Decision Report 201900728

Summary

C complained on behalf of their parent (A) about the care and treatment A received at Raigmore Hospital. C was concerned that A was told by the hospital, following a CT scan, that they had a brain tumour (and likely metastases due to their lung cancer) when it later became apparent after an MRI scan that A had a stroke rather than a brain tumour.

We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant in acute medicine. We found many aspects of A's care and treatment to be reasonable. However, the CT scan report stated there was uncertainty over a diagnosis of metastases and that an MRI scan should be carried out. Over a 24-hour period, a diagnostic momentum increased. This meant whilst there was uncertainty around this diagnosis it was not picked up by successive clinicians and the working diagnosis became more certain despite a confirmatory MRI having yet to be carried out. A and their family were led to believe by successive clinicians over a 7-day period that A had a brain tumour when this was not certain. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure of successive clinicians to pick up on the fact the CT brain scan was uncertain around the diagnosis of a metastasis which led them to convey to A and their relatives that it was definitive. 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:

• The board should ensure CT scans commenting on diagnostic uncertainty should not be taken as definitive in their diagnostic conclusion.

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.