Decision Report 202102246

Summary

C complained that the care and treatment that their sibling (A) received from the board was unreasonable. A had previously been diagnosed with breast cancer and had a mastectomy (surgical removal of the breast tissue). When A became ill, the symptoms were considered to be related to irritable bowel syndrome (IBS, a condition of the digestive system that can cause stomach cramps, bloating, diarrhoea and constipation). A's symptoms persisted and A was admitted to hospital on numerous occasions. A scan showed a tumour attached to their kidney and they died some months later.

C complained that despite A's multiple hospital admissions and concerns that the cancer had returned, the board failed to reasonably respond to A's worsening condition and delayed or failed in carrying out appropriate investigations.

We took independent advice from a consultant colorectal and general surgeon adviser. We found that, overall, there was a failure to adequately investigate symptoms, take into account patient history, and appropriately manage A's care, including acting on findings of sclerotic bone lesions (an unusual hardening or thickening of your bone) and a failure to consider an overarching diagnosis. Whilst the board did carry out a Significant Adverse Event Review (SAER) in relation to A's care and treatment, this failed to identify all of the failings highlighted above. As such, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaint. 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:

• Appropriate and timely investigations, including radiological investigations, should be considered for patients presenting with abdominal pain, recurrent vomiting and diarrhoea not known to be infective and with no explanation.
• CT KUB findings (scan of the kidneys, ureters and bladder) of sclerotic bone lesion should be investigated appropriately.
• When SAERs are carried out, failings should be identified appropriately and action should be taken to ensure that lessons are learned.

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.