Decision Report 201607588

Summary

Mr C complained about the care and treatment provided to his late wife (Mrs A) by the board. Mr C complained that when Mrs A was diagnosed with throat cancer, she was prescribed radiotherapy treatment despite the fact that she had previously undergone radiotherapy some years prior. Mr C said that he had concerns that this contributed to Mrs A's later diagnosis of mouth cancer. Mr C also complained that the board unreasonably delayed in diagnosing Mrs A with mouth cancer.

During our investigation, we took independent advice from an oncologist and an ear, nose and throat surgeon. We found that it was reasonable for the board to prescribe radiotherapy for Mrs A's throat cancer, as the area did not overlap with the previously radiated area and therefore would not cause any harm. We did not uphold this aspect of Mr C's complaint. However, we found that prior to Mrs A's diagnosis of mouth cancer, there had been a failure to examine the inside of Mrs A's mouth despite her reporting symptoms and having previously had throat cancer. We found that this resulted in around a month's delay in diagnosing Mrs A with mouth cancer. Therefore, we upheld this aspect of Mr C's complaint.

Mr C also complained that the board had failed to deal with his complaint in a timely and reasonable manner. We found that the board had experienced difficulties in locating Mrs A's medical records, but that they had not explained this to Mr C until around two months after the response was due. We also found that the board had advised Mr C that the medical records were lost, when they were not. We found this, along with the lengthy delay Mr C had in waiting for a response to his complaint, to be unreasonable. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable delay in diagnosing Mrs A's mouth cancer and for failing to deal with his complaint in a timely and reasonable manner. The apology should meet the standards set out in the SPSO guidelines on apology, available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Consideration should be given to establishing guidelines for a standard follow-up examination of patients who have been treated for head and neck cancer.
• Between the written notes and the clinic letter, it should be clear what has and has not taken place.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.