Decision report 201202449

Summary

Mr C's mother (Ms A) was admitted to hospital with chest pain. A CT scan (a special scan using a computer to produce an image of the body) was carried out, and suggested an underlying tumour. The board decided that a biopsy (a sample of tissue) was required to diagnose Ms A's condition. The sample was taken at hospital two weeks later. The results confirmed that Ms A had high grade lymphoma (a type of cancer). A chemotherapy regime (a treatment where medicine is used to kill cancerous cells) was planned, but Ms A started to deteriorate and died four weeks after admission to hospital. Mr C was concerned about the time taken to diagnose Ms A's condition and that she had not been adequately hydrated when she was under the care of the board.

As part of our investigation, we sought independent advice from a medical adviser. He considered that the board needed to obtain a biopsy to diagnose Ms A's condition. He further explained that the biopsy would have been difficult to obtain because of its location and the risks involved. The adviser considered it reasonable that medical staff were fully appraised of the situation and had to consider the best way of obtaining a biopsy. We accepted the adviser's view, and did not uphold this complaint.

Mr C also complained that Ms A had not been adequately hydrated. Ms A's medical notes indicated that instructions had been given to administer intravenous (IV - administered into a vein) fluid to rehydrate Ms A. This therapy was started two days after the instructions to do so had been given. We were critical of this and upheld this complaint.

Recommendations

We recommended that the board:

• bring this issue to the attention of staff involved and all other relevant staff and ensure that where IV fluid is considered to be required for a patient it is recorded and commenced without delay; and
• issue a written apology to Mr C for failing to ensure that Ms A was adequately hydrated.