Decision Report 201404207

Summary

Early in 2013, Mr C was seen at Dumfries and Galloway Royal Infirmary as he had been experiencing throat discomfort. The consultant he saw said that no abnormality had been revealed and he discharged him with an assurance that all was well. However, Mr C's throat problems continued and, in July 2013, he found a lump on the side of his neck. His GP referred him urgently to hospital where, on examination, he was found to have throat cancer requiring urgent surgery. Mr C complained to the board who acknowledged that the consultant should have had greater suspicion about Mr C's symptoms and done a more extensive examination. These findings were discussed with the consultant but he remained of the view that it had been appropriate not to diagnose Mr C as having throat cancer.

Mr C complained to us. We investigated and took independent advice from a consultant surgeon who specialised in ear, nose and throat surgery. Our investigation confirmed the board's own findings about Mr C's complaint that the consultant did not show enough suspicion about his symptoms given current accepted risk factors; did not examine him appropriately; and that furthermore, as Mr C's symptoms were untypical of the diagnosis initially given, Mr C should not have been discharged without follow-up. Later, Mr C was not seen within an appropriate timescale as dictated by the urgent GP referral.

Mr C also complained about the board's delay in dealing with his complaints on this matter and we found that this had been the case and that he had not been kept fully updated. In light of this, we also upheld this complaint.

Recommendations

We recommended that the board:

• provide a formal apology for failures in care and treatment;
• ensure that the case is reviewed by the consultant as part of his next appraisal;
• discuss the case at the next Ear, Nose and Throat department's clinical governance meeting so that all members of staff are made aware of the circumstances and can learn from them;
• make a formal apology for the delay and lack of information; and
• consider current complaint response times and assure us that they meet the targets required in stated policy.