Decision report 201201261

Summary

Mr C complained that he was unreasonably told that he had lung cancer, when in fact he had tuberculosis (a bacterial infection mainly affecting the lungs). Mr C explained that he was admitted to hospital for investigation of possible lung cancer. After a CT scan (a special scan using a computer to produce an image of the body) he was told that he had lung cancer and part of his lung would need to be removed. Mr C said the procedure was carried out, but when he received his patient discharge letter it showed his diagnosis as pulmonary tuberculosis.

Mr C's own account and the information in his medical records showed that at the time he was admitted to hospital he was aware that it was a possibility rather than a certainty that he had lung cancer. Having read Mr C's medical records, our independent medical adviser said that in later discussions Mr C was told of the likelihood rather than the certainty that the abnormality represented a lung cancer. The adviser said that, given that in his opinion the likelihood of Mr C having lung cancer at that point was at least 80 to 90 percent, it was not unreasonable to say that he might have lung cancer.

Our investigation did find a number of examples of the board failing to record information in Mr C's medical records, or entering incorrect information, so although we did not uphold the complaint, we made a recommendation about this.

Recommendations

We recommended that the board:

• feed back our findings on the board's record-keeping to the staff involved.