University Hospitals of Leicester NHS Trust failed to follow up Oakham woman’s condition leading to her death, says ombudsman

A woman was denied precious time with her family before her death because of Leicester hospital failings, a healthcare watchdog has ruled.

The unnamed 80-year-old, from Oakham, was found to have a nodule – a small, dense area – in her left lung after a hospital visit in November 2017.

However, staff at the University Hospitals of Leicester NHS Trust (UHL), which runs the city’s three hospitals, did not book her in for a follow-up as they should have done, resulting in a six month delay in her care, the healthcare ombudsman has ruled. It was later determined that she had cancer, but by the time the diagnosis was made, the disease had progressed to stage four, the most severe stage, meaning it had spread to other parts of her body.

Had the disease been caught earlier, the woman might have lived longer, the ombudsman said, and been able to spend more time with her loved ones. UHL has apologised to the family, and said it had improved its referral processes following this case. Her daughter, who wished to remain anonymous, has spoken of the family’s upset over the lost opportunity.

She said: “Right from the diagnosis we were questioning why the scan hadn’t been followed up. It delayed my mum’s treatment for six months, which could have made a difference to how long she lived.

“There were things mum wanted to do that were not ticked off her bucket list because she was too ill or the end came up sooner than we thought. It was so upsetting.

“Time was taken away where we could have spent more quality time together. It wouldn’t have been years I don’t think, but who knows.”

The ombudsman ruled that UHL staff should have “immediately” and “directly” referred the woman to the respiratory team for a follow-up scan. If they had, the cancer would have been diagnosed in December 2017, it added.

Instead, they wrote to her GP, asking that the doctor refer her for a scan in February 2018. It was not until a review in April 2018 that Leicester hospitals realised this had not happened, and the woman was rushed in for an urgent CT scan towards the end of May that year.

The scan revealed that the woman had lung cancer, which at that stage had progressed to stage four, the most severe level. At the time of the first scan, it was at stage one, the least severe, and would have “likely” still been at that stage in December when the urgent follow-up scan should have taken place, the watchdog said. The woman died in February 2019.

The ombudsman said that, had the hospital followed up on her care as it should have, the woman might have lived longer. However, due to the woman’s age and prior ill health, as well as the aggressive nature of the type of cancer she had, the watchdog added that it could not be sure how much longer quicker care would have given her.

UHL has already apologised to the family, the ombudsman said. It has also shown it has “taken appropriate action to learn” from the errors in the woman’s care.

However, the ombudsman also ruled that it should pay a financial remedy of £3,300 to the daughter in recognition of the “distress” and “uncertainty” she had suffered “knowing that her mother should have been diagnosed earlier and received treatment that would have extended her life”.

Parliamentary and Health Service Ombudsman Rebecca Hilsenrath said: “Cancer has or will at some stage of our lives affect almost all of us either by being diagnosed with the disease ourselves or knowing somebody who has. This case had a tragic outcome. Even though the mother’s cancer was terminal at the point she sought medical assistance, the delay in her diagnosis meant important time with her family was lost and this can never be restored.”

Andrew Furlong, medical director at University Hospitals of Leicester NHS Trust, said: “On behalf of the trust, I offer our condolences to the family, and our sincere apologies for their experience. We deeply regret that we did not provide timely care. While sadly we cannot change the outcome in this case, we have introduced new guidance for colleagues and have improved consultant-to-consultant referrals, to ensure the learning improves our services.”