Decision Report 201700308

Summary

Mrs C was diagnosed with jak2+VE primary polycythaemia (a cancer where the bone marrow makes an excess of red blood cells). Mrs C complained that staff at Beatson Cancer Centre failed to take appropriate action to establish the cause of abnormal blood tests, and that if they had taken action, a diagnosis could have been made earlier.

We obtained independent advice from a clinical adviser who noted that, in the year prior to Mrs C's diagnosis, a doctor at the oncology clinic at Beatson Cancer Centre had ordered a full blood count inadvertently, which was not part of the usual practice from an oncology perspective. The full blood result revealed a high haemoglobin level and, according to the relevant guidance, further action should have been considered to determine the cause of the high haemoglobin level. However, as the oncology doctor was unaware that a full blood count had been ordered, there was no reason for the doctor to establish the result of the full blood test. It was noted that Mrs C already had a long previous medical history of high haemoglobin levels, which the clinicians were aware of, and she was not displaying symptoms of polycythaemia when she attended for clinical review in the year prior to her diagnosis. We found that Mrs C's high haemoglobin level at that time was of minimal clinical significance and Mrs C did not appear to have suffered any complications as a result.

We also reviewed the process where, in addition to the electronic reporting of the abnormal result, the laboratory would phone the clinician to highlight the abnormal result. We found that the criteria was not met in Mrs C's case, and that, according to the standard operating procedure, a phone call to alert the clinician was not required in this case. As such, we found that there had not been a failure in the reporting process. We did not uphold the complaint.