Source · PSOW (Public Services Ombudsman for Wales)

Aneurin Bevan University Health Board

PSOW (Public Services Ombudsman for Wales) Upheld Reference PSOW-202005324 Sector Health Category Clinical treatment in hospital Decided 08 February 2022

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On 25 April 2019 Mr X’s GP referred him on an urgent suspected cancer (USC) basis for an enlarging lump on his buttocks. On 6 June the GP wrote that Mr X still awaited an appointment despite a USC referral. The same day, Mr X saw the Consultant Colorectal Surgeon and was referred for an MRI scan that subsequently reported a suspicious ill-defined mass within tissues of the left buttock. On 16 July a biopsy diagnosed sarcoma, which was later confirmed. Mr X was referred to another hospital and on 26 September underwent surgery. Sadly Mr X died on 2 February 2020 from metastatic cancer. Mrs X complained about whether the treatment Mr X received at Nevill Hall Hospital was timely and reasonable.

The Ombudsman found that Mr X’s USC referral was not prioritised for 17 days; the interpretation and assessment of the GP’s referral was not as expected of an enlarging lump on the USC pathway; Mr X should have been routed to the correct speciality; on 6 June Mr X could have been referred to the appropriate service when booking the MRI scan but was not; a delay in arranging a biopsy before 16 July when it could have been taken in the clinic or concurrently with the MRI scan on 20 June, and that there was a serious breach of the 62-day cancer standards referral to treatment (RTT). He found that the delay did not have a significant effect on Mr X’s treatment or prognosis. The Ombudsman upheld the complaint.

The Health Board agreed to implement the Ombudsman’s recommendations within 1 month and apologise to Mrs X for the identified failings. The Health Board agreed within 3 months to review the USC pathways to ensure improvements are made to minimise avoidable delays, and to report its findings and steps taken to improve the 62-day USC RTT standards to the Ombudsman.

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