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Grampian NHS Board

  • Report no:
    201708494
  • Date:
    March 2019
  • Body:
    Grampian NHS Board
  • Sector:
    Health

Summary

Mrs C complained about the care and treatment that her late husband (Mr A) received from Grampian NHS Board (the Board).  Following his GP referral to the Board, Mr A was diagnosed with kidney cancer.  He had surgery to remove part of his kidney, which appeared to have removed all of the cancer.  However, around two years later, it was found that Mr A's kidney cancer had returned.  He was referred for further surgery to remove the rest of his kidney, which was then cancelled.  When Mr  A attended oncology (cancer specialists) to discuss other treatment options, he was told his cancer was terminal and it had spread more widely than previously identified.  Sadly, Mr A died early the next year.

Mrs C complained about a delay in first diagnosing and treating Mr A's kidney cancer.  She also complained about a delay in diagnosing and treating Mr A's kidney cancer when it returned and spread to other areas of his body.  Mrs C raised particular concerns that there was a delay in advising them of the seriousness of Mr A's condition. 

We took independent advice from a consultant urologist and a consultant radiologist, which we accepted.  We found that there was an unreasonable delay in diagnosing Mr A's kidney cancer, as his first GP referral was not actioned by the Board.  We found there was also an unreasonable delay in diagnosing that Mr A's kidney cancer had returned and spread.  This was due, in part, to a series of failings in interpreting the results of Mr A's scans.  We also found significant failings in the communication with Mr A about his condition and its seriousness.

Mrs C was also unhappy with how the Board dealt with her complaint.  We found that there was an unreasonable delay in dealing with Mrs C's complaint.  We also found the Board failed to thoroughly investigate or address all of Mrs C's concerns.  We were very concerned that the Board's review failed to identify or acknowledge the significant failings in their communication with Mr A and his family.

We upheld Mrs C's complaints.  We made a number of recommendations to address the issues identified.  The Board have accepted the recommendations and will act on them accordingly.  We will follow up on these recommendations.  The Board are asked to inform us of the steps that have been taken to implement these recommendations by the date specified.  We will expect evidence (including supporting documentation) that appropriate action has been taken before we can confirm that the recommendations have been implemented.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

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

Complaint number

What we found

What the organisation should do

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

(a) and (b)
  • The Board unreasonably delayed in diagnosing Mr A's kidney cancer;
  • The Board unreasonably delayed in diagnosing Mr A's kidney cancer had returned and spread;
  • The communication with Mr A about his condition was unreasonable; and
  • The Board's complaints handling was unreasonable

Apologise to Mrs C for the unreasonable delays in Mr A's care and treatment; the failure to communicate reasonably with Mr A about his condition and the failings in the Board's complaints handling

A copy or record of the apology.  The apology should meet the standards set out in the SPSO guidelines on apology available at:

www.spso.org.uk/leaflets-and-guidance

 

By:  22 April 2019

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's cancer treatment times, for both the partial nephrectomy and radical nephrectomy, exceeded the national targets

In similar cases, patients should receive treatment within 62 days of the referral and within 31 days from the decision to treat, as per the national targets

 

 

  • Evidence that the findings of this investigation have been fed back to the relevant clinicians in a supportive way that promotes learning
  • Evidence of the steps being taken to reduce waiting times for treatment and better meet the national targets
     

By:  20 May 2019

(a) There were multiple instances where clinically significant abnormalities were missed when CT scans were reported and reviewed Radiological findings should be accurately reported as far as possible
  • Evidence that the findings of this investigation have been fed back to the relevant radiologists in a supportive way that promotes learning
  • Confirmation that the individual radiologist(s) will discuss this case at their next appraisal
     

By:  20 May 2019

(a) The multidisciplinary team (MDT) did not review and/or identify the errors in the reporting of Mr A's CT scans

There should be systems and safeguards in place to ensure:

  • the MDT actively review CT scan imaging, including, where appropriate, a re-assessment by a radiologist and a comparison with older imaging 

And

  • the radiologist is resourced, with the time, technology and support, to do this before the MDT for all cases and to issue addenda afterwards if required

Evidence of the systems in place to ensure that CT scan imaging is reviewed appropriately before MDTs and how this will provide necessary safeguards
 

By:  20 May 2019

(a) The MDT referred Mr A for a radical nephrectomy when it was not technically feasible Systems should be in place to ensure the surgeon (for patients due to undergo complex or major surgery), inputs to the MDT on whether the surgery being considered or recommended by the MDT is technically feasible

Evidence that the Board has reviewed and where appropriate amended its approach, to ensure the views of operating surgeons on technical feasibility are considered.
 

By:  20 May 2019

(a) There was a delay in carrying out the imaging requested by the MDT to investigate the extent of Mr A's cancer Systems should be in place to ensure requests for imaging by the MDT are  followed up with an urgent imaging request and an automatic MDT review as soon as the imaging has been completed

Evidence that the Board has reviewed the MDT approach and supporting processes to ensure that any imaging requested by the MDT is carried out within an appropriate timescale
 

By:  20 May 2019

(a) The consultant urological surgeon's communication with Mr A about his condition was unreasonable Patients should be given prompt, clear, realistic and honest information about their condition, its seriousness and the likely chance of success from any treatment options
  • Evidence that the findings of this investigation have been fed back to the individual consultant urological surgeon in a supportive way that promotes learning.
  • Confirmation that the individual consultant urological surgeon will discuss this case at their next appraisal.
  • An explanation about how this will inform wider learning in the Board

By:  20 May 2019

(a) There were errors in CT scan reports by the private company used by the Board for radiology outsourcing Radiological findings should be accurately reported

Confirmation that the Board has a system in place to feedback reporting discrepancies to any private radiology companies they use for outsourcing work
 

By:  20 May 2019

 

We are asking The Board to improve their complaints handling:

Complaint number What we found Outcome needed What we need to see
(b) There was an unreasonable delay in the Board's complaints investigation, partly because they tried to arrange a meeting with Mrs C before issuing a formal response to her concerns

Complaints should be handled in line with the model complaints handling procedure.

The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs

Evidence that the outcome of this investigation has been fed back to staff in a supportive manner which encourages learning, and that all staff are aware of and understand the complaints handling procedure
 

By:  20 May 2019

 

 

 

(b) The Board’s own complaints investigation did not identify or address all of the failings in the care provided to Mr A The Board's complaints handling system should ensure that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement

Evidence that the Board have reviewed why its own investigation into the complaint did not identify or acknowledge all the failings highlighted here
 

By:  20 May 2019

Evidence of action already taken

The Board told us they had already taken action to fix the problem.  We will ask them for evidence that this has happened:

Complaint number What we found Outcome needed What we need to see
(a) The Board told us they have improved the pathway for GP referrals

The Board should have a clear reliable pathway for both electronic and paper referrals

 

Details of the current referral pathway for electronic and paper GP referrals and how they are actioned
 

By:  22 April 2019

 

 

 

(b) The Board told us that they discussed the errors in the CT scan reporting at a radiology discrepancy meeting As far as possible, radiological findings should be accurately reported
  • Evidence that this case has been discussed at the departmental radiological 'learning from discrepancies' meeting.
  • Confirmation that in discussing these errors, the CT scan imaging was examined and compared with earlier CT scans
     

By:  22 April 2019

Feedback

Points to note:

Adviser 2 explained that it would have been best practice for the reporting radiologist to make a direct referral to the MDT in 2014.  However, they might not have been aware of the local process to do so because they were working remotely for a private company.  The Board might wish to make private companies aware of the local process for radiologists to make direct MDT referrals.

Adviser 1 noted that Mr A waited four weeks to be told about his kidney cancer, after his diagnosis was confirmed by the January 2014 CT scan and his treatment was discussed by the MDT.  The Board might wish to consider if it is possible to streamline this process so patients are offered earlier urology appointments in similar circumstances.

Adviser 1 considered that the Board could have written to Mr A about the histology findings at the same time as they wrote to his GP.  The Board might wish to consider copying patients into these types of GP letters in future.

Adviser 2 commented that the use of standardised CT protocols would make it easier to compare any follow-up CT scans with previous CT scans.  The Board might wish to carry out a review of CT protocols to ensure that optimum diagnostic quality imaging is obtained across the whole range of clinical scenarios or possible pathologies.

Updated: March 20, 2019