Summary
Mrs C complained about the care and treatment provided to her late husband (Mr C) by Fife NHS Board (the board). Mrs C's complaint related to delay in diagnosing that Mr C had lung cancer and the treatment provided to Mr C. Mrs C complained that the standard of care Mr C had received had been poor.
We took independent advice from a consultant respiratory physician. We found that Mr C was high risk for lung cancer, given his history as a former smoker with a background of heavy exposure to asbestos, and presenting with a cough and breathlessness. There were also concerning features in Mr C's radiology results and his case was complex. Despite this, Mr C was removed from an expedited cancer referral pathway without his case being discussed at a lung cancer multi-disciplinary team (MDT) meeting and without consideration given to a tissue biopsy being carried out. There was also no evidence that there had been any discussion with Mr C to enable him to make an informed decision about his future treatment. We also considered that that the board did not appear to have followed national standards and guidelines in Mr C's case.
The advice we received was that this represented serious failings in Mr C's care and treatment and that if such action had been taken, this could potentially have resulted in a different outcome for Mr C. As such, we upheld this complaint. The board have told us they now have systems and processes for patients in a similar situation to Mr C which they say are significantly different from what was previously in place and are willing to have their lung cancer service independently audited and peer reviewed. In view of the failings we identified, we made a number of recommendations to address this.
Mrs C also complained about the palliative nursing care Mr C received following his cancer diagnosis. We took independent nursing advice. We found that although the board had taken action following Mrs C's complaint, the advice we received was that there were serious failings in the nursing care provided to Mr C following his cancer diagnosis which had not been identified or addressed by the board. There had been a failure to comply with professional and clinical standards for practice which would be expected of the nursing staff and the palliative care provided had fallen below the standards which Mr C and his family should have reasonably expected. We upheld this complaint and made a number of recommendations to address the issues identified.
Mrs C also complained that the board's handling of her complaint was inadequate. We were satisfied there were failings in how the board responded to Mrs C's complaint and upheld this part of her complaint. We made recommendations to address these failings.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mrs C:
|
Complaint number |
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|---|
|
(a), (b), (c) |
There were serious failings in diagnosing that Mr C had lung cancer and in the treatment he received. There were serious failings in the nursing care provided to Mr C after his cancer diagnosis in June 2015. There were failings in the Board's handling of Mrs C's complaint |
Apologise to Mrs C for the failings in: Mr C's diagnosis and treatment; the nursing care provided to Mr C after his cancer diagnosis in June 2015; and the handling of Mrs C's complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance |
A copy or record of the apology By: 21 March 2018 |
We are asking The Board 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) |
Mr C was unreasonably removed from the expedited lung cancer referral pathway without his case being discussed at a lung MDT meeting, which led to a delay in diagnosing that he had lung cancer. This adversely impacted on Mr C's outcome |
Patients who present with suspected lung cancer symptoms should not be removed from the expedited lung cancer referral pathway without the case being discussed at a lung MDT meeting |
A copy of the current systems and processes in place on the removal of patients from the cancer referral pathway showing they take into account national guidance and the appropriate process for discussion at a lung MDT meeting. Evidence of the review of patients who were removed from the referral pathway in the same year as Mr C. Evidence that the Board has carried out an independent and impartial review of the lung cancer service which includes considering the appropriateness of any decision to remove a patient from the lung cancer care pathway without an MDT meeting being held. The evidence is to include providing SPSO with a briefing document outlining the scope of the review; who will be carrying out the review; and a report on the outcome of the review. Evidence that this report has been shared with relevant staff and managers in a supportive way for reflection and learning By: 21 August 2018 |
|
|
(a) |
There was a failure to involve Mr C in making an informed decision about his treatment |
Patients should be fully informed and involved in decisions about their treatment |
Evidence that this report has been shared with relevant staff and managers in a supportive way for reflection and learning By: 23 April 2018 |
|
|
(a) |
There was a failure to refer Mr C to a lung MDT meeting when cancer was diagnosed and it became apparent that the skin lesion was metastatic |
Patients should be appropriately referred to a MDT meeting. |
Evidence that patients are being appropriately referred for discussion at MDT meetings within the lung cancer service (this could be evidence provided as part of the audit referred to above) By: 23 April 2018 |
|
|
(b) |
Mr C and his family did not receive the standard of palliative nursing care and support which they should have reasonably expected to receive |
Patients who require palliative nursing care and their families should the receive care and support needed. This should be adequately led, co-ordinated and person-centred |
Details of a review of the Palliative Care Service with evidence that any training needs identified as part of the review are being met, or planned (with definitive timescales, not simply a broad intention). Evidence that this report has been shared with relevant staff and managers in a supportive way and that reflection and learning have taken place By: 23 April 2018 |
|
|
(b) |
There was a failure by nursing staff to comply with national guidance and standards; in particular, in relation to assessing and managing pain and distress; and maintaining care plans |
Nursing staff should ensure that national guidance and standards are adhered to; in particular, in relation to the assessment of pain and distress and managing care plans |
Evidence that this report has been shared with relevant staff and managers in a supportive way for reflection and learning By: 23 April 2018 |
|
|
(b) |
There was a failure to comply with NMC and Scottish Government requirements for prescribing |
The Board should ensure that systems are in place to ensure that nurse prescribing complies with NMC standards and Scottish Government guidance |
Details of the system in place (including procedures or instructions to staff) to ensure the safe prescribing of medicine by all non-medical prescribers which follows NMC and Scottish Government standards and guidance Evidence that the Board have reviewed whether relevant nursing staff have received sufficient training in the prescribing of medication, particularly to address the failings identified in this report and evidence of how training will be kept up to date By: 23 April 2018 |
|
| (b) | There were omissions in record-keeping in relation to the recording of nursing care provided to Mr C | Nursing records should be maintained in accordance with the nursing and midwifery code of practice and standards |
Evidence that the findings of this report have been shared with relevant staff and managers in a supportive way, and what action has been taken as a result. By: 23 April 2018 |
|
| (c) | The Board's handling of Mrs C's complaint fell below a reasonable standard | Staff should be aware of the importance of keeping complainants updated and providing a full response |
Evidence that the model CHP has been circulated with attention drawn to matters of particular relevance By: 23 April 2018 |
|
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:
|
Complaint number |
What we found |
What the organisation say they have done |
Evidence SPSO needs to check that this has happened and deadline |
|
(c) |
The Board acknowledged that documents relating to a meeting about Mr C's case had not been located during the Board's investigation of Mrs C's complaint |
The Board had raised what had occurred with the department responsible and taken action to address how they stored health records; and they were also introducing a new electronic system during 2017 which will provide a single point for all patient information to be logged electronically |
Evidence, such as: discussions about what occurred; the changes that have been made; and revised procedures or instructions to staff about the storage of patient information records By: 23 April 2018 |