Scottish Public Services Ombudsman

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  • Report number:
    201602345
  • Date:
    April 2017
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
    Health
  • Keywords:
    delay in treatment, communication, complaints handling

Summary
Mrs C complained about the care and treatment provided by the board to her late husband (Mr A).  Mr A was diagnosed with pseudomyxoma peritonei (a very rare type of cancer that usually begins in the appendix) and the clinicians involved in his care decided to arrange for scans to be carried out every six months to monitor any development of the cancer.  However, after two scans, further follow-up was not arranged.  Mrs C complained that Mr A did not receive treatment for the pseudomyxoma peritonei until four years after the initial diagnosis, by which point it had progressed considerably.

During the investigation, we took independent medical advice on Mr A's care and treatment from two consultants in colorectal surgery, one of whom has extensive experience in the treatment of pseudomyxoma peritonei.  We found that the delay in Mr A receiving treatment was largely due to a failure to review a scan that was carried out and make further appointments to monitor Mr A's condition.  However, we also found that there was a failure of board staff to discuss Mr A's case at a multi-disciplinary meeting when he was first diagnosed, and to discuss Mr A's case with a specialist pseudomyxoma peritonei unit.  We further found that there was a failure of the responsible consultant to communicate with Mr A and his GP regarding the diagnosis.

Mrs C also complained about the handling of her and Mr A's complaints.  Mr A's first complaint to the board did not receive a response.  When Mrs C later made a complaint, it did not receive a response for over a year, and Mrs C had to regularly contact the board for updates as they were not keeping her informed of progress.  The final response that Mrs C received was a copy of an investigation that had been carried out into Mr A's care, and did not address all of the issues raised in the complaint, apologise to Mrs C and Mr A for failings identified, or give information as to remedial action taken or proposed.  Additionally, details of how to contact the SPSO were not given to Mrs C.  I considered the large number of failings in basic and fundamental complaints handling principles to be unreasonable.

Redress and recommendations
The Ombudsman recommends that the Board:

  • apologise to Mrs C for the failings identified in complaint (a) in relation to the delay in treatment for Mr A's pseudomyxoma peritonei;
  • provide evidence that MDT meetings are being held to discuss this type of cancer in line with their standards;
  • review their processes for ensuring that scan results are reviewed and followed up, and ensure that current processes are sufficient to avoid a repeat of the failings identified by this investigation;
  • consider implementing a policy to discuss the treatment options for all cases of proven or suspected pseudomyxoma peritonei with a specialist unit;
  • draw the comments of Adviser 1 regarding communication of diagnoses to patients and GPs to the attention of the relevant consultant;
  • apologise to Mrs C for the failings in complaints handling identified by this investigation;
  • remind the relevant staff that formal complaints should be passed on to the complaints department; and
  • review their handling of this complaint and identify areas for improvement.

Download report number 201602345 as a PDF (69.18 KB)

Updated: May 18, 2017