delays in treating her. The first planned treatment was less than one month after it was first suspected that she had cancer. The investigations carried out and the actions taken were entirely reasonable and appropriate.

Mrs C also complained about the hospital's communication with family members. We found that in general, the team's communication with Mrs A and her family was appropriate and in line with her wishes. The consultant had kept Mrs A informed of the progress of the investigations and treatment. When Mrs A was initially discharged from hospital, the diagnosis of cancer had not been confirmed. In addition, before she was readmitted, staff were proceeding with a plan for Mrs A to be treated, and her condition was, therefore, not terminal at that point. However, when Mrs A was readmitted to hospital, it was identified that her condition was in fact terminal. Miss B complained that before she knew this, a doctor asked her whether Mrs A should be resuscitated. Although we upheld this aspect of the complaint, we did not make any recommendations, as the consultant had apologised to Miss B and the board had discussed the matter with the junior doctor involved.