Overview
The complainant (Mr C) raised concerns about delays by NHS Lanarkshire (the Board) in diagnosing his lung cancer and about the way that the diagnosis was communicated to him. Mr C had been attending the Neurology Department at Monklands Hospital (Hospital 1), when a Computerised Tomography (CT) scan at Southern General Hospital in May 2012 showed a suspected nodule in his lung. A second CT scan was requested in June 2012, but Mr C was not told about the suspected nodule in his lung. On 14 August 2012 Mr C was attending his GP Practice about another matter, when he was informed that the May CT scan had shown a possible diagnosis of cancer. There were repeated delays in arranging the second CT scan and Mr C did not undergo this CT scan until 7 September 2012 at Hairmyres Hospital, despite both he and his GP pursuing the matter. Following the second CT scan, Mr C was not seen by the Neurology department until 18 September 2012, when he was told it was almost certain that he had cancer. He was then seen by a respiratory consultant on 3 October 2012, and a biopsy was carried out on 4 October 2012. It was confirmed to Mr C that he had cancer of the lung on 15 October 2012.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the Board failed to carry out appropriate tests in order to diagnose Mr C’s condition within a reasonable timescale (upheld); and
- (b) the Board failed to keep Mr C reasonably informed about the results of his tests (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) confirm when the order-comms system will be fully operational in all the hospitals they are responsible for;
- (ii) provide evidence that they have reviewed with the clinical staff involved why no report of the failures identified in this report was made on the Datix system;
- (iii) provide evidence that they have carried out a Critical Incident Review;
- (iv) review the arrangements for providing cover for absent staff to ensure that urgent test results are reviewed timeously;
- (v) review the procedures within the Radiology Department at Hospital 1 to ensure that urgent test requests are identified and treated appropriately to avoid undue delay to patients;
- (vi) provide evidence that clinical staff have been reminded of the importance of effective communication with patients, especially when there may have been changes to their diagnosis; and
- (vii) apologise in writing for the failures identified in this report.
The Board have accepted the recommendations and will act on them accordingly.