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Management of a man with oesophageal cancer (14HDC00294)
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14HDC00294, 16 December
General surgeon ~ Anaesthetist ~
General practitioner ~ District health board ~ Medical centre ~
Oesophageal cancer ~ CT scan ~ Follow-up ~ Management of referrals
~ Record keeping ~ Rights 4(1), 4(2), 4(5)
A 62-year-old man was diagnosed with oesophageal cancer and
underwent chemotherapy and an Ivor Lewis oesophagogastrectomy
procedure (surgery to remove the oesophagus and part of the
stomach) and had a feeding tube inserted. The surgeon's registrar
wrote to the man's general practitioner (GP) noting that there were
no further treatment options if the cancer recurred, and that while
they did not normally follow up with serial imaging, the GP could
get back in touch and request a surveillance scan, which could be
arranged at the six- or 12-month mark.
The man's condition began to decline. He attended an appointment
with the GP with, among other things, severe constipation and
abdominal pain, and requested a scan. The GP sent a request for a
CT scan to the surgical clinic at a public hospital. The GP did not
provide any information regarding the man's physical symptoms or
any assessment findings. Unfortunately, the referral was not
actioned by the DHB.
The man reported to the GP that he was waking up with a "sharp
burn" at the base of his throat and was experiencing fatigue and
shortness of breath on exertion. The GP considered these to be new
symptoms that could be attributable to the re-emergence of cancer,
but he did not inform the man of this.
At the request of the man, the GP re-sent the CT referral
letter. He did not make any additions or amendments to the original
request. As there was no indication on the referral letter as to
the declining health of the man or of the urgency of the request,
the referral letter was left to be reviewed by the surgeon when he
returned from leave about a month later. Upon the surgeon's return
he sent a request for a CT "to look for recurrent disease".
The man underwent a CT scan. No obvious metastasis was reported,
but it was noted that oesophageal distension was indicative of
recurrent disease, and follow-up was suggested. Further
investigations were undertaken, which indicated a blockage in the
man's upper abdomen. The man was scheduled for laparoscopic surgery
in order to attempt to unblock his digestive tract, and to confirm
whether his cancer had returned. Prior to the laparoscopy, the man
had signs of a chest infection including shortness of breath, and
underlying acute lung disease.
The surgeon was unable to complete the laparoscopic procedure
owing to the distribution of the recurrent cancer. Sadly, the man
did not regain consciousness following the procedure and died in
the early hours of the morning.
It was held that the GP did not provide sufficient information
in the initial referral. Neither did he proactively offer the man
the option of private CT scanning or review by the surgeon in
private at that stage. Further, the GP did not provide updated
information about the man's worsening symptoms in the second
referral, discuss the possibility of private referral with the man,
or contact the hospital or the surgeon about the delay.
Accordingly, the GP failed to provide the man with services with
reasonable care and skill, and breached Right 4(1).
Adverse comment was made that the GP did not have a conversation
with the man about his symptoms, likely prognosis, and options
available to him when he presented with symptoms that were
consistent with the return of cancer.
The medical centre did not breach the Code.
Adverse comment was made about the scheduling error by the
surgeon, the follow-up arrangements in place after the Ivor Lewis
procedure, and that the surgeon did not document the discussion he
had with the man regarding the risks and benefits of undergoing
The anaesthetist's record-keeping was inadequate in a number of
areas and, accordingly, it was found that that he breached Right
4(2) for failing to keep clear and accurate patient records in
accordance with his professional obligations. Adverse comment was
made in relation to the anaesthetist's statement that he did not
think that he discussed the risk of perioperative death with the
It was recommended that the GP organise an independent GP peer
to conduct a random audit of 10 referrals to specialist secondary
services that the GP instigated within the last 12 months. It was
recommended that the GP attend training on communication and report
The DHB's system for management of referrals was inadequate, as
the man's initial referral was not tracked sufficiently in order to
ensure that triage occurred. Accordingly, it was found that the DHB
breached Right 4(5).
It was recommended that, the DHB review the effectiveness of the
following measures it implemented as a result of its internal
- The criteria and process of follow-up oesophagectomy.
- The plan for communication between cancer support nurses, GPs
- The centralised referral process with regard to tracking and
triaging of referrals.
- The guidelines for management of communication regarding
life-threatening events in the operating theatre.
It was recommended that the DHB report to HDC on the
implementation of the remaining recommendations from the internal
It was recommended that the anaesthetist undergo further
training on record-keeping and report to HDC with evidence of the
content of the training and attendance.
It was recommended that the surgeon:
a) Review the effectiveness and
appropriateness of his approach taken to follow-up.
b) Review the effectiveness of the
written information provided to patients on discharge from
c) Report to HDC on the
implementation of his post-oesophagectomy treatment plan, which he
intends to provide to GPs when a patient is referred back into
It was recommended that the GP, the anaesthetist and the DHB
each provide a written apology to the man's wife for their breaches
of the Code.