Summary
Ms A, who suffered from a number of physical disabilities and other conditions, began to complain of headaches in December 2013. She had surgery to remove a nasal ulcer, and a CT scan revealed no abnormality of her sinuses.
Subsequently, Ms A attended the practice on a number of occasions complaining of vomiting and headaches. At the same time, Ms A’s mother contacted NHS 24 with concerns about Ms A and she was seen by the board’s out-of-hours service. Ms A’s medical practice prepared a referral letter to neurology. In the meantime, Ms A was admitted to the surgical service at Raigmore Hospital with abdominal pain. Ms A was seen by a neurologist on the ward and diagnosed with occipital nerve compression. Following her discharge, Ms A was seen by GPs from the practice, again with headaches and other symptoms. Ms A was given an appointment for an MRI scan. Ms A died at home before this could be carried out. A post-mortem found that the cause of death was a haemangioblastoma (a tumour of the central nervous system within the brain).
During the investigation, my complaints reviewer sought advice from a GP, a nurse, a neurologist, a neuroradiologist, and a neurosurgeon.
I found the practice did not provide a reasonable standard of care in relation to the examination and referral of Ms A’s headache symptoms. I also found the board’s out-of-hours service failed to provide Ms A with appropriate care and treatment. Regarding Ms A’s admission to hospital, I found failings in relation to the neurological examination recorded and a failure to review a CT scan of Ms A’s sinuses.
I am also particularly critical of the way the board handled this complaint and their lack of focus on their failings and ways to improve their services.
Redress and recommendations
The Ombudsman recommends that the practice:
- apologise to the family for the failings this investigation has identified;
- conduct a significant event analysis for review by this office; and
- confirm that the staff involved will discuss this issue as part of their annual appraisal, including identifying the relevant Scottish Intercollegiate Guidelines Network (SIGN) and Scottish Cancer referral guidance as a learning.
The Ombudsman recommends that the board:
- apologise to the family for the failings this investigation has identified;
- confirm the out-of-hours staff identified will discuss this case as part of their annual appraisal, including identifying the relevant SIGN and Scottish Cancer referral guidance as a learning point;
- assess the performance of the out-of-hours staff involved, and identify any training needs;
- confirm the neurologist will discuss this case as part of their annual appraisal;
- should review arrangements for ward consultations (including considering the availability of previous scans for review and encouraging consultants to dictate letters as if it were an out-patient consultation);
- conduct a significant event analysis for review by this office, given the seriousness of this case, and my findings;
- provide my office with an explanation of why a serious incident review was not undertaken in this case; and
- review complaints handling in this case to establish why the failings in care were not identified.