Dr C complained about the care and treatment that he received from the Health Board after he was diagnosed with myeloma (a type of blood cancer). The investigation considered whether: a) A stem cell transplant was appropriately considered, in view of national guidelines and the COVID-19 pandemic during a telephone consultation on 20 October 2020.
b) A light chain assay test (a blood test used in the diagnosis and monitoring of myeloma) should have been requested following a consultation on 3 February 2021, instead of later in June, the results of which suggested biochemical disease progression.
c) Dr C’s ongoing treatment and disease progression were appropriately managed.
The Ombudsman concluded that whilst the initial decision to defer Dr C’s stem cell transplant was reasonable due to the onset of the pandemic, treatment options and decisions should have been reviewed on a regular basis and discussed with Dr C, including during a consultation in October 2020. In addition, the Ombudsman found that Dr C should have been offered maintenance therapy after the decision to defer the transplant. The Ombudsman also noted that a request for a light chain assay had been missed from blood request forms in preparation for Dr C’s consultation in May 2021 and that there were other gaps in monitoring in early 2021. As a result, the Ombudsman upheld Dr C’s complaints.
The Health Board agreed to: • Provide Dr C with a meaningful apology for the failings identified.
• Share the report with the Consultant Haematologist for reflection, learning purposes and discussion at his next appraisal.
• Discuss the report at a Quality and Safety meeting, or in an alternative appropriate forum, and provide feedback on whether there are any wider actions or improvements that should be taken forward as a result of that discussion.
• Ensure that there is a formalised review process in place for the regular monitoring of myeloma patients, including assurances that all the required blood tests have been requested.
• Consider what steps should be put into place to satisfy itself that there is a continuity of care for patients at times when locum consultants are regularly used.