Overview
The complainant (Mr C) raised a number of concerns that this brother (Mr A) had been inappropriately cared for and treated in Highland NHS Board (the Board) hospitals between February and October 2010.
Specific complaints and conclusions
The complaints which have been investigated are that the Board:
- (a) delayed in diagnosing Mr A's cancer, including a delay in Mr A being reviewed by Gastroenterology (upheld);
- (b) inappropriately discharged Mr A from Caithness General Hospital on 9 June 2010 (upheld); and
- (c) did not adequately communicate to Mr A the details of his diagnosis and prognosis (not upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) review endoscopy waiting times, taking into account SIGN and NICE guidance, and report on what steps will be taken to address capacity issues to avoid delays such as that identified in this case;
- (ii) explain how cancelled endoscopies will be treated as adverse events;
- (iii) review the circumstances of Mr A's admission and discharge on 8 and 9 June 2010, with a specific focus on the potential for an inter-hospital transfer, and discharge criteria, and report on the lessons learned;
- (iv) review admission clerking and medical record-keeping at Hospital 1, to ensure it is in line with current standards; and
- (v) remind consultants of their responsibility to inform patients personally of their test results and likely consequences, and to note this in the medical records.
The Board have accepted the recommendations and will act on them accordingly.