• Report no:
    201701715
  • Date:
    May 2018
  • Body:
    Dumfries and Galloway NHS Board
  • Sector(s):
    Health

Summary

Mr C complained about the care and treatment provided to him by the board after he was diagnosed with prostate cancer.  His prostate cancer was considered low risk and the plan was for active surveillance, which involves having a PSA test (prostate specific antigen: a marker in blood tests which can indicate prostate problems) three to four times a year, and an MRI scan six months after diagnosis.  However, Mr C complained that he was not given a PSA test until nearly a year after his diagnosis, and the MRI scan was not organised in a timely manner. 

We took independent, professional advice from a urologist.  We found that the board failed to:

  • arrange follow-up appointments;
  • arrange PSA tests that required to be undertaken;
  • check that PSA tests were undertaken as intended;
  • make adequate and timely arrangements for an MRI scan which took
    Mr C’s special needs into account; and
  • provide Mr C with information that might have enabled him to make alternative arrangements to get the necessary tests done.

Given these failings, we upheld this aspect of Mr C's complaint. 

Mr C also complained that the board failed to communicate appropriately with him regarding the monitoring of his prostate cancer.  We found that when Mr C was diagnosed the need for regular PSA testing and the MRI scan were not communicated to him or his GP appropriately.  We also found that when Mr C was contacted regarding the MRI scan, the information he was given did not answer all of his questions, nor was he fully informed of his options.  We upheld this aspect of Mr C's complaint.

Finally, Mr C complained about the board's handling of his complaint.  We found that Mr C's complaint to the board had been incorrectly logged as a concern rather than a complaint.  We also found that communication with Mr C throughout and after the complaints process had been poor.  We upheld this aspect of Mr C's complaint. 

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mr C:

Complaint number

What we found

What the organisation should do

Evidence SPSO needs to check that this has happened and the deadline

(a), (b), & (c)

The Board failed to provide appropriate monitoring following a diagnosis of prostate cancer; failed to communicate appropriately; and handled Mr C’s complaint unreasonably

Apologise to Mr C for failing to provide appropriate monitoring following a diagnosis of prostate cancer; failing to communicate appropriately; and handling his complaint unreasonably

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance

Copy or record of apology

By:  20 June 2018

 

We are asking the Board to improve the way they do things:

Complaint number

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline

(a)

The Board failed to provide appropriate monitoring following a diagnosis of prostate cancer Prostate cancer patients on active surveillance should be properly and appropriately monitored

Evidence of a review of current systems to monitor prostate cancer patients on active surveillance, which includes an assessment of the reliability and effectiveness of these systems and any improvements to be made as a result of the review

Evidence that there has been a review of all prostate cancer patients on active surveillance to ensure they are being actively followed up

By:  15 August 2018
(a) There was a failure to make adequate and timely arrangements for a scan which took Mr C’s needs into account There should be a system in place to accommodate patients with special needs such as claustrophobia who are required to undergo scanning

Evidence that a system has been put in place to make arrangements for patients with special needs such as claustrophobia to undergo scanning and that this system has been communicated to all the relevant staff

By: 15 August 2018
(b) When Mr C was diagnosed with prostate cancer it was not communicated to him that he would need three monthly testing and scanning after six months Patients on active surveillance for prostate cancer should have the follow-up requirements clearly explained to them

Evidence that this has been considered and a system is in place to ensure that patients on active surveillance for prostate cancer have the follow-up requirements clearly explained to them

By: 15 August 2018
(b) When Mr C was contacted regarding scanning, the information he was given did not answer his questions, nor was he fully informed of his options Clear information should be given regarding options for scanning, and staff should make efforts to ensure they are answering all of a patient's questions 

Evidence that this has been fed back to the relevant staff in a supportive way that encourages learning 

By: 4 July 2018
(c)

Mr C’s complaint was handled unreasonably

Complaints should be accurately logged and responded to in line with the complaints handling process

Evidence that this has been fed back to the relevant staff in a supportive way that encourages learning 

 

By: 4 July 2018

(c) Communication with Mr C during and after the complaint process was poor Communication with complainants should be pro-active, and complainants' requests for contact should be returned

Evidence of a review of the communication during and after the complaints process in this case, including an assessment of why staff failed to return Mr C's requests for contact and what action will be taken to avoid this recurring in the future 

By: 15 August 2018

 

Feedback
Points to note
The Board could consider raising awareness of their clinical staff about the current options of Healthcare in Europe for patients.