Source · SPSO (Scottish Public Services Ombudsman)

Grampian NHS Board

SPSO (Scottish Public Services Ombudsman) Not Upheld Reference 201907793 Sector Health Category Clinical treatment / diagnosis Decided 01 June 2021

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Full decision

Summary

C complained to us, on behalf of A, that the board failed to appropriately diagnose and treat A during their attendances at Aberdeen Royal Infirmary. A had chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed) and had also previously been diagnosed with probable left sided lung cancer several years earlier. At that time, it was agreed that A would receive high dose palliative radiotherapy (a treatment using high-energy radiation).

Over a period of eight months, A was admitted to hospital nine times. The first five of these admissions were to a respiratory ward and the last four to a general medical ward. They were treated for worsening of COPD and increasing frailty. A had a fall during one of the admissions, but was subsequently discharged home. C said that at that time, A was not fit for discharge as they required to be readmitted again a few days later when they were told that they had terminal cancer. A's condition subsequently deteriorated further and they died the following month.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly). Although the board had acknowledged that the clinical records did not show that A's underlying diagnosis of cancer was discussed with them in appointments in the final two years of their life, we found that there was no evidence that the board failed to properly diagnose and treat A during the relevant hospital admissions. We did not uphold this complaint.

C also complained that the board failed to communicate appropriately with A during this period, despite them having power of attorney for A. We found that A's care and treatment were discussed reasonably with both C and A and we therefore, did not uphold this complaint.

C complained that the board failed to handle A's complaint in line with their obligations. We were satisfied that the board dealt with A's complaint in accordance with their complaints handling policy and this complaint was not upheld.

Finally, C complained that the board unreasonably failed to certify correctly the cause of A's death. Whilst the initial death certificate was not incorrect, it was revised to give more clarity. Although we found that it would have been better for C to have been provided with a more detailed explanation for the required change in the first place, it is not unusual for death certificates to be revised in these circumstances. We did not uphold this complaint.

Related reading

View Decision Report 201907793 as a PDF (24.97 KB) Updated: June 23, 2021

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