Mrs C complained on behalf of her husband, Mr C, about the care and treatment he received from Swansea Bay University Health Board relating to delayed mouth cancer diagnosis and treatment, following an Urgent Suspected Cancer (“USC”) referral on 24 February 2023. The investigation considered whether there were inadequate investigations and diagnostic assessments following the first consultation on 7 March, leading to an incorrect diagnosis and inappropriate debridement treatment on 28 March. The investigation also considered whether there were delays with subsequent diagnostic assessments and obtaining results, which further delayed Mr C’s diagnosis of mouth cancer and caused delays in treatment via surgery.
The Ombudsman found that the clinical investigations and diagnostic assessments following Mr C’s first consultation on 7 March were appropriate and reasonable. The debridement treatment was found to be appropriate, and diagnostic assessments were requested and carried out within appropriate timeframes. These aspects of the complaint were not upheld. However, there was a delay in reporting the biopsy histology and a delay in the timeframe for surgery. Although the delays did not result in any impact on the overall prognosis or outcome for Mr C, the distress caused by the prolonged wait, and the fact that the surgical treatment was more extensive than it may otherwise have been, was an injustice to Mr C. The Ombudsman upheld this part of the complaint. The Ombudsman recommended that the Health Board apologise for the failings identified; review its guidance/procedure regarding timescales for reporting and returning biopsy pathology; share the report with clinicians in the Head and Neck specialism; and provide the Ombudsman with evidence of the improvements in current treatment times indicated by the Health Board.