• Case ref:
    201704790
  • Date:
    August 2018
  • Body:
    Forth Valley NHS Board
  • Sector(s):
    Health
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Upheld, recommendations

Summary

Mr C complained on behalf of his late wife (Mrs A) about the care and treatment she received at Forth Valley Royal Hospital. Mrs A had been experiencing tingling in her fingers, which continued to worsen. Mr C complained there was an unreasonable delay in carrying out a scan to investigate Mrs A's condition. He also considered that there was an unreasonable delay in giving Mrs A the results of the scan. After Mrs A was referred for surgery, her mobility declined. Mr C felt that, with earlier surgery, she may have been walking normally.

We took independent medical advice from a consultant orthopaedic surgeon (a doctor who specialises in conditions involving the musculoskeletal system). We found that Mrs A was appropriately referred for an urgent scan and that it was carried out within a reasonable timescale. However, we considered that there was a delay in reporting the results and in giving Mrs A the results, which was unreasonable as there were significant clinical findings that required urgent surgical intervention. The adviser considered that earlier surgery was likely to have improved Mrs A's outcome and mobility. However, they explained that a good outcome was not guaranteed, as her condition was degenerate and it was unlikely she could have been walking normally. In light of these delays identified, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mr C for the delay in reporting Mrs A's scan and in telling her the results. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

  • Urgent scans should be reported promptly.
  • A process should be in place so that significant findings in scans and x-rays are immediately flagged up to the referring clinician (this could, for example, be through a generic phone number or email address that is checked and acted on daily).

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.