Decision Report 201601601

Summary

Mrs C complained about the care and treatment that was provided to her late niece (Miss A) by Hairmyres Hospital and Wishaw General Hospital. Miss A had been referred to the board by her GP due to gynaecological problems she had been suffering with. The GP referral was downgraded from urgent to routine by the board. Miss A attended the board's out-of-hours service at Hairmyres Hospital on two occasions between the date of the GP referral and her gynaecology appointment.

Miss A was seen at the gynaecology department at Wishaw General Hospital within the timescales for a routine appointment and, following examination, arrangements were made for day surgery investigations. A number of weeks before the arranged date for surgery, Mrs C became increasingly worried about Miss A's health and took her to Wishaw General Hospital, where she was admitted. Miss A was subsequently diagnosed with cervical cancer.

Mrs C complained that there was an unreasonable delay by staff at Wishaw General Hospital in diagnosing that Miss A had cancer and that the out-of-hours service at Hairmyres Hospital did not take reasonable action in light of the symptoms that Miss A presented with.

In investigating Mrs C's complaints, we took independent advice from a consultant gynaecologist, an out-of-hours GP and a consultant histopathologist (a consultant in the study of changes in tissues caused by disease).

On the basis of the advice we received, we upheld Mrs C's complaint about the delay in staff diagnosing that Miss A was suffering from cancer. While we found that it was reasonable to downgrade the GP referral to routine on the basis of the information available at that time, the advice we received was that there was insufficient urgency in arranging appropriate investigations after Miss A was seen at the gynaecology department at Wishaw General Hospital. Although we considered that there was an unreasonable delay, the advice we received was that earlier diagnosis would not have affected Miss A's prognosis. We found that the board had already identified some improvements to be made in this area, but we made further recommendations as a result of our findings.

We did not uphold Mrs C's complaint about the out-of-hours service at Hairmyres Hospital as the advice received was that reasonable care and treatment were provided for the symptoms that Miss A reported.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that appropriate investigations were not urgently arranged for Miss A following her attendance at the gynaecology department at Wishaw General Hospital. This apology should comply with SPSO guidelines on making an apology, found at www.spso.org.uk/leaflets-and-guidance.

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

• Patients with symptoms that are potentially indicative of cervical cancer should be referred for colposcopy (a procedure used to look at the cervix in detail) and seen urgently.

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.