Summary
Mr C complained about the care and treatment provided to his late wife (Mrs A). Mrs A was diagnosed with bladder cancer in April 2015 and Mr C complained that both before and after the diagnosis there were delays in providing necessary appointments. Mr C also complained that there were unreasonable delays in the treatment of Mrs A's cancer after she had cardiac surgery, and that there were failings in communication between specialists treating her.
We took advice from a consultant urologist. With regards to delays in appointments, we found that there was an unreasonable delay between the results of a biopsy being taken and a subsequent resection. We also found that there was an unreasonable delay from the time of diagnosis to the time that Mrs A discussed definitive management with a surgeon. We considered these delays to be unreasonable. We upheld this aspect of Mr C's complaint.
We also found that there was a delay in Mrs A being provided with treatment for her bladder cancer. We identified a failure of the urology service to act upon a letter which stated that Mrs A would be suitable to go ahead with treatment for her bladder cancer in a months' time. We further found that the possibility of Mrs A's condition deteriorating, and her treatment options, were not fully discussed with her, and that there was a delay in Mrs A being offered palliative radiotherapy. We determined that there were multiple failings in communication between specialists treating Mrs A regarding her condition and treatment.
Mr C also complained about the board's handling of his complaint, specifically that they did not address all of the issues which he had raised. We considered that the board had failed to address some important questions Mr C had asked, and therefore we upheld this aspect of Mr C's complaint.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
|
Complaint number |
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|---|
|
(a), (b) and (c) |
|
Provide a written apology to Mr C for the failings identified |
Copy of apology letter which meets with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance By: 27 September 2017 |
We are asking Greater Glasgow and Clyde NHS Board - Acute Services Division to improve the way they do things:
|
Complaint number |
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|---|
|
(a) |
There was a delay between the results of the biopsy being reported on 10 February 2015 and Mrs A having a resection on 22 April 2015 |
In similar cases patients should receive treatment within 31 days from decision to treat to first treatment, as per the Scottish Government targets |
Documentary evidence of a review of urology treatment waiting times for patients with cancer and the steps being taken to better meet National guidelines By: 22 November 2017 |
|
(a) |
There was a period of approximately two and a half months from the time Mrs A was diagnosed with muscle invasive bladder cancer to the time she saw a surgeon to discuss definitive management |
In similar cases, timescales between histology reporting and out-patient appointments in the urology service should be shorter |
Documentary evidence of a review of the timescales between histology reporting and out-patient appointments in the urology service and details of steps being taken to shorten timescales By: 22 November 2017 |
|
(b) |
The urology service failed to act on the letter of 3 November 2015 stating that Mrs A could go ahead with surgery for her bladder cancer in a month's time |
Letters between services should be shared at the appropriate time and acted upon where necessary |
Documentary evidence that this finding has been shared and discussed with relevant staff. This could include, for example, minutes of discussion at a staff meeting or copies of internal memos, emails or notes of feedback given about this complaint By: 25 October 2017 |
|
(b) |
Mrs A was not offered palliative radiotherapy at an earlier point |
Palliative radiotherapy should be considered and offered as early as possible to reduce patients' pain |
Documentary evidence of the learning from this case and any subsequent changes to procedures, instructions and training provided to clinical staff By: 25 October 2017 |
|
(b) |
When Mrs A suffered the MI, her options should have been discussed more thoroughly with her and the possibility of disease progression whilst she was undergoing cardiac surgery and recovery should have been made clear |
The Board should demonstrate that staff are aware of the need to ensure patients are made fully aware of the possibility of disease progression if treatment for other health issues is required; and of their options for treatment |
Documentary evidence that this finding has been shared and discussed with relevant staff. This could include, for example, minutes of discussion at a staff meeting or copies of internal memos, emails or notes of feedback given about this complaint By: 25 October 2017 |
|
(c) |
There were failings in communication between the oncology and urology teams with regard to Mrs A's condition and treatment |
The Board should demonstrate that they have reflected and learned from this case to ensure that there is better communication and coordination between teams, including discussion at multi-disciplinary team meetings as appropriate, so that patients receive good and timely care |
Documentary evidence that the relevant board staff have considered Ms A's case and how to ensure better communication and coordination of care between departments and hospitals. This could include evidence such as a minute of a staff meeting; an action plan, instructions to staff and/or a revised protocol By: 25 October 2017 |
|
(d) |
The Board failed to address all of the issues that Mr C raised in his original complaint |
The Board should ensure that complaint responses correctly identify and respond to all issues raised by complainants |
Documentary evidence that this finding has been shared and discussed with relevant staff. This could include, for example, minutes of discussion at a staff meeting or copies of internal memos, emails or notes of feedback given about this complaint By: 27 September 2017 |
Evidence of action already taken
Greater Glasgow and Clyde NHS Board - Acute Services Division told us they had already taken action to fix the problem. We will ask them for evidence that this has happened:
|
Complaint number |
What we found |
What the organisation say they have done |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|---|
|
(b) |
There were unreasonable delays in the treatment of Mrs A's cancer |
Reviewed the pathway available to bladder cancer patients to improve the services available and the coordination of care |
Copy of the bladder cancer pathway, highlighted to show the changes and/or additions By: 27 September 2017 |