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The Parliamentary and Health Service Ombudsman (PHSO) is urging the government to invest in the NHS workforce and put the safety of cancer patients ‘at the top of the agenda’.
The calls come following a series of investigations into cancer by the PHSO, Rob Behrens. Mr Behrens carried out more than 1,000 investigations related to cancer between April 2020 and December 2023, which highlight continued issues with delayed diagnosis and treatment.
Mr Behrens says this is the result of an ‘over-stretched and exhausted’ workforce working in a system at ‘breaking point’. He says the government must act urgently to protect both patients and healthcare staff.
“Everyone deserves safe and effective care. But patient safety will always be at risk in environments that are understaffed and where staff are exhausted and under unsustainable pressure.
“We need to see concerted and sustained action from Government to make sure NHS leaders can prioritise the safety of patients and are accountable for doing so. A key part of this is investing in the workforce, for today and for the long-term, including providing full funding for the long-term workforce plan,” he said.
Delays in cancer diagnosis and treatment
In total, the PHSO carried out 1,019 investigations related to cancer over the course of three and a half years. In total, 185 were upheld or partly upheld.
The most common issues investigated included treatment delays, misdiagnosis, failure to identify cancer, mismanagement of condition and pain management. Poor communication, complaint handling and end-of-life care were also key issues raised during the investigations.
The effect of delayed diagnosis and treatment is clearly highlighted in one case recently closed by the PHSO. Sandra Eastwood died after two CT scans were misread, meaning she missed out on the chance of treatment.
Mrs Eastwood was discharged from hospital in June 2020 after being diagnosed with a haematoma caused by taking Warfarin for a heart valve replacement. However, her symptoms got worse, and in May 2021, she was diagnosed with Gastro-Intestinal Stromal Tumour (GIST).
The PHSO found that had Mrs Eastwood been diagnosed when she had the scans in 2020, her cancer might not have spread, and she may have been eligible for surgery. However, by the time she was diagnosed, this was no longer an option.
Earlier diagnosis of GIST, and treatment where surgery is an option, has a 95% survival rate.
Government must act to protect patients from harm
Rob Behrens, Parliamentary and Health Service Ombudsman, said: “What happened to Mrs Eastwood was unacceptable and her family’s grief will no doubt have been compounded by knowing that mistakes were made in her care.”
Sandra’s husband John said: “The whole experience was very distressing, which is why I went to the Ombudsman. I didn’t want this to happen to anybody else. Reading through their investigation report, had the hospital staff read the scans correctly and operated, my wife could have been here for another five to 10 years.”
Mr Behrens published a report in 2021 about recurrent failings in the way X-rays and scans are reported on and followed up across the NHS service, but says Sandra’s case clearly shows that not enough is being done to improve these services.
“The government must act now to prioritise this issue and protect more patients from harm,” he said.