Decision Report 201403430

Summary

Mrs C was referred to Aberdeen Royal Infirmary with pain on her left side, which her GP thought might be due to kidney problems. She was x-rayed, had an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) and was discharged with a diagnosis of constipation with no planned follow-up. Mrs C continued to be unwell and was treated by her GP for constipation (as advised in her hospital discharge letter). Mrs C collapsed at home and was readmitted to the hospital several months later. At that time a computerised tomography (CT) scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) was performed and a large mass, thought to be an ovarian cyst, was found. Mrs C had surgery to remove this mass and was advised that primary cancer had been found in her colon and it was this that had spread. Mrs C was offered chemotherapy but was advised that this was only to relieve symptoms as the diagnosis was terminal.

Following surgery to remove the primary cancer from the colon, Mrs C was told she was not terminally ill and that the spread of the cancer had not occurred as had been previously suspected.

We took independent advice from a medical adviser who said that the board's initial actions and their diagnosis of constipation were reasonable. Our adviser also considered that the treatment provided once the cancer was detected was reasonable and appropriate.

Nevertheless, our adviser said that it would have been good practice to have a bowel surgeon present during Mrs C's surgery given the known presence of abnormalities in the colon. Our adviser was also of the view that the pathology report following this surgery did not suggest a terminal diagnosis and he did not consider that the terminal diagnosis given to Mrs C had been appropriate. For these reasons, we concluded that the care Mrs C received was not reasonable.

Recommendations

We recommended that the board:

• apologise to Mrs C for incorrectly diagnosing her condition as terminal;
• ensure the staff involved in the diagnosis reflect on their diagnosis in light of our medical adviser's comments, in particular to ensure pathology reports are appropriately taken into account; and
• review the surgery carried out in light of our medical adviser's view that a bowel surgeon should have been directly involved.