Overview
The complainant (Mr C) had part of a lung removed following a diagnosis of cancer at Crosshouse Hospital (Hospital 1). He was subsequently found not to have cancer and Mr C complained that the treatment had been unnecessary. Mr C also said that staff at Hospital 1 had delayed in communicating the change in diagnosis to him and had not answered his questions fully. In addition, Mr C complained that there had been a delay in putting him back on the kidney transplant waiting list and that the response to his complaints by Ayrshire and Arran NHS Board (the Board) had been inadequate.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) there had been an error in the diagnosis of cancer, which led to an unnecessary operation (upheld);
- (b) there were problems with the communication to Mr C about the new diagnosis and the response to his questions about this (upheld);
- (c) there had been an unreasonable delay in ensuring Mr C was put back on the kidney transplant list (upheld); and
- (d) the responses to Mr C's complaints were inadequate (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) undertake a short, focussed audit of lung fine needle aspirations (FNA)s carried out by the department;
- (ii) review, as a matter of urgency, the clinical use of such FNAs by Hospital 1;
- (iii) emphasise to clinical staff involved the importance of taking and documenting a full clinical history; this matter should be confirmed with Consultant 1 as part of his annual appraisal;
- (iv) emphasise to staff involved the importance of timely and open communication;
- (v) alert staff to the need to ensure appropriate communication with patients and file management, in an effort to prevent the situation recurring, where a patient could be concerned about information placed in his/her file which has not been discussed with him/her;
- (vi) undertake a full review of the operation of their complaints process and the relationship of this to clinical governance, as a matter of urgency;
- (vii) establish why an incident review was not considered and this matter not re considered by the lung cancer multi-disciplinary team and take appropriate steps to ensure that their own policies and procedures are followed by clinical and complaints handling staff; and (viii) make a full apology to Mr C for the failings identified in this report.
The Board have accepted the recommendations and will act on them accordingly.