Source · SPSO (Scottish Public Services Ombudsman)

Ayrshire and Arran NHS Board

SPSO (Scottish Public Services Ombudsman) Upheld Reference 201801992 Sector Health Category clinical treatment / diagnosis Decided 01 May 2019

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Full decision

Summary

Ms C complained about the care and treatment her husband (Mr A) received from the board at University Hospital Crosshouse. Ms C complained that there was a delay in diagnosing and treating Mr A's squamous cell carcinoma (a type of cancer of the skin's cells). Mr A had been under the care of the board, as he had a suspicious area of damage on his tongue. Mr A was later diagnosed with cancer in his tongue, which had spread to his neck. Mr A's cancer appeared to have been successfully treated with surgery and chemo-radiotherapy (where drugs and high-energy waves are used to treat cancer cells), however, Mr A's cancer was later found to have returned and spread further. Mr A died of widespread cancer later that year.

We took independent advice from a consultant ear, nose and throat (ENT) and head & neck surgeon. We found that there was an unreasonable delay in telling Mr A he might have cancer in his tongue and in carrying out surgery on Mr A's tongue, once the decision to treat it had been made. We also found that when Mr A later complained of pain in his shoulder, this should have been noted in his medical records and it was not. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case: Apologise to Ms C for the failings identified in Mr A's care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future: Patients suspected to have cancer should receive prompt treatment once the decision to treat has been made.

The board should ensure that there is appropriate recording of reported symptoms at clinic appointments.

Related reading

View Decision Report 201801992 as a PDF (26.02 KB) Updated: May 22, 2019

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