Mrs A complained about her brother, Mr B’s, care and management by the Health Board. We investigated her concerns about whether Mr B’s clinical management between January and June 2023 was appropriate. We also investigated whether the cancer diagnosis Mr B received in May 2024 could have been identified sooner. Finally, we investigated Mrs A’s concern that the Health Board’s complaint response was compromised by factual inaccuracies.
The investigation found that, while Mr B was seen within an appropriate timescale following a dental referral in January 2023, the decision to remove him from the cancer pathway at his appointment in February 2023 was not appropriate. This led to a delay in carrying out a biopsy, reaching a diagnosis and commencing treatment for Mr B’s diagnosed cancer. This was a service failure. Even taking into account the delay in confirming Mr B’s oral cancer diagnosis, Mr B’s management and treatment would have been the same, even if the diagnosis had been reached sooner. This complaint was not upheld.
The investigation found, in relation to the concern about whether Mr B’s cancer diagnosis in May 2024 could have been identified sooner, that the Health Board’s management of a non-specific lung nodule during a staging CT scan in May 2023 was appropriate and its management of Mr B at a maxillofacial appointment in February 2024 was appropriate, following a GP referral reporting a new lesion on the tip of Mr B’s tongue.
The investigation found that while there were elements of the clinical management at a rheumatology appointment in April 2024, to investigate a cause for Mr B’s back pain, that were appropriate, there were a number of red flag indicators that, taken together should have prompted further assessment of Mr B’s symptoms. This was a service failure. Even taking this into account, an earlier identification of Mr B’s lung lesion and metastatic disease would not have altered the trajectory of Mr B’s cancer, management of if, or led to further or different treatment. This complaint was not upheld.
A number of factual inaccuracies were identified in the Health Board’s complaint response which were significant, and which included information about another patient’s management. This amounted to maladministration. This caused an injustice to Mrs A who lost trust in the Health Board’s investigation and complaint response and suffered additional distress due to a catalogue of errors which justifiably made her feel that her brother’s life was not important. This complaint was upheld.
The Health Board agreed to apologise to Mrs A for the complaint handling failures and acknowledge the distress this caused. It also agreed to review the current complaint process to check it is sufficiently robust to ensure details relating to unrelated complaints cannot be uploaded or saved and to review the quality assurance process for complaint responses around factual accuracy.