Mid Scotland and Fife

Overview

The complainants (Mr and Mrs C) raised concerns about the actions of Perth and Kinross Council (the Council) following it being identified that the land on which their home is situated might be contaminated.

Specific complaints and conclusions

The complaints which have been investigated are that the Council:

• (a) failed to respond in a timely manner to correspondence from Mr and Mrs C and their solicitors and to include them in relevant meetings (partially upheld); and
• (b) failed efficiently to handle arrangements for Mr and Mrs C's temporary decant to enable demolition of their home, remediation of the land, and a replacement house to be constructed (partially upheld to the extent that the Council could have acted earlier to confirm decant arrangements).

Redress and recommendations

The Ombudsman recommended that the Council review the circumstances of this complaint to ascertain whether guidelines should be produced for dealing with future similar circumstances.

The Council have accepted the recommendation and have started a process of review.

Summary
Mrs C was scheduled to have a colonoscopy procedure (examination of the bowel with a camera on a flexible tube) at Hairmyres Hospital.  It had been planned that Mrs C would be under general anaesthetic.  This was because a previous colonoscopy procedure using conscious sedation (to relax and provide pain relief) had been a painful experience for her.  However, the operating theatre was unexpectedly unavailable so the procedure was carried out in the endoscopy unit using conscious sedation.  Mrs C said that she experienced excessive pain and discomfort during the procedure, and continued to experience pain for more than a month afterwards.  Mrs C said that she asked many times for the procedure to be stopped and nursing staff also asked for the procedure to be stopped.  However, the doctors (a senior staff grade surgeon and a consultant colorectal surgeon) continued nonetheless.  Mrs C said she had been left severely traumatised by what occurred.

As part of my investigation, I obtained independent advice from an adviser who is a consultant colorectal surgeon.  Regarding Mrs C's complaint that the colonoscopy procedure went ahead without the general anaesthetic, the adviser said that, as Mrs C had prepared for the procedure and waited a long time that day, it was reasonable for it to be attempted using conscious sedation.  However, it should have been clearly understood that if Mrs C experienced excessive discomfort, the procedure should be stopped immediately and rescheduled to be carried out using a general anaesthetic.  The adviser considered that the consultant had not complied with General Medical Council guidelines on obtaining informed consent and had communicated with Mrs C poorly.  They also found it concerning that these communication failings had not been acknowledged by the consultant or the board.

Mrs C complained that the procedure was carried out without a reasonable level of sedation.  The adviser said that the sedation Mrs C received was not enough to provide her with an appropriate level of comfort.  As it would have been unsafe to increase the sedation given to Mrs C, the procedure should have been stopped.

Mrs C also complained that the procedure was unreasonably continued despite her requests for it to stop.  The adviser said that, in the initial absence of the consultant, it was reasonable for the surgeon to begin the procedure.  However, the adviser considered the consultant made a serious error in not giving the surgeon a clear explanation of Mrs C's previous poor experience of colonoscopy and clear instructions to stop if the procedure was too painful or distressing for her.  There was evidence in Mrs C's medical records that she and nursing staff asked the surgeon to stop and, in the adviser's view, on arriving to find both patient and nursing staff requesting that the procedure should be stopped, it was unreasonable for the consultant to have taken over and continued.  The adviser considered that the evidence clearly demonstrated the withdrawal of Mrs C's consent for the procedure.

I upheld all the complaints.  My investigation identified a number of serious failings including poor communication, poor record-keeping, poor understanding of the consent process, and a failure to stop the procedure when asked by Mrs C.  I was also concerned that the board and the consultant did not appear to have understood, acknowledged or sufficiently appreciated the seriousness of the failings.  Nor had they identified all the learning required or taken sufficient remedial action.  I also noted the similarity of the circumstances of another recent complaint (case 201402959) and have taken the recommendations made in that complaint into account in making recommendations in this case.

Redress and recommendations
The Ombudsman recommends that the board:

• and the consultant apologise to Mrs C for the failings identified in this complaint in relation to poor communication and in obtaining informed consent;
• share with the consultant the comments of the adviser in relation to obtaining informed consent from a patient;
• arrange for the consultant, if they have not already done so, to undergo training and a suitable continuing professional development course to improve their communication skills and understanding of the consent process and to provide evidence of this;
• apologise to Mrs C for the failing identified in this complaint in relation to carrying out the procedure without a reasonable level of sedation;
• and the consultant apologise to Mrs C for the failings identified in this complaint in relation to poor communication, a failure to stop the procedure when asked by Mrs C, a poor understanding of the consent process, and poor record-keeping;
• arrange for the consultant and the surgeon to undertake training, if they have not already done so, to improve their communication skills and an understanding of the consent process, particularly where a patient withdraws their consent;
• bring to the attention of the consultant the comments of the adviser to give consideration to submitting a report about what occurred in Mrs C's case to a local morbidity and mortality meeting;
• review the Global Rating Scale (GRS) data from all of their endoscopy units and reflect on the comments of the adviser in relation to achieving good GRS scores;
• provide evidence that all their endoscopy units have standardised documentation for recording of patient discomfort during colonoscopy, in line with recommended practice;
• provide evidence that all their endoscopy units have standardised guidelines for procedural sedation and for withdrawal of consent;
• consider, if they have not already done so, developing  guidelines for all their endoscopy units in respect of recommendations (ix) and (x); and submit a synopsis of this case together with current standardised documentation and guidelines to their Endoscopy Governance Group in order to provide dissemination of learning and to minimise variability of colonoscopy practice within their hospitals; and
• provide evidence of the action they say has been taken.

Summary
Mr C had surgery for bowel cancer and then started chemotherapy to reduce the risk of his cancer recurring.  He suffered significant gastrointestinal side effects from the chemotherapy, including abdominal cramps and diarrhoea.  He went to the emergency department at Victoria Hospital but his oncology consultants (cancer specialists) were not told about his visit.  A week later, Mr C started to have regular sickness and diarrhoea and he visited his GP twice for treatment.  Three days before his second cycle of chemotherapy, Mr C was reviewed by an associate specialist oncologist, who assessed Mr C's diarrhoea as grade 0 (on a scale of zero to five, where grade 5 is the most severe).  The oncologist pre-authorised the administration of the drugs at a reduced dosage and made a note that Mr C's side effects should be observed closely.  Mr C continued to experience diarrhoea and he reported this to the nurses at the chemotherapy unit when he went to receive the second cycle of chemotherapy.  His condition deteriorated over the next few days and NHS 24 referred him to Victoria Hospital, where a scan showed evidence of severe chemotherapy-related inflammation, and possible perforation, of the colon.  Mr C's chemotherapy was stopped and he had an operation on his colon, spending five weeks in hospital.

Mr C complained that his symptoms of chemotherapy toxicity were not recognised within a reasonable time and that he should not have been given another cycle of chemotherapy treatment.

I took independent advice from an adviser who specialises in oncology.  The adviser said that the symptoms Mr C described amounted to grade 2 or 3 diarrhoea.  The board's guidance stated that further treatment should not have been prescribed until the diarrhoea had settled to grade 1 or lower.  The adviser found that the toxicity assessment by the associate specialist oncologist was inadequate and that further chemotherapy should not have been prescribed.  He also said that when Mr C reported his on-going diarrhoea to nursing staff, they should have asked for medical advice before administering chemotherapy.  The adviser said that Mr C should have been able to easily get advice about his problems, for example, from a 24-hour cancer treatment telephone helpline.  He commented that the lack of access to a single point of advice about chemotherapy-related problems resulted in poor communication of these problems to the oncology team treating Mr C.

The advice I have received is that Mr C had considerable difficulty accessing medical advice when he developed problems.  I found that there were failings at almost every contact Mr C had with health care professionals in relation to the second cycle of chemotherapy and that the system in place to ensure he was treated safely was inadequate.  I found that better arrangements were needed to ensure that patients were properly assessed on the day of treatment at the chemotherapy unit, and that the nursing staff must raise any concerns with medical staff.  In view of the failings identified, I upheld the complaint and made recommendations.

Redress and recommendations
The Ombudsman recommends that the Board:

• bring the failures to the attention of relevant staff and ensure they are addressed as part of their annual appraisal;
• review the governance arrangements of this unit in light of my findings; and
• apologise to Mr C for the failures my investigation identified.

Summary
Mrs A had a complex medical history, including heart problems and a low blood count.  She fell ill, complaining of central chest pain, and an ambulance was called.  The paramedics recommended that, due to the possibility of a heart attack, she was taken to Hairmyres Hospital because of the cardiac unit there.  Mrs A was reviewed by a junior doctor in the emergency department, who diagnosed stable angina secondary to anaemia (chest pain due to the blood not carrying enough oxygen).  Instead of the cardiac unit, she was transferred to Ward 2, the hospital's medical assessment unit.  Within 48 hours she was transferred again to Ward 11, then moved to the high dependency unit and, finally, to a side room for palliative care (care provided solely to prevent or relieve suffering) where she died a few days later.

Mrs A's daughter (Mrs C) complained about the care and treatment Mrs A received when she was admitted to the emergency department at Hairmyres Hospital.  In particular, she was concerned that staff did not check Mrs A's medical records to see what her anticoagulation level (INR - a measure of how long it takes blood to clot) should be, and that she was given a high dose of aspirin and other blood-thinning drugs, which seemed to cause major internal bleeding.  She complained that Mrs A was not admitted to a cardiac ward and that she was moved from Ward 2 to Ward 11 when she was very ill.  She also complained about a lack of communication and the junior doctor's failure to listen to Mrs A.

I obtained independent advice from a consultant physician.  My adviser said that the doctors missed opportunities early in Mrs A's admission to identify the severity and complexity of her conditions, and to reduce the risk and extent of her internal bleeding.  He considered that they failed to carry out the appropriate tests and was critical that, given her symptoms and abnormal blood tests, an early referral to cardiology was not made.  My adviser said that Mrs A was incorrectly given her warfarin (a drug used to prevent blood clots) when it should have been withheld.  As a result, her INR was raised to a high and dangerous level.

The advice I have received is that the staff caring for Mrs A should have considered the potential seriousness of her illness in more detail, and that they failed to properly monitor her condition.  I am concerned that advice from a cardiologist was not sought when Mrs A was admitted to the emergency department.  It was also not sought at a time when, according to my adviser, signs were very suggestive that she had had a heart attack.  I found that better care would have been provided to Mrs A if she had been transferred to the cardiac unit, as she would have received higher levels of monitoring and specialist care at an earlier stage.  I am concerned Mrs A's condition was worsened by the care she received, particularly by continuing to administer warfarin when it should have been stopped.  I am also concerned that Mrs A's medical history was not documented in enough detail and that the target INR level in her records was incorrect, despite it previously having been set at a lower level by board staff due to Mrs A’s condition.

My investigation found that, given the severity of her illness, Mrs A's outcome may not have been different.  However, better care of Mrs A might have increased her chances of survival.  It might also have given her family the reassurance that this outcome was despite good medical care, rather than her chances of survival being reduced by poor medical care.  In view of the failings identified, I upheld the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise to Mrs C for the failings identified in this complaint;
• present this case at a departmental Mortality and Morbidity meeting and report back to the Ombudsman on any learning or improvements that are identified;
• ensure that medical staff involved in this case include this case as a significant event analysis in their annual appraisal; and
• make further attempts to contact doctor 1 and ask doctor 1 to include this case in the educational supervision process of their current post.

Summary
Mr C complained to the Ombudsman about the standard of care provided to his son (Mr A) in the community and in Stratheden Hospital, where he was taken by his parents in a moment of crisis.  Mr A had been diagnosed several years previously with paranoid schizophrenia, and he had a history of self-harming and attempting suicide.  Mr A was admitted to hospital, but absconded within hours and was found dead on a nearby railway line.  Mr C believed that Mr A's suicide risk was not properly assessed on admission, and that actions were not taken that could have ensured his safety.

I obtained independent advice from a mental health nursing adviser and a consultant psychiatrist adviser.  Both advisers noted the risk assessment in Mr A's medical records that was done when he was admitted to hospital.  They said that the form was unsigned and that important sections were either left blank or completed without much detail.  The form did, however, record Mr A's history of self-harm, suicide attempts and absconding behaviour.  Both advisers said that the assessment should have been collaborative, including Mr A, his parents and all involved staff.  It also should have assessed and discussed the many known factors that increased Mr A's risk of serious self-harm or suicide.  As this was not the case, my advisers considered that this risk assessment was inadequate, and I agreed.

Further to this, on the day after admission, a doctor began the process to detain Mr A under a Short Term Detention Certificate.  My adviser on mental health noted that this showed the doctor must have considered Mr A to be a significant risk to himself, yet did not ensure that Mr A was under constant observation from that time.  Both advisers considered this to be unreasonable.  They said that Mr A's detention was not recorded in his notes so it was not clear if nursing staff knew about the decision to detain him.  My adviser on mental health was also concerned that Mr A was able to leave the ward and hospital without staff realising, which was unreasonable.

Given the advice received, I considered that the care and treatment provided to Mr A in the hospital was below a reasonable standard.  I upheld the complaint and made several recommendations.

Mr C also complained about the medical care and treatment provided to Mr A in the community.  The advice I received is that Mr A's care package was appropriately planned and delivered, and his needs were met.  However, the needs of his parents, who played an essential role in supporting him, were not examined.  Mr C and his wife would have been entitled to a carer's assessment, which would have explored how much choice they had in their provision of care, and the impact on them, including their health, domestic needs and relationships.  I considered this to be unreasonable.  I therefore upheld the complaint and made recommendations.

Redress and recommendations
The Ombudsman recommends that Fife NHS Board:

• review their admission procedures to ensure there is multi-disciplinary involvement in the risk assessment of emergency admissions;
• remind all staff of the importance of accurate contemporaneous record-keeping;
• contact Doctor 1's current employer and ask them to ensure that this report is considered and reflected on in his next appraisal;
• review the risk assessment tools used by staff to ensure they include an adequate review of historical risk factors;
• review the procedures followed during nursing handover to ensure that patients are adequately monitored during this period;
• review the procedure followed for Short Term Detention Certificates, to ensure both multi-disciplinary  involvement, including carers and named persons;
• review their procedures for community care provision to ensure the needs of carers are pro-actively considered; and
• apologise unreservedly to Mr C and his family.

Summary
Miss C, who had a previous history of mental illness, had a psychotic episode and was taken by ambulance in the early hours of the morning to the emergency department at Wishaw General Hospital.  An initial mental health assessment was carried out identifying that she was seriously unwell and should be assessed by a doctor as soon as possible.  However, she was not assessed for over three hours.  A junior doctor examined her, took blood tests and contacted the on-call psychiatrist for advice.  The psychiatrist said that out-patient follow-up may be the best option and that they would review Miss C after her blood tests were done.  A couple of hours later, Miss C's parents were told that she was being admitted to the hospital for assessment.  However, Miss C was agitated, received sedation and was restrained by the police.  Later that morning her parents were told that she had been detained under mental health legislation.  She was transferred to Monklands Hospital as there were no beds available.

Miss C’s mother (Mrs C) complained that if Miss C had initially been properly assessed by a psychiatrist and admitted to Wishaw General Hospital, then the police would not have become involved and she would not have been detained.

As part of my investigation of Mrs C's complaint, I obtained independent advice from advisers in emergency medicine and psychiatry.  My adviser in emergency medicine considered that the triage nurse in the emergency department had appropriately assessed Miss C.  He said that the delay in assessment by a doctor was not ideal but, unfortunately, was not unusual in a busy emergency department at night.  My adviser found that the junior doctor's assessment was thorough and of a good standard, but that the junior doctor failed to recognise the severity of Miss C's illness.  Due to a lack of detail in Miss C’s records, my emergency medicine adviser could not state definitively that she required hospital admission but, in his opinion, it was highly likely that she did.  He said that the junior doctor should have questioned the advice of the on-call psychiatrist and insisted on an urgent psychiatric assessment in the emergency department, escalating this to a consultant if the request was refused.  He also said that when Miss C's condition deteriorated and three doses of sedatives were required, she should have been thoroughly re-assessed.

My psychiatric adviser considered that Miss C's psychiatric assessment was unduly delayed and that her condition was allowed to deteriorate during this delay.  He said that it had been unreasonable for the on-call psychiatrist to say that out-patient follow-up may be the best option for Miss C, and he also considered that the standard of note-keeping was inadequate.  In view of all of these failings, I upheld this aspect of Mrs C's complaint and made recommendations.

Mrs C also complained that the board's handling of her complaint was inadequate.  Having carefully considered their initial response to her complaint, I do not consider that it was an adequate response to the issues she had raised about Miss C's treatment, as they failed to show how these had been investigated.  After this, Mrs C met staff from the board, then wrote to them.  The board's response again did not acknowledge their failings or address all of Mrs C's concerns about Miss C's treatment in the emergency department.  Therefore, I also upheld this aspect of the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• issue a written apology to Mrs C for the failure to provide reasonable care and treatment to Miss C in hospital on 18 September 2013;
• remind medical and nursing staff in the Emergency Department that acute mental health patients are high-risk patients;
• take steps to try to put a low threshold in place for the involvement of senior medical staff in decision-making regarding the discharge of such patients;
• take steps to ensure that the assessment and management of acute mental health presentations is discussed during the induction programme for new junior doctors in the Hospital's Emergency Department;
• take steps to ensure that it is emphasised in the induction programme of junior on-call psychiatrists that it should normally be the case that acute mental health patients attending the Emergency Department following an emergency should have a thorough psychiatric assessment;
• remind relevant psychiatric staff that patients being considered for discharge directly from the Emergency Department should have their follow-up and circumstances taken into consideration;
• consider if there should be a change to the process to allow the member of staff carrying out the triage to consider direct referral for psychiatric assessment in high-risk cases;
• emphasise to relevant staff involved in the complaint the importance of keeping accurate records that would be fully adequate for the purposes of later scrutiny;
• consider if there should be a protocol for emergency tranquilisation in the Emergency Department;
• issue a written apology to Mrs C for the failure to satisfactorily respond to her complaint; and
• make the staff involved in the handling of Mrs C's complaint aware of our decision on this matter.

Summary
Mrs C had previously suffered from mouth cancer and was treated at Monklands Hospital.  After finding an ulcer in her cheek, she contacted the consultant previously in charge of her care, and was seen at Monklands Hospital again, where the ulcer was found to be cancerous.  Mrs C's case was discussed at the multi-disciplinary team (MDT) meeting, who decided to refer Mrs C to the Southern General Hospital for treatment.

However, this was not done until a week later.  The referral was by email from the consultant to his colleagues with details of Mrs C's (and other patients') cases, rather than a formal referral by letter.  It is not clear whether the email was received.  Around this time the head and neck / maxillofacial (the diagnosis and treatment  of diseases affecting the mouth, jaws, face and neck) consultants at the Southern General Hospital decided that, due to lack of capacity, they would no longer accept referrals of patients they considered could be treated locally (such as Mrs C).  It is unclear whether the management team instructed the consultants to do this, or whether the Southern General Hospital was required to accept Mrs C's referral under the existing funding arrangements.  Mrs C was not told that there was a problem with her referral.

Mrs C grew increasingly concerned about the delay, and phoned the consultant at Monklands Hospital several times over the next few weeks to follow this up.  Finally, about a month after the MDT, Mrs C emailed the consultant, outlining her strong concerns, and the consultant phoned the Southern General Hospital and arranged an urgent appointment for Mrs C.  Mrs C said that her treatment from Southern General Hospital staff was excellent from that point on.

Mrs C complained about the delay in the scan and the MDT meeting, as well as the delay in referring her to the Southern General Hospital.  Mrs C was concerned that the delay may have worsened her outcome, as she was initially told that surgery would be performed with the aim of providing a cure.  However, the surgery that she subsequently received significantly reduced her quality of life and gave her a low chance of surviving her cancer.  Mrs C also complained about the lack of communication from Monklands Hospital staff about what was happening.

My investigation found that the delay in arranging Mrs C's surgery was unreasonable, and outwith the national HEAT (Hospital Efficiency and Access Targets) standards.  I found it was unreasonable for the Monklands Hospital consultant to wait one week before referring Mrs C, and also that the email sent by the consultant was not an adequate referral.  I also found that there was a breakdown in the referral process between Monklands Hospital and the Southern General Hospital, which meant that no plans were made for Mrs C's surgery at either hospital until she followed this up repeatedly.  I am concerned that an important decision (not to accept certain referrals) could be made and implemented at NHS Greater Glasgow and Clyde without clear, recorded management approval.  I am also strongly critical of the poor communication between the consultants at both health boards, as they apparently discussed Mrs C's case without clearly agreeing who would be responsible for her treatment (both hospitals appeared to think the other would be responsible).  It was only through Mrs C's courage and perseverance in following up her own appointment that this matter was resolved.

I also found that Monklands Hospital staff failed to communicate reasonably with Mrs C about her treatment.  Staff did not return her calls on at least one occasion and, although the consultant phoned the Southern General Hospital to follow up the referral and offered to perform the surgery himself, no-one contacted Mrs C to explain what was being done or to check that the appointment had come through.

In reporting on this complaint, I outlined significant concerns about the way in which both boards provided information during my investigation.  NHS Lanarkshire failed to provide a key piece of evidence relating to this complaint until after my investigation was concluded.  NHS Greater Glasgow and Clyde also provided new evidence at a late stage, which directly contradicted information they had previously given during the investigation.  This caused unnecessary difficulties and delays in completing the investigation, and undoubtedly added to Mrs C's distress.  I also raised concerns at the lack of appreciation both boards have shown of the impact these events have had on Mrs C, and of the value of her complaint.  This case involves a patient who was left without any plans for her cancer surgery for several weeks, as the boards were unable to effectively communicate about, and resolve, an administrative disagreement over who was responsible for the surgery.  In this context, I am disappointed that the boards were not more proactive about acknowledging that Mrs C's experience was unacceptable, and acting to prevent a recurrence.

Redress and recommendations
The Ombudsman recommends that Lanarkshire NHS Board:

• issue a written apology to Mrs C for the failings I found; and
• bring my findings to the attention of Consultant 1, for reflection as part of his next annual appraisal.

The Ombudsman recommends that Greater Glasgow and Clyde NHS Board:

• issue a written apology to Mrs C for the failings I found;
• feedback my findings to all staff involved, for reflection and learning; and
• ensure there is a clear procedure for authorising and recording any decisions not to accept referrals, and that staff are aware of this.

The Ombudsman recommends that both boards:

• conduct a joint significant event analysis to investigate and address the cause(s) of the delay in Mrs C's referral, and share the results with my office and with Mrs C, if she wishes.

Summary
Mr C complained to us about the way the council handled a planning application for a development in the rear garden of a hotel next to his mother (Mrs A)'s property.  Mr C raised a number of concerns about the handling of the matter by the council's planning service including issues around neighbour notification; the description of the proposed development; the need for a design statement (required for some proposed developments within conservation areas, which Mr C said applied in this case); inaccuracies in the submitted plans; and considerations about environmental health, potential noise and light pollution, and potential daylight and sunlight restrictions caused by the proposed development.  He also complained that representations from the local preservation trust objecting to the proposal had been disregarded, and that the council made their decision before the statutory deadline given to the community council to respond to the planning application had passed.  In addition, Mr C complained that the structure that was built was different to that for which permission was given by the council.

We took independent planning advice on this complaint.  Although we found that in some cases, the council's actions had been reasonable or had been decisions that they were entitled to take in the course of their consideration of the development, there were a number of aspects to their handling of the matter that we were critical of.

We found that the council should have sought to change the applicant's description of the structure, as it did not accurately reflect the permission being sought and may have misled interested parties; they acted unreasonably in not requiring a design statement to be submitted with the application, which my planning adviser told me had major consequences for the assessment of the application; the council delayed in logging an objection received and the handling report stated that no representations had been received.  This was a serious omission which also was consequential to the way in which the application was subsequently handled. We found that the council failed to complete a daylight and sunlight assessment; the development was not properly assessed for its impact on the conservation area that applied to the location; and the decision was made prior to the end of the time allocated for statutory consultation with the community council.

In relation to Mr C's complaint that the final structure differed from what was applied for, my adviser told me that there is no specific requirement on the council in relation to how much an application can vary: this is for them to decide.  However, in this case, the council failed to appropriately log the objection made, which had a knock-on effect in relation to the council's decision to treat some of the variations as minor so, on balance, I upheld Mr C's complaint about this.

In view of all of these failings, based on the advice received from my adviser, I recommended that the council should consider taking enforcement action or discontinuance under section 71 of the Town and Country Planning (Scotland) Act 1997.  I also found that the council had failed to respond adequately when Mr C had raised his concerns with them.

Redress and recommendations
The Ombudsman recommends that the Council:

• (i)  review their procedures for ensuring that properly made representations on an application are registered without delay and then taken into account for the purposes of the assessment of the application;
• (ii)  consider whether a system to record on file all relevant details found on a site visit against a comprehensive, standard checklist should be introduced;
• (iii)  consider the options for enforcement and/or whether it would be appropriate to pursue a section 71 discontinuance or alteration order;
• (iv)  also take this matter into account when considering what action to take to remedy the failings we have identified in complaint (a) above.  This should include Mr C's comments about the roof panels;
• (v)  issue a written apology to Mr C for all of the failings identified in this report; and
• (vi)  make all of the officers involved in the handling of both the application and Mr C's complaint aware of our findings.

Summary
Mr A had an operation in May 2011 to remove half of his large bowel due to a malignant tumour.  In May 2012, Mr A had a follow-up appointment and his GP was contacted to say that blood tests had been taken, a scan was to be arranged, and that Mr A would be seen again in six months.  Mr A had his scan in July 2012.  No action was taken by the board as a result of the scan test, and Mr A did not have another appointment until September 2013.  It was at this appointment that he learned that the results from the July 2012 scan indicated that it was likely that cancer had spread to his liver and one of his lungs.  At this point a second scan was arranged, but there were further delays at this point in obtaining a scan.  Mr A's daughter (Mrs C) had to contact the board a number of times to get an appointment for her father.  She complained to the board but was not satisfied with their response, and so complained to my office.  Mr A began chemotherapy in late 2013, and died in August 2014.

As part of my investigation I took independent advice from a consultant physician and a consultant oncologist.

On Mrs C's first complaint about the delay in assessing her father's test results, I found that a combination of errors and inadequate systems resulted in a failure to assess and refer Mr A for treatment of his cancer.  My physician adviser noted that the board had not more thoroughly investigated the handling of the test and scan results in their response to Mrs C. Given that neither set of results had been handled correctly, the adviser was concerned that this reflected a more general failure of results gathering / scrutiny by the board.  Whilst some changes to test result handling procedures have been made by the board since the time period under investigation in this case (as a result of a recommendation in a previous SPSO case 201305802), further action will be required to fully address the concerns outlined in my investigation.  My adviser was also concerned to note that the board's response to Mrs C's complaint did not reflect on their role in regard to the long period between follow-up appointments. I am therefore concerned that this situation could arise again.

The delays in arranging a second scan were also unacceptable.  Whilst the board accepted that Mrs C had to make an unreasonable number of calls to chase an appointment, they have not apologised for this.  My advisers both noted that, given the circumstances surrounding the initial delay in communicating the scan results to Mr A, it was not reasonable to leave Mr A and his family waiting again for the second scan.  The board had also not apologised to Mrs C for the second delay, and I am very critical of this.

Mrs C had noted that when her father saw the cancer specialist after the second scan, he was told that even if the July 2012 scan result had been picked up earlier, he would not have been offered further surgery and that starting chemotherapy at an earlier stage would have been unlikely to make any difference to his prognosis.  However, the advice I received from my oncology adviser was that Mr A received very poor care: even if there was no treatment to cure his cancer at that time, being told of the results more than a year prior to when he actually found out would have given him and his family more time to know that he was terminally ill and to plan accordingly.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  apologise to Mrs C for the delay in acting on the spread of cancer reported in July 2012;
• (ii)  ensure this case is raised with the Registrar and Consultant 1 for discussion at their annual appraisals;
• (iii)  review the process for the booking of out-patient clinic appointments;
• (iv)  take steps to ensure all laboratory staff are fully aware of the process for dealing with referrals without appropriate requesting clinician details;
• (v)  ensure radiology staff have a robust system in place for notifying referring clinicians of urgent and unexpected results;
• (vi)  consider the introduction of a safeguard whereby the radiology department copy unexpected results of malignancy direct to the relevant multi-disciplinary team; 
• (vii)  report on the outcome of the ongoing Board level review of the tracking of test results in both paper and electronic formats and the role of individuals who order tests and report their results;
• (viii)  apologise to Mrs C for the delays in arranging the follow-up scan; and
• (ix)  ensure that all administrative and medical staff involved in this complaint are aware of the findings of this investigation.

Overview

The complainant (Mr C) raised concerns in relation to delays in diagnosing his late wife (Mrs C) with lung cancer, and specifically that an x-ray taken over five months before her eventual diagnosis had not been properly read. Mr C complained that this mis-led clinicians into dismissing lung cancer as a diagnosis, despite other serious, persistent symptoms.

Specific complaints and conclusions

The complaints which have been investigated are that the Board:

(a) unreasonably failed to properly read an x-ray taken in January 2012
(upheld); and
(b) unreasonably delayed in diagnosing Mrs C’s illness (upheld).

Redress and recommendations

The Ombudsman recommends that Fife NHS Board:

(i) arrange an external review of their radiology practice and procedures, in consultation with The Royal College of Radiologists, and provide evidence of this review to the SPSO;
(ii) highlight to all clinical staff the need to review x-rays as well as x-ray reports, when diagnosing patients; and
(iii) apologise to Mr C for the failings identified in this report.

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