Fatal Delays in Kidney Cancer Diagnosis and Treatment

• What happened to the client?
  Mrs H initially attended A&E presenting with a three-week history of bleeding, alongside a 10-week history of loss of appetite and weight loss. Whilst the A&E doctor initiated treatment for a presumed urinary tract infection, they raised explicit concerns that she may have cancer due to her age and symptoms.

• Was there a delay in diagnosis?
  Yes, following her A&E attendance, there was a string of administrative and clinical errors leading to a 116-day delay in her being put on the cancer pathway and final diagnosis of kidney cancer. These critical failures included a failure to trigger an urgent two-week wait (2ww) referral, a failure to add her to the Patient Tracking List, a failure to action radiology alerts identifying cancerous kidney tumours, and a failure to discuss her case at a Multidisciplinary Team (MDT) meeting

• What symptoms did she have afterwards?
  Following her formal diagnosis, staging scans showed significant disease progression and Mrs H suffered a severe physical decline. Just two months into her chemotherapy treatment, further scans diagnosed a bowel perforation, leaving her with severe abdominal complications that her body was too weak to handle.

• What were the consequences?
  Mrs H died a few days after her bowel perforation diagnosis. Following her passing, the hospital commenced its own internal investigation; the subsequent report highlighted critical lessons learned and set out specific local recommendations to ensure these systemic failures are never repeated. The delays in diagnosis and treatment of kidney cancer caused Mrs H’S unnecessary pain and suffering.  

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