• Case ref:
    201101064
  • Date:
    February 2013
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
    Health
  • Subject:
    clinical treatment; diagnosis
  • Outcome:
    Not upheld, action taken by body to remedy, recommendations

Summary

Mr C complained that a hospital failed to provide his late father (Mr A) with appropriate care and treatment when he developed cancer. There were several components to this complaint that included an incomplete colonoscopy (examination of the bowel with a camera on a flexible tube), discharge from the hospital when unwell, and delays with arranging a biopsy (tissue sample) and a scan. The board had acknowledged some failings before Mr C brought his complaint to us and we also looked at the action they had taken about this.

Our investigation included taking independent advice from one of our medical advisers. We took account of his advice as well as evidence from Mr C and the board. Our investigation found that the concerns Mr C raised reflected the complexity of this difficult and involved case. This included that Mr A had a number of symptoms under investigation (not linked to the cancer) when he also developed symptoms of the cancer that caused his death. Based on all the evidence, we came to the conclusion that there were no grounds to uphold the individual components of Mr C's complaints. We did find some evidence of delay between two investigative procedures, and made recommendations to address this.

On balance, however, we considered that overall Mr A received an acceptable standard of care and treatment in terms of the way that he presented to the hospital and we did not uphold the complaint.

Recommendations

We recommended that the board:

  • advise of the steps taken to ensure similar delays to those experienced do not recur;
  • ensure that scans are recorded in patient case notes regarding when and where they take place;
  • advise on the steps taken to address multiple consultant involvement regarding ownership and co-ordination of a patient's care;
  • ensure all patient case notes are filed sequentially;
  • advise on the general surgery and clinical governance group (GSCCG) decision regarding the minuting of actions after a review of a complaint has taken place;
  • advise on the results of the Steering Group's investigation of this case;
  • advise on the setting up of the regional working group on the investigation and management of cancers with unknown primary sources; and
  • advise whether the GSCCG presentation to the Integral Care and Partner Services clinical governance steering group has taken place.