In this case, the patient attended their GP with stomach pains. The patient was referred for an ultrasound scan and blood tests. The patient was then diagnosed with cirrhosis (scarring or fibrosis of the liver caused by long-term liver damage. Over time the build-up of scar tissue prevents the liver working properly).
The patient was a type 2 diabetic whose diabetes was being controlled with diet and exercise. They were told there was some fat on the liver and the patient should continue with the diet and exercise and would be reviewed in 12 months.
After this 12-month review, the consultant organised Hepatocellular Carcinoma (HCC) Surveillance ultrasounds every 6 months, however the next appointment was cancelled, and no further referrals were made. The patient was next seen for an ultrasound two years later. An ultrasound at this time revealed a 6cm diameter HCC tumour on the patient’s liver.
Main Learning Points
When the patient’s surveillance appointments were cancelled, they were not rescheduled. By not appropriately surveying the patient’s condition, the tumour grew without diagnosis for two years.
- The consultant was not aware that the patient’s scans had been cancelled and not rescheduled. By not taking reasonable efforts here delays were caused which resulted in tumour growth and delayed diagnosis.
Reducing the Risk of Litigation
TMLEP recommends the following:
With regard to point (1):
All patients with liver cirrhosis should be considered for a hepatocellular carcinoma screening programme.
Where scans need to be cancelled, they should be rearranged in a timely manner and the treating clinician should be made aware of the cancelled referral.
- Patients should be informed of all appointment bookings, cancellations and rebookings. This allows them to follow-up any missed communications that might occur,
With regard to point (2):
Patients should be seen in clinic regularly if there are concerns to ensure scans or other tests are not missed. In these instances, for any patient that has an investigation - the results should be fed back to them. This can be a nurse-led clinic or Consultant. This ensures all parties are kept in the loop and oversights are reduced.
- Where surveillance is required, the treating clinician should check for the scan reports and, if they are not present, organise for a scan to be undertaken. Proforma/package of care or care bundles for patients with stable cirrhosis that includes HCC surveillance, which can be nurse-led, would assist with this.
6-monthly ultrasound surveillance for patients with cirrhosis (with or without serum alpha-fetoprotein measurement) is important as it may lead to early detection of Hepatocellular Carcinoma (HCC). HCC may be asymptomatic until it is at an advanced stage. Early detection is important to allow prompt treatment that can improve survival.