Decision Report 201802782

Summary

Ms C complained that the board failed to provide a reasonable standard of care and treatment to her brother (Mr A) after he was referred by his GP for bowel problems. Mr A underwent a number of tests and was diagnosed with rectal cancer with liver metastases (tumours that have spread to the liver from other areas of the body).

We took independent advice from a consultant oncologist (a doctor who specialises in the diagnosis and treatment of cancer) . We found that there were no unreasonable delays in progressing Mr A’s treatment. The actions of staff in relation to carrying out liver and pelvic MRI scans were also reasonable. However, it had not been reasonable to wait until after a multidisciplinary team meeting to confirm the diagnosis of cancer to Mr A. There also should have been more evidence of involvement from a colorectal cancer nurse specialist, and it should have been clear to Mr A who to contact for information and support.

In relation to a consultation that Ms C and Mr A attended about Mr A’s treatment, we found that there should not have been a formal discussion with Mr A and his family about treatment until the relevant investigations had been completed. When he was seen, this should have been by an oncologist and not a colorectal surgeon. In addition, at the meeting Mr A was told that a further test had been arranged the previous week, whereas this test was only requested on the day of the meeting. In view of these failings, we upheld Ms C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide Mr A with reasonable care and treatment. The apology should meet the standardsset out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

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

• There should be early contact with patients to discuss the diagnosis
• All patients, newly diagnosed or with a suspected diagnosis of colorectal cancer, should have access at diagnosis to a clinical nurse specialist for support, advice and information.
• The board should consider when to arrange the key out-patient appointment and who the primary clinician should be.