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Case ref:201904180
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Date:September 2020
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Body:A Medical Practice in the Lanarkshire NHS Board area
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
C complained about the time taken by the practice to refer them to the breast clinic. C initially attended at the practice with pain in their breast, which was diagnosed as musculoskeletal pain. C later returned to the practice with ongoing pain and a new lump in their breast. The practice referred them urgently to the breast clinic and a scan found a large breast cancer.
We took independent advice from a GP and from a breast surgeon. We found that the treatment provided at the initial appointment was, for the most part, reasonable, and we did not find sufficient evidence to conclude that the practice missed the breast cancer in that appointment. However, we considered that the practice should have advised C, at their initial appointment, to return within three months (in keeping with guidelines). Ideally, the practice should also have sent the referral to the breast clinic as 'urgent – suspected cancer' rather than simply 'urgent', although we accepted that, on balance, this was not unreasonable. Based on the failings identified, we upheld C's complaint. We noted that the practice accepted both these points and considered the action taken was appropriate for reflection and learning .
Under section 16G of the SPSO Act, SPSO has a responsibility to monitor and promote good practice in complaint handling by organisations under our jurisdiction. We found that the practice failed to fully reflect on and learn from C's complaint until prompted by this office. We therefore made recommendations to address the failings we identified.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for not advising them to return within three months, and for failing to fully reflect on their complaint until prompted by our investigation. 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 practice should be willing to reflect on and learn from complaints (without being prompted by an investigation from this office).
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.