Decision Report 201603323

Summary

Mrs C complained about a delay by clinicians at the Victoria Infirmary in diagnosing that her husband (Mr A) had a cancerous tumour at the site of a previous operation.

Mr A was under two-yearly surveillance following his original surgery. Several years after his original surgery, Mr A reported new symptoms to clinicians and his GP. However, it took six months for a diagnosis of a colonic tumour to be made. Mrs C felt that the diagnosis should have been reached at an earlier stage.

We obtained independent medical advice. We found that Mr A should have been on yearly rather than two-yearly surveillance, in accordance with British Society of Gastroenterology guidelines. Arrangements were made for a procedure to be performed five months after Mr A began to report symptoms, but in the meantime he reported further symptoms. An appointment with a consultant was cancelled due to a change in the consultant's work patterns and this led to Mr A having to attend A&E with deteriorating symptoms.

We found that the clinicians should have arranged further investigations into the cause of Mr A's reported symptoms at an earlier stage. We therefore upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• share the findings of this investigation with relevant staff and ask them to reflect on their actions; and
• apologise to Mr A and Mrs C for the delay in arranging a medical review for Mr A.