Overview
The complainant (Ms C) raised concerns that her late sister (Ms A) was not told of her diagnosis for three weeks after having a scan which showed she had cancer. Ms A was then told she would be referred to oncology, but no appointment was offered for a further three weeks. Sadly, Ms A died a few days before the appointment was offered.
Specific complaints and conclusions
The complaints which have been investigated are that Lanarkshire NHS Board (the Board) unreasonably delayed:
- in informing Ms A of her diagnosis (upheld); and
- in offering Ms A an oncology appointment (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- undertake a specific internal enquiry to determine why the results of Ms A's scan were missed by both Accident & Emergency staff and radiology. The investigation should identify process improvements to ensure this situation does not reoccur, and the results of the investigation should be shared with Ms A's family, if they wish;
- issue a written apology to Ms C and her family for the failings this investigation identified;
- raise the findings of this investigation with Consultant 1 for reflection as part of their next performance appraisal; and
- review the Board's complaints handling processes and templates to ensure that: complaints involving more than one hospital are fully investigated and addressed, with input from all relevant staff (regardless of where the complaint is received); and any failings are clearly identified, and the causes for these, and any action to address them, explained.
The Board have accepted the recommendations and will act on them accordingly.