Source · SPSO (Scottish Public Services Ombudsman)

A Medical Practice in the Grampian NHS Board area

SPSO (Scottish Public Services Ombudsman) Partly Upheld Reference 201602184 Sector Health Category clinical treatment / diagnosis Decided 01 August 2017

Full decision

Summary

Mr C complained about the care and treatment provided by the practice to his late wife (Mrs A). Mr C complained that the practice had missed red flag symptoms prior to her diagnosis of carcinoma of the epiglottis (cancer in the tissue that covers the windpipe). He also complained that the next year, the practice missed red flag symptoms for cancer of the floor of the mouth.

We took independent advice from a GP. We found that Mrs A had suffered from throat discomfort for around three months before the practice referred her to a specialist. National guidelines state that persistent throat discomfort for three weeks should have led to an urgent referral, particularly as Mrs A was a smoker. We therefore upheld this aspect of Mr C's complaint, although we found that as the carcinoma of the epiglottis was cured, the delay in referral did not result in any significant injustice.

We further found that when Mrs A first presented with oral symptoms, the practice acted in an appropriate and timely manner, therefore, we did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case: Apologise to Mr C for the failure to provide appropriate treatment to Mrs A. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future: GPs at the practice should be familiar with the Scottish cancer referral guidelines.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Related reading

View Decision Report 201602184 as a PDF (12.8 KB) Updated: March 13, 2018

View original on SPSO (Scottish Publ… website

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