Decision Report 201806377

Summary

Mrs C complained about the care and treatment her daughter (Miss A) received when she presented to the board with unexplained weight loss and upper abdomen pain. In particular, Mrs C complained about the investigations carried out to try and diagnose Miss A and the delay in diagnosing her with stomach cancer.

We took independent advice from a consultant general surgeon. We found that the majority of the investigations and tests carried out to try and diagnose Miss A were reasonable. However, we also found that:

a request for an endoscopic ultrasound (procedure that allows a doctor to obtain images and information about the digestive tract and the surrounding tissue and organs) should have been marked as urgent;

that the board did not enquire about the status of the endoscopic ultrasound request with the other hospital when it had not been scheduled within a certain period of time;

a lesion on Miss A's skin was not excised urgently; and

that the board should have considered requesting another urgent endoscopic ultrasound or a repeat scan when Miss A's symptoms were ongoing.

We also found that the interim discharge summaries did not contain sufficient information about the treatment provided, investigations carried out or any

follow-up treatment/recommendations and that the formal discharge letters were not sent within a reasonable period of time.

In light of the above, we upheld Mrs C's complaints, though we found that Miss A's prognosis would have remained poor even if an earlier diagnosis had been made.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to mark the requested endoscopic ultrasound as urgent; enquire about the status of the endoscopic ultrasound request; urgently excise the lesion on Miss A's skin; consider requesting an urgent endoscopic ultrasound or a repeat CT scan; ensure interim discharge summaries contained sufficient information; and send formal discharge letters within a reasonable amount of time. 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:

• Patients in a similar situation, who present with an abnormal mass in the upper stomach and persistent symptoms of pain, anaemia and weight loss, should have endoscopic ultrasounds requested on an urgent basis.
• Where an endoscopic ultrasound has been requested but not carried out within a reasonable time frame, this should be followed up.
• Where the board considers that a lesion should be urgently removed, the procedure should be carried out urgently.
• A request for an urgent endoscopic ultrasound or a repeat CT scan should be considered for patients in a similar situation with suspected stomach cancer who have normal gastric emptying studies and ongoing symptoms four months after presenting to the board.
• Interim discharge summaries should contain sufficient information to plan a transfer of care, including the treatment provided, investigations carried out and any follow-up treatment/recommendations.