Decision Report 201403024

Summary

Mrs C, who is an advice worker, complained on behalf of her clients (Mr and Mrs A) that there was a delay in diagnosing Mr A's cancer.

During our investigation, we took independent advice from one of our medical advisers, following which we upheld Mrs C's complaint. The adviser said that there was an unreasonable delay in the diagnosis of Mr A's cancer. Two abnormal chest x-rays should have been reported to the clinicians caring for Mr A, which would have prompted them to consider further investigations. This did not happen and was a failure in care. We noted that the board had accepted that the diagnosis of cancer should have been reached sooner, which might have enabled treatment to have started earlier and afforded Mr A an improved outcome. We noted that the matter was to be discussed by the appropriate clinical staff to increase staff awareness of this type of situation and to take more appropriate action in the future.

Recommendations

We recommended that the board:

• report back to us on the outcome of the discrepancy meeting attended by the Head of Radiology to discuss this case.