Overview
The complainant (Mr C) had a lump on his lower left leg removed in 1998 at Stonehouse Hospital (Hospital 1). This was diagnosed at the time as a benign fibromatosis. Some years later, Mr C became aware of a second lump close to the site of the first and he consulted his GP, on 12 July 2004. Mr C was referred by his GP to Hairmyres Hospital (Hospital 2).[1] The referral letter referred to the lump as a recurrence of a 'ganglion' which had been removed in 1998. Following removal of the second lump in May 2005 at Hospital 2, Mr C was diagnosed as having a rare form of cancer and referred for further treatment to a specialist group at the Beatson Centre in Glasgow (the Centre).[2] Mr C complained to the Ombudsman about the GP's diagnosis in the referral letter. In the course of the Ombudsman's investigation, samples from the lump removed in 1998 were re-examined and also found to be cancerous. Concerns were raised that this had not been diagnosed by Hospital 1 in 1998 and also about the treatment Mr C had received in 2004/2005 from Hospital 2 and in 2005 from the Centre. As a result, the investigation was widened to include these aspects of his care.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) a GP unreasonably misdiagnosed a lump on Mr C's leg as a ganglion (not upheld);
- (b) the care and treatment provided by Hospital 1 and Hospital 2 was inadequate (not upheld); and
- (c) the care and treatment provided by the Centre was inadequate (not upheld).
Redress and recommendations
The Ombudsman recommends that:
- (i) the Practice feed back to clinical staff the adviser's comments in connection with note keeping and referral letters;
- (ii) this report be shared with the clinical staff involved in Mr C's care and treatment by Lanarkshire NHS Board to consider whether the learning identified could be shared more widely; and
- (iii) Lanarkshire NHS Board consider whether the procedures in place are adequate to ensure that the outcomes of tests are appropriately communicated to GP Practices.
The Practice and Lanarkshire NHS Board have accepted the recommendations and will act on them accordingly.
The Ombudsman has no recommendations in respect of Greater Glasgow and Clyde NHS Board.
[1]Lanarkshire NHS Board are responsible for Hospital 1 and Hospital 2.
[2] Greater Glasgow and Clyde NHS Board are responsible for the Centre.