Staffing shortages at a hospital run by Barking, Havering and Redbridge University Hospitals NHS Trust were a factor in the case of a grandmother whose “painful” death from bladder cancer could have been avoided, a report by the health service ombudsman has revealed.
Pamela North died aged 73 following a nine-month delay in diagnosing her cancer, which meant it was “too late” for potentially life-saving treatment, found the ombudsman, who also criticised an “inadequate” investigation by the trust.
“It is vital that lessons are learnt by the NHS to prevent the same mistakes from happening to someone else”
Despite going to King George Hospital in Goodmayes, Redbridge, several times for numerous tests and scans, which showed clear symptoms of bladder cancer, the retired school cleaner was not diagnosed until nearly a year after first being referred by her GP, the ombudsman found.
At one point a kidney X-ray and examination did not take place “due to the hospital not having sufficient staff capacity to meet demand”, shows a summary of the case that was published this week.
Had she been properly examined when she first attended hospital in March 2015 and given prompt chemotherapy and radiotherapy treatment, she would have had almost a 70% chance of surviving, the report concluded.
But by the time Ms North – who was from Dagenham in Essex and is referred to as Mrs D in the report – was diagnosed in January 2016 “her cancer was too far advanced so that treatment was no longer possible”.
“This nine-month delay meant that Mrs D was more likely to die than survive and meant she had to endure painful symptoms of kidney failure,” said a summary of the case.
“The trust’s investigations did not identify these failings or acknowledge that if it had provided the right care and treatment then she could have survived, causing her son significant distress,” it said.
“I would like to take this opportunity to again apologise. We accept that we fell short of the quality of care we aspire to.”
Ms North’s son – James North – took the case to the ombudsman who “fully upheld” his complaint.
The summary of the case, which was released with the family’s consent, shows that on her first visit to hospital Ms North was given a cystoscopy, but the images were poor due to debris in the bladder and a repeat test was ordered.
She went on to have an ultrasound and CT scan plus more cystoscopies in April and May, which revealed symptoms including swollen kidneys, enlarged urinary bladder neck and evidence of bleeding.
“We found that the trust failed to identify the cancer at an early stage and subsequent investigations were delayed and inadequate,” said the report summary.
“The presence of debris in the bladder and an obstructed right ureter are highly suggestive of cancer,” it said. “A prompt examination under general anaesthetic with biopsies being taken would have enabled the trust to diagnose cancer in March 2015.”
However, the summary revealed that some key tests did not happen – apparently due to lack of staffing.
“The trust planned to review Mrs D within six weeks so that it could take an X-ray of the kidney and ureter and an examination of the upper urinary tract, but this did not happen due to the hospital not having sufficient staff capacity to meet demand,” the summary continues.
The summary said Ms North had abnormally high levels of the waste product creatinine in her urine – showing her kidneys were failing – as did another scan that revealed “significant impairment” of the right kidney.
“Various blood tests showed progressive deterioration of the kidneys but these were not acted upon,” said the report.
In September 2015, Ms North was admitted to hospital with kidney failure where she had yet more tests but “no bladder biopsies were taken”.
It was only in January 2016 when she was again admitted to hospital as an emergency case that an endoscopy revealed bladder cancer and an MRI scan confirmed it was “at an advanced stage”.
Ms North was referred to another trust which told her the cancer was too advanced to be operated on. She was treated with palliative radiotherapy in Match 2016 but died in May of that year.
Health service ombudsman Rob Behrens described it as a “tragic case” and stressed the need for lessons to be learned.
“Doctors and nurses do a tremendous job caring for hundreds of thousands of patients day in and day out. But as this tragic case shows, it is vital that lessons are learnt by the NHS to prevent the same mistakes from happening to someone else,” he said.
“Time and time again we find NHS investigations into deaths inadequate, causing further suffering to families who have lost their loved ones,” said Mr Behrens.
“This case also shows the importance of complaining so that changes and improvements are made to NHS services,” he added.
The trust has made a formal apology to the family for the failings in Ms North’s care and treatment and – on the ombudsman’s recommendation – paid out a sum of £10,000.
The family has donated the money to the Saint Francis Hospice in Romford, which cared for Ms North in the final weeks of her life.
Trust chief executive Matthew Hopkins said improvements had been made in the two years since Ms North’s death.
“I would like to take this opportunity to again apologise to Mrs North’s family for the distress they have suffered in this case,” he said.
“We accept that we fell short of the quality of care we aspire to, and that the complaints process did not provide them with the appropriate reassurance,” said Mr Hopkins.
He highlighted that the trust had made “significant progress” in the past two years, including making “substantial improvement to our complaints-handling processes, to ensure we are thoroughly and comprehensively investigating and reviewing any area where we may have fallen short of the high standards we set ourselves”.
Meanwhile, a spokeswoman said the trust had also made “huge progress” when it came to the diagnosis and treatment of cancer.
Since July 2017, it has hit the target for ensuring 85% of patients diagnosed with cancer start treatment within 62 days.
“Against a national backdrop of stagnating or declining performance, this is a strong indicator of the commitment and success we are having in improving our care for cancer patients,” said the spokeswoman.
“We are committed to continuing to improve our care and will learn all the lessons we can from this case,” she added.