Decision Report 202309586

Summary

C complained on behalf of their parent (A) about the care and treatment they received from the board following neurosurgery (surgery performed on the nervous system, especially the brain and spinal cord). C complained that the board did not provide follow-up care to A and they were not referred to oncology (cancer specialists) for further treatment. C said that A required further surgery to treat recurrent disease a few years later as a result.

The board’s complaint response explained that an administrative error had occurred which had led to A not receiving follow-up care from neurosurgery or a referral to oncology. The administrative error had been managed via staff training to prevent it from happening again. In response to our enquiries the board confirmed that no internal review, such as a Serious Adverse Event Review (SAER), had taken place.

We took independent advice from a neurosurgery adviser. We found that it was unreasonable that A had not received the planned clinical follow-up after their surgery. It was also unreasonable that SAER or Duty of Candour guidance had not been followed in this case. As such, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The board should initiate statutory duties and processes for learning when it becomes known that a potential harm has occurred. Including, but not limited to, Duty of Candour and adverse event review processes.

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.