Decision Report 201507460

Summary

Mr C complained that the board failed to clearly diagnose his late mother (Mrs A's) pulmonary fibrosis (a lung condition), and failed to communicate the diagnosis and manage the condition appropriately. Mrs A's pulmonary fibrosis was first identified in a scan carried out five years prior to her death. She regularly attended her GP and hospital over the intervening years with symptoms that included breathlessness. We obtained independent medical advice from a consultant respiratory physician, a consultant general physician and a consultant in emergency medicine. We identified that there were missed opportunities to appropriately refer Mrs A to respiratory medicine. In particular, an attendance at an ageing and health clinic did not result in an onward referral despite clear evidence of progression of Mrs A's condition. We were assured, however, that the limited available treatment options for pulmonary fibrosis meant an earlier referral was unlikely to have altered Mrs A's prognosis. Nonetheless, we recognised that earlier specialist intervention would have afforded Mrs A and her family the opportunity to better understand the nature of her condition and be assured that her symptoms were being appropriately managed. We upheld this aspect of the complaint.

Mr C also complained that the board did not respond to his letters of complaint fully and within a reasonable timeframe. We noted that the board's response to Mr C's initial complaint was issued in good time and attempted to address the specific concerns raised. Mr C then wrote to the board on a further two occasions listing several additional questions and outstanding concerns. We noted that the NHS complaints procedure does not make provision for further stages of the process and complainants who remain dissatisfied should be referred to the SPSO. We, therefore, did not consider that the board were obliged to provide the additional level of detail requested by Mr C. However, having agreed to provide a further written response, we considered that the board unreasonably delayed in doing so. We noted that the board had already apologised for the delay. We also considered that they could have responded with greater clarity. We therefore upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• apologise to Mr C and his family for the failure to clearly diagnose, communicate and manage Mrs A’s pulmonary fibrosis;
• carry out a review of Mrs A’s care and treatment and report the outcome back to us, ensuring that the failings this investigation has identified are fully reflected upon and account taken of the medical adviser's suggested areas for improvement;
• remind complaints handling staff of the importance of responding fully and accurately to complaints, and ensuring that the response represents the board’s definitive position in order that any subsequent disagreement can be appropriately referred to us; and
• remind complaints handling staff that, in circumstances where they choose to engage in further correspondence with a complainant, they should respond in a timely manner and keep them informed of any delays.