Decision Report 202401232

Summary

C, an independent advocate, complained on behalf of B, about the standard of medical and nursing care provided to B’s late spouse (A) by the board following a liver cancer diagnosis.

B complained about A’s diagnosis, noting that A was initially seen to have one lesion and to be suitable for a liver transplant, however, three months later multiple lesions were found and A was no longer seen as a viable candidate. B also complained of subsequent delays in cancer treatment and that the nursing care provided to A was below a reasonable standard, including failures to prevent an unwitnessed fall.

B said that communication from clinicians regarding A’s diagnosis, prognosis and treatment was lacking detail and infrequent, and that the board’s stage two complaints response was inaccurate.

We took independent advice from a consultant hepatologist (specialist in diseases of theliver, gall bladder, bile ducts and pancreas) and a registered nurse adviser. We found that A’s diagnosis and treatment were reasonable and did not consider that multiple lesions had been unreasonably missed initially. We did not uphold this aspect of the complaint.

However, we found that there had been failings with respect to communication, particularly when A’s care was transferred to a specialist transplant unit outwith the board. We also found that the nursing care provided was unreasonable, including failings to record comfort, pain, and personal care, and in relation to delirium, falls prevention and risk assessments. Lastly, we noted inaccuracies in the complaints responses provided to B. As such, we upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients (and where appropriate their family / carers) should be kept fully informed in a timely manner about their diagnosis, prognosis, and treatment.
• Patients who are admitted to hospital should have appropriate risk assessments carried out.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaint responses should be accurate, clear, and supported by the relevant evidence. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at HYPERLINK "https://www.spso.org.uk/training-courses" https://www.spso.org.uk/training-courses .

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.