Setting the Scene
The Patient attended the Trust as they had been having difficulties swallowing solid food for over ten years. The Patient had received treatment for this but had seen no improvement in the last year. Unfortunately, OGD (examination of the oesophagus (gullet), stomach and duodenum; also known as gastroscopy/endoscopy) was not carried out and as a result, there was a delay in the Patient being seen by a Gastroenterologist and subsequently a delay in diagnosing oesophageal cancer.
The main learning points from this review stem from the following events:
When the Patient represented with no improvement in symptoms, OGD was not undertaken to investigate the symptoms further.
The Clinician assessing the Patient did not have access to the full records for the Patient and so was unable to ascertain whether OGD had already been undertaken.
- The referral notes were completed inadequately, and this led to a perception that OGD had already been undertaken when in fact it had not.
Recommendations to Prevent Incident Recurrence and Improve Patient Safety
TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:
1. Clinicians need to ensure they have reviewed the relevant records before deciding on a course of treatment.
When deciding on how best to treat a patient, the clinician involved needs to be aware of the patient’s clinical picture. It is therefore imperative that the clinician reviews the appropriate medical records in order to ascertain how the patient has already been treated and thus how it is best to proceed. If they do not have access to these records, they should be pursued, and a decision not made on how to proceed until the full clinical picture to date is understood.
2. Referral notes must contain accurate information about the patient, why they are being referred and what treatment they have already undergone.
To avoid incorrect assumptions being made about a patient’s care, referral notes need to be completed accurately. They need to describe what is known to be true and anything that is speculative or not known yet should be noted as such.
3. Clinicians should not rely on second hand information about a patient’s treatment/clinical picture.
Clinicians should not base their decisions on second-hand information from other clinicians and should have solid evidence of what exactly occurred before choosing how best to proceed when treating a patient. Relying on various comments by clinicians which do not necessarily correlate with each other is inappropriate.
4. When a patient has been struggling to swallow solid foods for over ten years and treatment has not proved effective, OGD should be undertaken to rule out possible sinister causes.
Dysphagia is considered a very sinister symptom and when this is not resolving despite treatment, OGD should be carried out to rule out any sinister causes such as cancer.
It is of vital importance that reoccurring symptoms are investigated appropriately as soon as possible. To ensure that this occurs, referral notes need to be completed correctly so that the right information is reported to the next clinician, who can then make their decisions with this in mind. In addition, it is imperative that clinicians do not rely on second-hand information and that they review the medical records for a patient before deciding on a treatment plan.