Decision Report 201702191

Summary

Mr C complained about the care and treatment his late father (Mr A) received at the Royal Alexandra Hospital. In particular, Mr C complained about an unreasonable delay in diagnosing and treating Mr A's metastatic melanoma (skin cancer that has spread). Mr C also complained about a failure to communicate clearly from the outset to Mr A that he was suspected to have cancer.

We took independent advice from a plastic surgeon. We found that appropriate investigations were carried out into Mr A's condition. However, we found that Mr A's treatment plan should have been discussed by the multi-disciplinary team when there were concerning findings from his full body scan. We also found that it would have been appropriate for Mr A to have been offered a scan. We upheld this aspect of the complaint.

We found that discussions with Mr A about his condition were not recorded. The board acknowledged failings in their record-keeping and outlined steps that they had taken to address this. We upheld the complaint and we have asked the board to provide evidence of the action that they said they have taken to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in referring Mr A to the regional multi-disciplinary team to discuss his treatment plan; for not offering a scan and for the failure to properly document discussions with Mr A in which he was told he might have cancer.

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

• High risk cases of melanoma should be discussed by the regional multi-disciplinary team before surgical treatment is carried 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.