Decision Report 202303181

Summary

C complained about delays in the care and treatment provided to their spouse (A) who was diagnosed with lung cancer following an abnormal chest X-ray. C said that there was a delay in A being provided with a CT scan result by the respiratory consultant, and a further wait to be seen by the oncologist (cancer specialist) following A’s biopsy (a medical procedure that involves taking a small sample of body tissue so it can be examined under a microscope). C asked whether A’s diagnostic pathway influenced their treatment, in that patients with more curable grades of cancer were treated sooner.

We took independent advice from a consultant oncologist. We found that there was no formal pathway for lung cancer patients in place at the time. We also found that the diagnostic pathway being used, was inadequate for all patients, not just for A or other patients with high grade cancer.

We found that due to a shortage of respiratory physicians at the time, there was a delay in arranging a review with the respiratory consultant. This resulted in delays to the biopsy which delayed a treatment plan. The board have accepted that the pathway for A was delayed and have made improvements to enable patients to follow the optimal lung cancer pathway. We found that there was an unreasonable delay in carrying out a respiratory review and that this, and a lack of formal pathway, had a significant impact on A’s overall treatment plan and experience. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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.