Summary
Mr A had an operation in May 2011 to remove half of his large bowel due to a malignant tumour. In May 2012, Mr A had a follow-up appointment and his GP was contacted to say that blood tests had been taken, a scan was to be arranged, and that Mr A would be seen again in six months. Mr A had his scan in July 2012. No action was taken by the board as a result of the scan test, and Mr A did not have another appointment until September 2013. It was at this appointment that he learned that the results from the July 2012 scan indicated that it was likely that cancer had spread to his liver and one of his lungs. At this point a second scan was arranged, but there were further delays at this point in obtaining a scan. Mr A's daughter (Mrs C) had to contact the board a number of times to get an appointment for her father. She complained to the board but was not satisfied with their response, and so complained to my office. Mr A began chemotherapy in late 2013, and died in August 2014.
As part of my investigation I took independent advice from a consultant physician and a consultant oncologist.
On Mrs C's first complaint about the delay in assessing her father's test results, I found that a combination of errors and inadequate systems resulted in a failure to assess and refer Mr A for treatment of his cancer. My physician adviser noted that the board had not more thoroughly investigated the handling of the test and scan results in their response to Mrs C. Given that neither set of results had been handled correctly, the adviser was concerned that this reflected a more general failure of results gathering / scrutiny by the board. Whilst some changes to test result handling procedures have been made by the board since the time period under investigation in this case (as a result of a recommendation in a previous SPSO case 201305802), further action will be required to fully address the concerns outlined in my investigation. My adviser was also concerned to note that the board's response to Mrs C's complaint did not reflect on their role in regard to the long period between follow-up appointments. I am therefore concerned that this situation could arise again.
The delays in arranging a second scan were also unacceptable. Whilst the board accepted that Mrs C had to make an unreasonable number of calls to chase an appointment, they have not apologised for this. My advisers both noted that, given the circumstances surrounding the initial delay in communicating the scan results to Mr A, it was not reasonable to leave Mr A and his family waiting again for the second scan. The board had also not apologised to Mrs C for the second delay, and I am very critical of this.
Mrs C had noted that when her father saw the cancer specialist after the second scan, he was told that even if the July 2012 scan result had been picked up earlier, he would not have been offered further surgery and that starting chemotherapy at an earlier stage would have been unlikely to make any difference to his prognosis. However, the advice I received from my oncology adviser was that Mr A received very poor care: even if there was no treatment to cure his cancer at that time, being told of the results more than a year prior to when he actually found out would have given him and his family more time to know that he was terminally ill and to plan accordingly.
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) apologise to Mrs C for the delay in acting on the spread of cancer reported in July 2012;
- (ii) ensure this case is raised with the Registrar and Consultant 1 for discussion at their annual appraisals;
- (iii) review the process for the booking of out-patient clinic appointments;
- (iv) take steps to ensure all laboratory staff are fully aware of the process for dealing with referrals without appropriate requesting clinician details;
- (v) ensure radiology staff have a robust system in place for notifying referring clinicians of urgent and unexpected results;
- (vi) consider the introduction of a safeguard whereby the radiology department copy unexpected results of malignancy direct to the relevant multi-disciplinary team;
- (vii) report on the outcome of the ongoing 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;
- (viii) apologise to Mrs C for the delays in arranging the follow-up scan; and
- (ix) ensure that all administrative and medical staff involved in this complaint are aware of the findings of this investigation.