Learning from cases: Oncology

Introduction

About the Author
Dr Heidi Mounsey is a medicolegal consultant and assists members in relation to many of the matters outlined in this booklet. She is a former anaesthetic registrar and is a Fellow of the Royal College of Anaesthetists. She joined Medical Protection in 2016.

Clinical negligence claims arising from oncology are rare, but medicolegal cases such as inquests, complaints, and regulatory matters are not uncommon.

The majority of claims reported to us are from private practice, whereas other case types can arise from the NHS and private settings.

COVID-19 meant there was a significant change to the way in which many doctors worked, including disruption to clinics, procedures, and a move to remote consultations. We also saw a large number of individuals contacting our medicolegal helpline for advice and support.

Issues arising as a consequence of COVID-19 included the prioritising of scarce resources, concerns over staffing levels and provision of PPE, COVID-19 vaccinations (including in relation to doctors who did not wish to be vaccinated and also those who had fraudulently obtained vaccinations for themselves or their family ahead of schedule), management of patients who refused to wear a mask, and worries about personal risk of exposure.

Medicolegal cases where COVID-19 is cited as a factor are ongoing, and it is likely the impact will continue to be felt for some time.

We understand that you work in complex and often pressured environments. We also know, following feedback from members, that experiencing a medicolegal case can be incredibly stressful. At Medical Protection we want to share our knowledge, experience, and expertise with you, so we can provide invaluable professional support.

Get more information about Medical Protection.

Analysis

We’ve analysed the support we provided UK-based oncology members in over 300 cases between 2016 and 2023. This covered a variety of matters, including:

We have studied all clinical negligence claims, including those defended, not pursued, and settled. We feel sharing our learnings about why patients decide to take action – and the reasons why claims are settled – is hugely valuable.

In our analysis of cases, such as regulatory and complaint matters, we have identified common themes that may lead to a concern being raised about a clinician.

Claims

Common themes in clinical negligence claims arising from private oncology practice included:

Case study

This case is based on a real scenario, with some facts altered to preserve confidentiality.

Mrs F, a 68-year-old woman with a past medical history of hypertension and diabetes, was diagnosed with adenocarcinoma of the lung. This was considered to be non-operable, and she was offered palliative chemotherapy. Mrs F opted to undergo this on a private basis under the care of Dr B, a consultant oncologist.

Her treatment was with carboplatin and pemetrexed, and she underwent two cycles with no concerns.

Prior to the third cycle of chemotherapy, an increase in creatinine was noted, having risen from 70μmol/L to 101μmol/L. It was considered, however, that it was still appropriate to proceed with the third cycle, and this was completed without complication. A CT scan showed a good response to treatment.

Blood results prior to the fourth cycle, however, demonstrated a further rise in creatinine to 173μmol/L. This result was not seen by the Consultant Oncologist when prescribing the chemotherapy – instead, Dr B reviewed the results from the previous cycle in error. Mrs F therefore received the fourth cycle, and the plan following this was for maintenance pemetrexed.

Blood test results several days prior to the first planned dose of maintenance pemetrexed showed a significant fall in haemoglobin from 110g/L to 59g/L, along with a rise in potassium from 4.5mmol/L to 6.3mmol/L and a creatinine of 589μmol/L. At the time of the blood test, Mrs F reported feeling breathless and fatigued.

The abnormal results were telephoned to the nursing staff by the laboratory, and the nursing staff left a message for Dr B relaying the low haemoglobin levels, but not the other results.

Dr B called the nursing staff in return to ask them to make arrangements to admit Mrs F urgently for a blood transfusion. Dr B did not enquire about any of the other blood test results at the time of the phone call, and the nurses did not convey any additional information about the remainder of the tests.

Mrs F was subsequently admitted, and the Resident Medical Officer (RMO) prescribed a two-unit blood transfusion, having been asked to do so by the nursing staff. No diuretics were prescribed and no treatment was given for the raised potassium. Dr B did not attend the hospital to review Mrs F, considering this to be a straightforward admission for a blood transfusion.

Partway through the transfusion Mrs F became acutely breathless and unwell. The RMO was asked to review the patient and contacted Dr B for further advice. At this point, Dr B was made aware of the other abnormal blood results, and arranged for transfer of Mrs F to the NHS setting for further management.

It was considered that Mrs F had developed fluid overload and acute pulmonary oedema. She required a period of time in intensive care. Following these events, her renal function remained poor, with a creatinine consistently around 500μmol/L, and it was considered that no further chemotherapy could be offered.

Mrs F brought a claim against Dr B alleging the following:

Expert evidence was obtained from a consultant oncologist and a consultant nephrologist. The experts concluded that no dose reduction at the time of the third cycle of chemotherapy was necessary, but the fourth cycle should not have proceeded. It was also concluded that Dr B should have looked at the full set of blood results obtained around the time of the transfusion, and Mrs F’s potassium level and renal function should have been addressed prior to starting the transfusion. Had this been the case, the episode of pulmonary oedema and the requirement for admission to intensive care would have been avoided.

It was considered, on the balance of probabilities, that the cause of Mrs F’s chronic renal failure was multifactorial, but that the administration of the fourth cycle of chemotherapy contributed more than minimally. In the absence of chronic kidney damage, it was agreed that further palliative chemotherapy was likely to have been considered, although it was noted that, due to co-morbidities and the advanced nature of the cancer, Mrs F’s renal function and performance status may have deteriorated in any event, such that further treatment would have been inappropriate.

The claim was settled for over £60,000, including damages and legal costs.

Learning Points

Ensure dates are checked when reviewing test results to ensure that information used to base clinical management or for prescribing decisions on is the most up to date. Had Dr B reviewed the most recent blood results, the fourth cycle of chemotherapy would not have proceeded.

Consider all relevant information when advising on the management of a patient, especially when doing so remotely. While it is acceptable to rely on information communicated by a colleague, Dr B retained overall responsibility for the patient and needed to ensure they were satisfied that they had relevant and sufficient information on which to base their clinical decision making. Had Dr B enquired about, or accessed, the rest of the blood test results at the time of advising a blood transfusion, Mrs F’s raised potassium and renal failure would have been identified earlier, and it is likely the episode of pulmonary oedema and the requirement for intensive care would have been avoided.

When admitting a patient to a private hospital on an urgent basis, consider whether it would be appropriate to review the patient in person on arrival, or ask that a colleague (such as the RMO) review them. Had Dr B attended the hospital to review Mrs F prior to the transfusion, or requested that the RMO review prior to prescribing blood, it is likely that the remainder of the abnormal blood results would have been identified at that point.

Common themes

Advice

We receive a large number of requests for written advice on a wide range of medicolegal issues, with common themes. These include:

Reports

Assistance was provided in over 50 report case types, including clinical negligence claims being made against Trusts, or for serious untoward incident investigations. The common themes identified include:

Complaints

Medical Protection assisted in responding to over 60 complaints arising from both NHS work and private practice. The majority of complaints come from patients or their relatives, but we also see complaints from other healthcare professionals, particularly related to communication, manner, and attitude. Common themes seen in complaints include:

Inquests

We assisted members in writing statements and attending coroners’ inquests on almost 60 occasions. An inquest is a fact-finding exercise that is conducted by the coroner, and in some cases, in front of a jury.

The purpose of an inquest is to find out who died, when, where, how, and in what circumstances. Our online factsheet about inquests gives further information about what to expect.

Our analysis identified the following themes, some of which were also seen in other cases:

Regulatory (GMC) and disciplinary cases

We are aware of the immense pressure and stress that many doctors go through during these investigations. We always aim to provide members with tailored care and expert support. GMC cases and hospital disciplinary matters have followed concerns raised by patients, relatives, or colleagues – both senior and junior. There was a mix of clinical and non-clinical concerns, but some investigations related to more than one concern or a series of serious clinical incidents.

The common themes were:

Where regulatory matters related to a single clinical concern, these were often closed, either at an early stage following an expert report obtained by the GMC – which did not raise significant concerns about the clinician’s practice – or following written reflection and evidence of learning presented to the GMC, without progression to the Medical Practitioners Tribunal Service for a hearing.

In cases involving probity, there is a high likelihood that a referral will result in a hearing, as illustrated by the following case study.

Case study

This case is based on a real scenario, with some facts altered to preserve confidentiality.

Dr K, a consultant oncologist, worked at an NHS Trust, while also holding practising privileges at a private hospital. During the period when self-isolation following a positive COVID-19 test was a legal requirement, Dr K developed symptoms of COVID-19 and tested positive.

He informed his NHS Trust of the positive test, and they confirmed that he was expected to self-isolate, as per the restrictions in place at the time and the hospital’s own policy. Dr K did not inform the private hospital of the positive test, although he was aware that their processes in relation to a positive COVID-19 test were the same as those of the NHS hospital, and that he was expected to self-isolate in line with government restrictions.

On what should have been day four of Dr K’s self-isolation period, he attended the private hospital to consult with five patients. He did not inform other staff at the hospital, or the patients, that he had tested positive for COVID-19. A colleague, Dr C, noted that Dr K did not look well, and asked about his health, to which Dr K said he was fine and reassured Dr C that he had taken a COVID-19 test which was negative.

The matter came to light the following day when Dr C, who worked in a different speciality, but the same NHS Trust as Dr K, attempted to contact Dr K in the NHS setting to seek advice about a patient. He was then informed by another colleague that Dr K was partway through a self-isolation period due to COVID-19.

Dr C was mindful that he had seen Dr K working the previous day and considered that there was no option but to inform the private hospital of this. The hospital subsequently referred the matter to the GMC.

The GMC referred Dr K to a tribunal, alleging breach of COVID-19 restrictions and hospital policy, and dishonesty in informing the colleague that he tested negative for COVID-19. It was further alleged that the attendance of Dr K at the hospital put colleagues and patients at increased risk of contracting COVID-19.

The tribunal heard evidence from a number of witnesses, including Dr K, and at the end of the hearing concluded that Dr K’s fitness to practise was impaired by reason of misconduct, and imposed a four-month suspension. No review hearing was ordered, and at the end of the suspension Dr K was able to return to work unrestricted, albeit in the NHS setting only, as the private hospital had removed his practising privileges.

In the absence of representation by a defence organisation, the cost of instructing a solicitor to assist with a regulatory or disciplinary matter can be significant. For example, the barrister fees alone incurred in representing Dr K in this matter were more than £18,000.

Oncology in the UK: top tips to minimise risk

Please note this is not an exhaustive list of recommendations, but some key learning points from our analysis: