Overview
The complainant (Mrs C) raised concerns about delays by NHS Lanarkshire (the Board) in diagnosing her father (Mr A)’s bowel cancer. Mr A was seen by a respiratory consultant (the Consultant) at an out-patient clinic at Monklands Hospital (the Hospital) on 24 July 2013 following a referral from his GP. Mr A had been suffering from breathlessness for a number of months and had been treated for a lower respiratory tract infection. The Consultant's diagnosis was that Mr A was suffering from mild asthma brought on by the lower respiratory tract infection and blood was taken for routine tests.
Tests of the blood taken by the Consultant showed that Mr A had a low level of haemoglobin (a protein found in red blood cells which carries oxygen around the body). The laboratory noted that there were features of iron deficiency and that blood loss should be excluded as a possible cause. The laboratory did not highlight the low haemoglobin level by telephone and the Consultant did not identify or act upon this abnormality when reviewing Mr A's results.
Due to his continuing symptoms, Mr A had further blood tests carried out by his GP on 9 September 2013 and was admitted to the Hospital the following day where he required a blood transfusion. He was subsequently diagnosed with colon (bowel/large intestine) cancer and liver metastases (the spread of cancer).
Specific complaints and conclusions
The complaints which have been investigated are that the Board failed to:
- take appropriate action when Mr A's blood result showed an abnormally low haemoglobin level (upheld); and
- ensure that Mr A received timely follow up treatment when the abnormally low haemoglobin level was discovered (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- confirm the outcome of their review of this incident and advise what steps have been taken to prevent recurrence in future;
- review their governance arrangements for identifying systems errors like this in future;
- apologise for the failure to implement the Telephoning of Results Protocol;
- apologise for the delay in Mr A's diagnosis;
- confirm that this matter will be, or has been, discussed at the Consultant's annual appraisal;
- conduct a Board level review of the tracking of test results in both paper and electronic formats; and the role of individuals who order tests and report their results; and
- make the outcome of any recommendations arising from the Board level review available to us, Mr A and his family.
The Board have accepted the recommendations and will act on them accordingly.