Decision Report 201601505

Summary

Ms C, an advocacy and support worker, complained on behalf of her client (Mrs B) regarding the care and treatment of her late husband (Mr A). Mr A was referred to the respiratory team at Inverclyde Royal Hospital with a worsening cough, and lung cancer was suspected. However, the diagnosis was not formally confirmed until a number of months later. Mr A was then informed that his condition was terminal and that he only had a few weeks left to live.

Ms C complained about the delay in diagnosing Mr A's cancer. Mr A was diagnosed with an empyema (a collection of pus between the lungs and inner chest wall) in the interim period and the board indicated that treating this became the priority. They said that delays caused by Mr A's impaired health meant that biopsies could not be carried out sooner.

We took independent medical advice from a respiratory consultant. We found that it was reasonable for the medical team to have focussed on the management of the empyema. It was noted that Mr A's case was discussed with the lung cancer multidisciplinary team on a regular basis. We considered that the cancer diagnosis was not unreasonably delayed and therefore, we did not uphold this part of Ms C's complaint. However, we found that there was a delay in commencing Mr A on antibiotics when an infection was identified following a bronchoscopy (a procedure that examines the inside of the lungs and airway). While we did not consider that this contributed to the delay in diagnosing the cancer, we made a recommendation in relation to this.

Ms C also complained that there was a lack of communication with Mrs B and Mr A by the medical team. We found that the medical records documented reasonable efforts by staff to communicate with both Mrs B and Mr A. However, the board reflected that their communication fell short of what they would expect. In particular, they acknowledged that sickness absence of key staff directly impacted on the level of support Mr A received. Therefore, we upheld this part of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for the unreasonable delay in commencing Mr A on antibiotic medication for the infection identified following the bronchoscopy procedure. 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:

• When test results identify the need for antibiotic treatment, medical staff should ensure that this is commenced within a reasonable timeframe.

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.