Decision Report 201609128

Summary

Mr C complained that the practice delayed in referring his late father (Mr A) for appropriate specialist investigation of his iron deficient anaemia (a condition where the blood lacks an adequate amount of healthy red blood cells). Mr C considered that an urgent colonoscopy should have been arranged, in line with cancer referral guidelines. He also raised concerns about the chosen referral pathway once a referral was eventually made, as the referral was to a vascular surgeon rather than directly for colonoscopy. Mr A was subsequently diagnosed with colorectal cancer which was not amenable to treatment and he later died. In responding to Mr C's concerns, the practice said they did not deem an earlier referral appropriate at the time in light of Mr A's other complex medical conditions.

We took independent medical advice from a GP, who advised that there were no current complex medical conditions which could have explained the significant deterioration in Mr A's red blood count. As such, they advised that cancer referral guidelines should have been followed and Mr A should have been appropriately assessed and referred for urgent investigation. We found no evidence of an appropriate examination having occurred and a referral was not made until almost nine months after iron deficient anaemia was diagnosed. We found that the referral should have been sent to a gastroenterologist or surgical doctor, rather than a vascular surgeon. In addition, the adviser highlighted that Mr A was prescribed an inappropriate dosage of iron supplements and he was not adequately monitored to assess his response to these. We concluded that there was an unreasonable failure to appropriately assess, treat and monitor Mr A's iron deficient anaemia, and an unreasonable delay in arranging appropriate specialist investigation. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable failure to appropriately assess, treat and monitor Mr A's iron deficiency anaemia; and the unreasonable delay in arranging appropriate specialist investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-guidance.

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

• The GP involved in Mr A's care should refer themself to NHS Grampian's clinical support group for review of their knowledge and practice in relation to clinical assessment, prescribing and referral guidelines.

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.