Decision Report 201606992

Summary

Mrs C, who works for an advocacy and support agency, complained on behalf of her client Mr A. Mr A's late wife (Mrs A) had been diagnosed with lung cancer. Mrs A began to suffer severe neck pain which subsequently spread to her shoulder and arm. Mrs A was admitted to Dr Gray's Hospital at the request of her GP. Given that a recent scan of the shoulder had shown no problems, a further x-ray or scan was not requested by clinical staff at the acute medical assessment unit. Mrs A was discharged home the following day. Mrs A's pain continued and a few days later she was admitted to Aberdeen Royal Infirmary. X-rays and a scan were performed which showed that Mrs A's cancer had spread to two cervical vertebrae (neck bones) and to the brain. Mrs C complained that the board had failed to provide Mrs A with adequate care and treatment during her admission to Dr Gray's Hospital.

The board acknowledged that Mrs A should have been referred to the oncology team and that a neck x-ray should have been performed. They apologised for the delay in diagnosis and that they did not recognise or control the cause and nature of Mrs A's pain. The board explained that they have taken action following this complaint, including using the National Cancer Treatment Helpline, as well as considering direct referral to the oncology team. They explained that they are working to maintain the awareness of these mechanisms to prevent a recurrence through information on their intranet and documentation in induction packs. We have asked the board to provide evidence of these actions.

We took independent advice from a consultant in acute medicine. The adviser's view was that the possibility of the cancer spreading to the cervical vertebrae or the spinal cord should have been considered. The adviser said that Mrs A's pain should have been managed as a possible malignant spinal cord compression (an issue that develops when the spinal cord is compressed by bone fragments, a tumour, an abscess or other lesion. This is an issue that is usually treated as a medical emergency). The adviser's view was that there should have been a discussion with oncology and that the use of steroids and an MRI scan should have been considered. The adviser stated that they would expect doctors working in an acute medical assessment unit to recognise this and perform this role. In light of this, we upheld the complaint.

Recommendations

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

• The board should have a malignant spinal cord compression protocol.
• All clinical staff within the Acute Medical Assessment Unit should be made aware of the malignant spinal cord compression protocol.
• Clinical staff within the Acute Medical Assessment Unit should learn from this case.

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.