Decision Report 202006744

Summary

C complained about the care and treatment provided to their late spouse (A). A was suffering from facial pain and numbness and underwent an MRI scan. The MRI reported a benign slow growing tumour at the base of A's skull which can usually be managed with pain killers or sometimes stereotactic radiosurgery (SRS, a high dose of radiotherapy to a small area) is considered. Shortly after, A's local health board referred A to Lothian NHS Board for treatment. A attended a telephone consultation with a neurosurgery consultant (specialist in surgery on the nervous system, especially the brain and spinal cord). A was not considered to have a diagnosis of cancer given the findings of the MRI scan and was referred on a routine basis for consideration of SRS treatment.

A's case was subsequently reviewed at a multidisciplinary team meeting by clinicians at Lothian NHS board. It was identified from a review of the MRI report received from A's local health board, that there were other not previously identified lesions in A's brain, which were in keeping with metastases (cancer that has spread from other areas of the body). A was referred on an urgent basis to their local health board for further investigations including an MRI scan and CT scan. A was diagnosed with cancer and died shortly after.

We took independent advice from a consultant neurosurgeon. We found that the MRI report did not show any sinister findings which required urgent intervention and that the board took appropriate action. However, the review of the MRI at the subsequent multidisciplinary team meeting identified metastatic lesions. We considered that the review of the MRI took place within a reasonable timeframe.

We took additional advice from a consultant radiologist (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) about the findings of the MRI performed by A's local board. We found that the report had not detected tiny abnormalities which, if identified at the time, would have raised the suspicion of metastases and led to earlier investigation to look for the source of the primary tumour elsewhere in the body. However, we considered that the undetected findings were subtle and likely to have been missed by a number of radiologists. Therefore, the MRI report findings were of a reasonable standard.

We considered that the board had provided A with reasonable care and treatment on receipt of the referral from A's local board. Therefore, we did not uphold C's complaint.

We provided some feedback to the board with respect to the importance of acknowledging and responding to concerns raised by GPs about a patient's symptoms, particularly pain.