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Decision Report 201702071

  • Case ref:
    201702071
  • Date:
    May 2018
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained about the care and treatment provided to his father (Mr A) at the Western General Hospital. Mr C complained that there was a delay in the board diagnosing Mr A's non-Hodgkin's lymphoma (a form of blood cancer), and that the board did not follow-up his complaint in a reasonable way.

We took independent advice from a consultant radiologist (a doctor who specialises in x-rays and scans) and from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that there was an error in the reporting of a scan that Mr A had undergone for an unrelated condition, which resulted in a delay in the cancer diagnosis. We found that the board had acknowledged this delay and had taken some action to address this failing, however we made a further recommendation on this matter.

We also found that, after a meeting had been held with Mr C regarding his complaint, there appeared to be some uncertainty within the board as to what action they had agreed to take. We found that they should have contacted Mr C to clarify what outcome he was seeking and the failure to do so meant there were perceived delays in complaint handling.

We upheld both of Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mr A for the unreasonable delay in diagnosing him with non-Hodgkin's lymphoma; and apologise to Mr C for failing to follow up his complaint in a reasonable way. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

  • As far as possible, scan findings should be accurately reported.

In relation to complaints handling, we recommended:

  • Where it is not clear what outcome is expected from a complaint, steps should be taken to find out.

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.

Updated: December 2, 2018