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Decision Report 201601137

  • Case ref:
  • Date:
    October 2017
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis


Mrs C's GP referred her to St John's Hospital for a blood transfusion because she was anaemic, had chest pains and was breathless. However, Mrs C said that when she was in the hospital the blood transfusion did not happen. She was discharged and told that an urgent endoscopy (a procedure where a tube-like instrument is put into the body to look inside) and colonoscopy (an examination of the bowel with a camera on a flexible tube) would be arranged for her. Mrs C said that she did not hear anything further and that the following month she was admitted to hospital again. She had a scan which showed a large tumour and she was diagnosed with bowel cancer. Mrs C complained that she was not properly cared for and treated during her first attendance at hospital.

We took independent advice from a consultant gastroenterologist. We learned that Mrs C did not have a blood transfusion because her blood flow was not compromised and she showed no symptoms of active bleeding. While we found it was reasonable to discharge Mrs C home with plans for urgent endoscopic investigations, the board subsequently failed to deal with this as a matter of urgency. We found that this was unreasonable and we upheld Mrs C's complaint.


We recommended that the board:

  • apologise to Mrs C for the delay;
  • confirm the situation with regards to waiting times for urgent endoscopies; and
  • ensure that, in the event that they cannot address the waiting times for urgent endoscopies, alternative scans, such as CT scans on the colon, are made available. This new protocol should be brought to the attention of referring clinicians.

Updated: March 13, 2018