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Case ref:201907885
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Date:May 2022
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Body:Forth Valley NHS Board
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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 board regarding the care and treatment provided to their late parent (A). Following a diagnosis of bladder cancer, the board identified that A would require heart surgery before they would be fit enough for bladder surgery. They referred A to another health board to provide that surgery, but this took a number of months to arrange and carry out. C told us that, by the time the heart surgery was completed, A's cancer had progressed to a point where treatment was no longer possible.
We took independent advice from an oncology consultant (a doctor who specialises in the diagnosis and treatment of cancer). We found that the board failed to identify radiotherapy as a possible alternative treatment, despite this advice being given by their oncology team. In addition, we found that the board had mishandled the referral to the other health board for heart surgery, failing to ensure that the other board were made aware of the urgency required. Then, when there were inevitable delays in surgery as a result, the board failed to identify that the window for treatment was closing.
For these reasons, we upheld C's complaints.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for failing to provide A with a reasonable standard of cancer treatment. 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:
- A full range of treatment options should be considered when deciding on a treatment plan, and reconsidered if the viability of the original plan changes.
- All referrals made to other boards for treatment should include full details of any time sensitivity around treatment. Where it is unclear if treatment can be provided quickly enough, direct communication should occur between the relevant teams to explore this and alternative treatment options.
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.