Decision Report 201500910

Summary

Mrs C complained that there was a four-month delay in the board carrying out her six-month follow-up scan at Gartnavel General Hospital to monitor her condition. When Mrs C had the scan done, it showed secondary cancer which she felt could have been avoided had her care plan been properly followed. In responding to the complaint, the board accepted that there had been an administrative error and apologised to Mrs C. They said that the scan would likely have gone ahead had a return clinic appointment been made then and took steps to remind administrative staff of their responsibilities. However, Mrs C remained concerned that the board were unable to explain why the error had occurred and if adequate steps had been taken to avoid the matter recurring.

We took independent advice from a consultant urological surgeon and found that the delay was unreasonable and not in line with local guidance. However, we considered that Mrs C's prognosis would not have been significantly affected had the scan and treatment been done sooner. We concluded that there was a lack of evidence to demonstrate whether or not the form requesting the scan was mislaid by either clinical or administrative staff or whether the urology doctor had in fact completed it in the first instance. Whilst an electronic system is now in place which will assist in reducing the likelihood of paper forms going missing, we made a recommendation to address the matter and we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• demonstrate what systems are in place to ensure that scan results are reviewed by the clinician responsible for the patient's care and that further monitoring takes place where appropriate; and
• draw these findings to the attention of the clinical team responsible for Mrs C's care.