Decision Report 201703801

Summary

Ms C complained about the care and treatment her late mother (Mrs A) received at Beatson West of Scotland Cancer Centre for metastatic breast cancer. Ms C raised concerns that there were delays between scans and treatment for Mrs A, and in particular that there was a lack of urgency when Mrs A's kidneys were failing.

We took independent advice from an oncology consultant (a specialist in the study and treatment of tumours). We found that whilst overall the scans and treatment for Mrs A's cancer were reasonable, when Mrs A's worsening kidney function was noted in a scan there was a delay in referring her to urology (the  branch of medicine and physiology concerned with the function and disorders of the urinary system). The referral was then lost which the board acknowledged and apologised for. However, they did not explain what action they had taken to prevent this reoccurring in the future, therefore, we made a recommendation on this matter. We also found that when a scan showed that there was disease progression, this should have been escalated to Mrs A's consultant in a more timely manner to allow a discussion regarding stopping Mrs  A's treatment to happen more quickly. We considered the care and treatment provided to Mrs A was unreasonable and upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the delay in referring Mrs A to urology and that the results of the scan which showed disease progression were not escalated to the consultant more promptly. 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:

• There should be a policy for escalating significant findings of investigations, in particular scans, to the relevant team or on call team in order to ensure that any required actions regarding these findings are not delayed until a patient attends clinic.
• There should be a system in place to ensure that referrals to urology are acknowledged and acted upon to prevent the situation of a referral letter going missing or not being acted upon.
• Patients with disease progression should have their results escalated to the consultant caring for them as quickly as possible to enable any discussion regarding stopping of treatment and switching to best supportive care to take place as soon as possible.