Decision Report 201909121

Summary

C complained on behalf of their parent (A) about the care and treatment provided by the practice. C considered that there was a failure to carry out reasonable physical examinations and appropriate tests based on the symptoms A presented with, prior to A receiving a diagnosis of untreatable Signet Ring Cell Carcinoma (a type of cancer).

We took independent advice from a GP. We found that there was a failure to refer A for an urgent investigation or for an urgent ultrasound due to their weight loss, new diabetic diagnosis and age. We upheld this aspect of the complaint. We found there was a failure to carry out a physical examination of A on two occasions and also a failure to ensure that an urgent referral letter was sent to the colorectal (conditions in the colon, rectum or anus) service within a reasonable timeframe. Therefore, we upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for a failure to refer A for an urgent investigation or an urgent ultrasound; a failure to carry out a physical examination of A; and a failure to ensure an urgent referral letter was sent within a reasonable timescale.The apology should meet the standards set 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:

• Ensure clinical staff are aware of colorectal referral guidelines relating to the need for a physical examination of a patient prior to referral.
• Ensure relevant clinical staff are aware of referral guidelines for newly diagnosed diabetes and weight loss.

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.