Decision Report 201801028

  • Case ref:
  • Date:
    August 2019
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis


Mrs C complained about the treatment provided to her husband (Mr A). Mrs C said that the board unreasonably removed Mr A's right kidney and ureter (the duct by which urine passes from the kidney to the bladder) on the basis of a diagnosis of cancer.

We took independent advice from consultants in urology (the medical specialism that deals with the male and female urinary tract, and the male reproductive organs) and pathology (the study of disease). We found that there were failings in relation to record-keeping which we drew to the board's attention. We also found that there had been a delay in the surgery being carried out which the board had apologised for. However, we found the investigations carried out which led to the diagnosis of cancer were reasonable. We also found that the biopsies (tissue samples) taken in this case were appropriately interpreted at the time and that a mistake had not been made. Therefore, we did not uphold the complaint.

Mrs C also raised concerns about the Significant Adverse Event Review (SAER) which had been carried out. We found that the SAER carried out was reasonable. We found that a comprehensive review of the case was carried out, and failings in the consenting process were recognised. We also found that there had been a thorough external review of the pathology slides and recommendations made for improvements. We did not uphold the complaint.

Updated: August 21, 2019