Decision Report 202102710

Summary

C complained about the care and treatment provided to their late spouse (A). A was diagnosed with pancreatic cancer. C was unhappy with the delays with A's treatment and said that these prevented A from receiving any treatment before their death.

The board said that their intention was to treat the cancer and that A was required to meet with a consultant to assess their fitness for surgery. The board said that the delay in meeting with a consultant was to allow the health board to carry out two multidisciplinary meetings, for some of A's symptoms (such as jaundice) to improve, and for other investigations and procedures to be carried out (such as, imaging scans and the fitting of stents). The board acknowledged that there was a delay in a PET-CT scan (where a drug is injected before the scan to help clinicians identify how certain body functions are working) being carried out due to failures in the drug production. The board said that when this fails, there is no back-up facility in Scotland to provide a replacement batch.

We took independent clinical advice from a consultant colorectal and general surgeon. We found that the timeframe for A's treatment could have been improved even with the allowable delays from the PET-CT scan. We considered that the investigations carried out were reasonable and the early scan and procedure to fit a stent were good points in the treatment pathway. However, the length of the pathway could have been improved and A's lengthy pathway to the offer of chemotherapy was unreasonable. The timing of the clinic appointment and PET-CT could also have been improved. Whilst we recognise some of the delays experienced could not be predicted or avoided, on balance, the timescale for A's pathway was unreasonable. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in assessing A's fitness for surgery and the impact this had on other investigations i.e. arranging a PET-CT scan, the delay in the PET-CT scan being carried out and A being identified as unsuitable for surgery. 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:

• Patients who are considered suitable for surgery should have early assessment to establish fitness for surgery.

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.