Decision Report 201507686

Summary

Mrs C's father (Mr A) was treated with radiotherapy for cancer of the tongue. Following his treatment, Mr A received ongoing support from the board's community dieticians and regular reviews at a joint cancer clinic in another health board. He also received speech and language therapy (SALT) as part of the cancer clinic for about six months, and was then referred back to the board for ongoing SALT care.

In the 18 months following his treatment, Mr A had increasing difficulty swallowing and suffered from recurrent mouth ulcers and pain. He also had several short hospital admissions with bleeding from the mouth. He was subsequently admitted to Borders General Hospital in June 2014 with weight loss, decreased ability to swallow and stridor (noisy breathing caused by a narrowed or obstructed airway). He underwent endo-tracheal intubation (insertion of a tube to maintain an open airway to the lungs) and was transferred to a different hospital. Mr A passed away about ten days later.

Mrs C complained about Mr A's care during this period, and raised concerns that clinicians failed to adequately respond to Mr A's mouth pain, malnutrition and weight loss, as well as infections in his mouth. Mrs C also raised concerns about communication during two hospital admissions, including that Mr A was incorrectly told that his cancer had returned in May 2014.

After taking independent advice from a consultant in general medicine, a SALT therapist and a dietician, we upheld two of Mrs C's complaints. We found that when Mr A's SALT care was referred back to the board, the referral was not actioned properly, which meant that Mr A did not receive any SALT support for about a year (until shortly before his final admission). We also found there were failings in communication during Mr A's final hospital admission (although we noted that the board had acknowledged and apologised for this). However, we found no evidence that Mr A was given incorrect information during his May 2014 admission.

Recommendations

We recommended that the board:

• apologise to Mrs C's family for the failings our investigation has found;
• demonstrate to us what action has been taken to ensure SALT referrals are properly actioned in future;
• review their processes for ensuring joined-up post-treatment care for patients with head and neck cancer; and
• demonstrate to us what steps are being taken to improve communication with patients and their families (and documentation of this) at Borders General Hospital.