Source · SPSO (Scottish Public Services Ombudsman)

Fife NHS Board

SPSO (Scottish Public Services Ombudsman) Upheld Reference 202000761 Sector Health Category Clinical treatment / diagnosis Decided 01 December 2022

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Full decision

Summary

C complained about a delay in diagnosing their late partner's (A) oesophageal cancer. The board had already acknowledged that A’s cancer could have been diagnosed sooner and apologised for failing to fully investigate their symptoms. However, C did not consider that the board had provided a satisfactory explanation as to why A’s cancer was not diagnosed at an earlier stage.

We took independent advice from an Ear, Nose and Throat (ENT) consultant. We found that initial examinations had identified a lesion in A’s throat, but that this was not found on a subsequent examination (a microlaryngoscopy - an examination of the throat with magnification). The board, therefore, did not arrange any further ENT follow-up. We noted C’s history and presenting symptoms and considered that there were multiple red flags for cancer. We found that further radiological investigations should have been ordered and that it was unreasonable for investigations to have stopped at that point. We upheld the complaint.

Recommendations

s] What we asked the organisation to do in this case: Apologise to C for failing to conduct further investigations. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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 202000761 as a PDF (25.5 KB) Updated: December 21, 2022

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