NHS Highland is reviewing its duty of candour policies after a lung cancer patient was misdiagnosed – delaying their treatment for three months.
The Scottish Public Services Ombudsman (SPSO) said NHS Highland was at fault after the patient complained about the way in which they were treated.
The SPSO has now ordered the health board to make sure it has met its obligations in being honest and transparent with patients, otherwise known as “duty of candour”.
The complaint about NHS Highland was made by an advocate, referred to in a report published today as “C”, and the patient as “A”.
The report stated: “A had attended the board for a chest x-ray following respiratory symptoms but the x-ray was reported as normal.
“A had a second chest x-ray a few months later which led to them being diagnosed with lung cancer.
“On review of the first chest x-ray it was found that this had been abnormal and was reported incorrectly.”
NHS Highland lung cancer patient
C complained to NHS Highland. The health board recognised that a mistake had been made through the reporting radiologist.
The report read: “The board advised that the chest x-ray had been outsourced to an external provider for reporting, and they had fed back this incident to the provider and radiologist, which had been investigated accordingly.”
The board apologised to A. At the same time it confirmed the misdiagnosis met the criteria for duty of candour.
This is a legal requirement on all health and social care providers in Scotland which seeks to ensure there is openness and transparency with the aggrieved party when something has gone wrong, and which seeks to learn from the incident.
An internal review at NHS Highland found it was “human error”, and that it was not considered to be indicative of a wider problem within the organisation.
Earlier this year, The P&J revealed seven people had died following mistakes by hospital staff in the Highlands and islands in 2021/22. The figures emerged as a result of the duty of candour legislation.
The SPSO report continued: “We took independent advice from a lung cancer physician.
Duty of candour
“We confirmed that A’s diagnosis of lung cancer had been delayed by around three months due to the first chest x-ray being incorrectly reported.
“We found that it was reasonable for A to have expected the abnormality in their chest x-ray to be identified.”
SPSO upheld C’s complaint – but made no further recommendations.
C also complained about the board’s handling of their complaint.
The SPSO report stated: ” It was our view that the board had not reasonably fulfilled their obligations in keeping with the duty of candour guidance. Therefore, we upheld this part of C’s complaint.”
An NHS Highland spokeswoman said: “We are reviewing our duty of candour arrangements and will be updating the SPSO by end of June.”
Conversation