Scottish Public Services Ombudsman

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  • Report number:
    201300651
  • Date:
    October 2014
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
    Health
  • Keywords:
    Delay in diagnosis, communication

Overview
The complainant (Mrs C) complained that a lengthy list of errors and omissions by various specialist services and a failure to co-ordinate her care and treatment caused her stress and ultimately led to a delay in her being diagnosed with multiple sclerosis and her starting treatment.

Specific complaints and conclusions
The complaints which have been investigated are that Ayrshire and Arran NHS Board (the Board) unreasonably failed to:

  • adequately assess Mrs C's condition (not upheld);
  • ensure that the various departments involved in Mrs C's care monitored her care and treatment appropriately (upheld);
  • ensure that the various departments involved in Mrs C's care co-ordinated and communicated appropriately with each other (upheld); and
  • ensure that the responses Mrs C received to her complaints were accurate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

  • issue a written apology to Mrs C for the failings identified in this report;
  • provide evidence of the improvements that have been made to the Board's out-patient's appointment systems;
  • consider developing a pathway regarding all suspected genetic disorders seen within Dermatology Services, so as to streamline access to geneticists;
  • ensure that the comments of the Dermatology Adviser, in relation to record-keeping and the Board's action plan, are brought to the attention of the relevant staff within Dermatology Services;
  • in cases involving several health boards, consider implementing the copying of clinical correspondence to a patient, so as to improve communication and provide the patient with the opportunity to be aware of the progress of their care;
  • consider reviewing the systems for Radiology referrals between hospitals;
  • review spinal magnetic resonance imaging (MRI) protocols to:  identify which part of the recall protocol failed in Mrs C's case; ensure where abnormalities are detected they are appropriately reported; and ensure appropriate consideration is given to examining the patient's whole spine in one scan;
  • carry out an audit to ensure there is a clear system for prioritising MRI scan requests according to the degree of clinical urgency;
  • ensure that communication protocols between Radiology Services and other clinicians are optimal;
  • ensure that the comments of the Radiology Adviser and the Neurology Adviser are shared with the appropriate staff; and
  • advise of the present position in respect of the planned move to digital case notes.

The Board have accepted the recommendations and will act on them accordingly.

Download report number 201300651 as a PDF (88.94 KB)

Updated: October 22, 2014