Summary
Mrs C had previously suffered from mouth cancer and was treated at Monklands Hospital. After finding an ulcer in her cheek, she contacted the consultant previously in charge of her care, and was seen at Monklands Hospital again, where the ulcer was found to be cancerous. Mrs C's case was discussed at the multi-disciplinary team (MDT) meeting, who decided to refer Mrs C to the Southern General Hospital for treatment.
However, this was not done until a week later. The referral was by email from the consultant to his colleagues with details of Mrs C's (and other patients') cases, rather than a formal referral by letter. It is not clear whether the email was received. Around this time the head and neck / maxillofacial (the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) consultants at the Southern General Hospital decided that, due to lack of capacity, they would no longer accept referrals of patients they considered could be treated locally (such as Mrs C). It is unclear whether the management team instructed the consultants to do this, or whether the Southern General Hospital was required to accept Mrs C's referral under the existing funding arrangements. Mrs C was not told that there was a problem with her referral.
Mrs C grew increasingly concerned about the delay, and phoned the consultant at Monklands Hospital several times over the next few weeks to follow this up. Finally, about a month after the MDT, Mrs C emailed the consultant, outlining her strong concerns, and the consultant phoned the Southern General Hospital and arranged an urgent appointment for Mrs C. Mrs C said that her treatment from Southern General Hospital staff was excellent from that point on.
Mrs C complained about the delay in the scan and the MDT meeting, as well as the delay in referring her to the Southern General Hospital. Mrs C was concerned that the delay may have worsened her outcome, as she was initially told that surgery would be performed with the aim of providing a cure. However, the surgery that she subsequently received significantly reduced her quality of life and gave her a low chance of surviving her cancer. Mrs C also complained about the lack of communication from Monklands Hospital staff about what was happening.
My investigation found that the delay in arranging Mrs C's surgery was unreasonable, and outwith the national HEAT (Hospital Efficiency and Access Targets) standards. I found it was unreasonable for the Monklands Hospital consultant to wait one week before referring Mrs C, and also that the email sent by the consultant was not an adequate referral. I also found that there was a breakdown in the referral process between Monklands Hospital and the Southern General Hospital, which meant that no plans were made for Mrs C's surgery at either hospital until she followed this up repeatedly. I am concerned that an important decision (not to accept certain referrals) could be made and implemented at NHS Greater Glasgow and Clyde without clear, recorded management approval. I am also strongly critical of the poor communication between the consultants at both health boards, as they apparently discussed Mrs C's case without clearly agreeing who would be responsible for her treatment (both hospitals appeared to think the other would be responsible). It was only through Mrs C's courage and perseverance in following up her own appointment that this matter was resolved.
I also found that Monklands Hospital staff failed to communicate reasonably with Mrs C about her treatment. Staff did not return her calls on at least one occasion and, although the consultant phoned the Southern General Hospital to follow up the referral and offered to perform the surgery himself, no-one contacted Mrs C to explain what was being done or to check that the appointment had come through.
In reporting on this complaint, I outlined significant concerns about the way in which both boards provided information during my investigation. NHS Lanarkshire failed to provide a key piece of evidence relating to this complaint until after my investigation was concluded. NHS Greater Glasgow and Clyde also provided new evidence at a late stage, which directly contradicted information they had previously given during the investigation. This caused unnecessary difficulties and delays in completing the investigation, and undoubtedly added to Mrs C's distress. I also raised concerns at the lack of appreciation both boards have shown of the impact these events have had on Mrs C, and of the value of her complaint. This case involves a patient who was left without any plans for her cancer surgery for several weeks, as the boards were unable to effectively communicate about, and resolve, an administrative disagreement over who was responsible for the surgery. In this context, I am disappointed that the boards were not more proactive about acknowledging that Mrs C's experience was unacceptable, and acting to prevent a recurrence.
Redress and recommendations
The Ombudsman recommends that Lanarkshire NHS Board:
- issue a written apology to Mrs C for the failings I found; and
- bring my findings to the attention of Consultant 1, for reflection as part of his next annual appraisal.
The Ombudsman recommends that Greater Glasgow and Clyde NHS Board:
- issue a written apology to Mrs C for the failings I found;
- feedback my findings to all staff involved, for reflection and learning; and
- ensure there is a clear procedure for authorising and recording any decisions not to accept referrals, and that staff are aware of this.
The Ombudsman recommends that both boards:
- conduct a joint significant event analysis to investigate and address the cause(s) of the delay in Mrs C's referral, and share the results with my office and with Mrs C, if she wishes.