Decision Report 201402688

Summary

Mrs C complained about the care and treatment that her late mother-in-law (Mrs A) had received. Mrs A had been referred to an orthopaedic consultant (a doctor who specialises in conditions involving the musculoskeletal system) and was seen in January 2013. She was re-referred by her GP practice in May 2013 but was not seen again until late July 2013. Mrs A died of widespread secondary cancer in October 2013, having been diagnosed a matter of weeks previously.

Our role was to assess whether the evidence indicated that Mrs A’s treatment was reasonable in the circumstances at the time. We took independent advice from our medical adviser, who said the steps taken by the orthopaedic consultant had been reasonable. In light of the symptoms Mrs A displayed in January 2013, the advice we received was that it would not have been normal practice to have carried out additional investigations for cancer.

The board did, however, acknowledge their delay in arranging Mrs A’s second appointment (the GP practice’s re-referral appeared not to have been acted upon promptly). We considered this to have been unreasonable and, although the advice was that this did not affect Mrs A’s overall outcome, the board acknowledged that earlier diagnosis would have led to better pain control and palliative care. We recognised the importance of receiving such care and so, on balance, we upheld Mrs C’s complaint because of the delayed second appointment and its possible impact on Mrs A’s palliative care. We also made two recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings we identified; and
• send us evidence of the steps taken to address referrals promptly and their effect.