Summary
Mrs C complained about the delay in arranging an endoscopy procedure for her late husband (Mr C). She said that although Mr C's GP requested an urgent referral for him, the required procedure was not undertaken until more than three months' later. At this time, a malignant tumour was found in his oesophagus which was later determined to be inoperable. Mr C died seven months after this.
Mrs C complained to the board who said that as Mr C's review was not marked 'urgent suspicion of cancer', it was not upgraded to be seen with the highest priority at a time when there were substantial waiting time delays for endoscopy procedures to be carried out. The board accepted that there had been a delay and said that they were planning to put procedures in place to increase their capacity to meet endoscopy waiting time targets.
We obtained independent clinical advice and found that the board's approach had not been a reasonable one in that there were too many priority streams for grading the urgency of endoscopies. There was already sufficient clinical information available for Mr C's case to have been triaged as a suspected cancer case and, from the available guidance, it appeared that Mr C's GP had followed the instructions given. We upheld the complaint.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mrs C:
|
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|
There was a delay in arranging an endoscopy for Mr C |
Send Mrs C a written apology for the unreasonable delay in arranging the endoscopy |
Provide a copy of the letter of apology by 21 July 2017 |
We are asking the Board to improve the way they do things:
|
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|
Delays in the provision of endoscopies |
The delay should be reduced |
Evidence of the steps being taken to meet Scottish Government standards by 21 August 2017 |
|
There were too many different priority streams for grading the urgency of endoscopies and the Board's guidance did not flag the pathway 'urgent suspicion of cancer' |
Remove the referral 'urgent suspicion of cancer' or make it absolutely clear that an alternative referral route is required |
Evidence of the replacement/new guidance by 21 July 2017 |
|
There were problems with triage |
Urgently review their triage process to ensure that patients with dysphagia are appropriately triaged |
Evidence that a review has taken place by 21 July 2017 |
Evidence of action already taken
The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened:
|
What we found |
What the organisation say they have done |
Evidence SPSO needs to check that this has happened and deadline |
|
Delays in the provision of endoscopies |
Provided a nurse endoscopist/ additional staffing from December 2016 |
Immediate confirmation that the additional staff are now in place This has been provided. |