Scottish Public Services Ombudsman

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  • Case ref:
  • Date:
    June 2014
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Some upheld, recommendations


Mrs C complained about the care and treatment provided to her late brother (Mr A). She said that in summer 2012 his GP urgently referred him to the ear, nose and throat (ENT) department at University Hospital Crosshouse. Mr A had a history of heart disease and ulcers but over recent months had been having difficulty swallowing. An ENT consultant arranged tests, the results of which appeared to be normal, and the consultant wrote to Mr A reassuring him and saying that she did not intend to follow him up. However, Mr A's symptoms did not improve and he was seen again as an emergency in October 2012. He was found to have a large mass in his neck. This was later confirmed to be an extensive tumour, and Mr A died some seven months later. Mrs C complained that Mr A's care and treatment were inadequate and that there had been a lack of urgency to progress this and a failure to diagnose him.

We obtained independent advice on the complaint from one of our medical advisers, and took all the available information into account, including Mr A's relevant clinical records and the complaints correspondence.

Our investigation found that Mr A's lifestyle indicated he was at very low risk from this type of illness and confirmed that initial tests did not reveal anything untoward. It was also clear, however, that although the ENT consultant had later reassured Mr A about his condition, this proved to be a false reassurance. The consultant had since told the board that, with hindsight, it would have been better if she had arranged to see Mr A again. Our adviser agreed that this would have been advisable and said that, when deciding whether to see him again after the tests, the ENT consultant only had sight of a copy of her letter to Mr A's GP and not his notes, in which it was clear she had noted that she intended to see him again. Her letter did not accurately reflect what she had written in the notes and what she had intended, and so we upheld this complaint. Mrs C also complained about the board's response to her written complaint but we did not agree with her that this was inappropriate.


We recommended that the board:

  • apologise to Mrs C for the additional stress and anxiety caused; and
  • ensure that the ENT consultant discusses these events at her next formal appraisal.

Download case 201303179 as a PDF (13.16 KB)

Updated: June 25, 2014