NHS Grampian bosses have apologised to a patient whose life has been “shortened” by a delayed cancer diagnosis.
The person, known only as C, had been in touch with specialists at the health board after suspecting they had cancer.
They claimed a tumour in their lung had been “unreasonably missed” – having “catastrophic consequences” for their prognosis.
After being unsatisfied with how their formal complaint was handled, C contacted the Scottish Public Services Ombudsman (SPSO).
The watchdog has now ordered NHS Grampian to make changes to the way it operates.
When investigating C’s claims, the SPSO took advice from a consultant radiologist, a respiratory physician and an orthopaedic specialist who deals in diseases and injuries affecting the musculoskeletal system.
It determined that C’s treatment was “reasonable,” adding their situation had been regularly reviewed with changes to antibiotics in a bid to improve their outcome.
However, it said part of the diagnostic process had led to a “significant injustice” for the patient.
In a newly-published decision report, the watchdog said: “We found that there was a significant delay in the diagnosis of lung cancer resulting from an unreasonable failure of radiological interpretation which led to significant injustice to C.
“This failure would shorten C’s life.
“We also found an unreasonable failure to follow up test results or to carry out a further scan, although we concluded that in themselves this would not have changed the outcome for C.”
Changes ordered after ‘significant failings’
The watchdog also pointed to “significant failings” in how NHS Grampian examined the initial complaint.
While it did identify radiological errors, it “did not apologise for these or explain how they occurred and what action the health board was taking to ensure they did not happen again.”
The SPSO said there had not been any consideration of the impact the errors had on C’s prognosis and treatment.
It told the health board to apologise and change how it operates.
This includes auditing a selection of x-rays and scans to ensure there is no “systemic” issue which could affect other patients, and to ensure test results are followed up “appropriately”.
Bosses have been told to pass the watchdog’s feedback on to relevant staff, and review the complaint handling failures and issues regarding radiology.
A spokesman for NHS Grampian said: “We accept the findings of the SPSO and its recommendations.
“This case unfortunately represents an occasion where we did not meet the high standards we aspire to.
“We have already apologised to C but would take this opportunity to do so again publicly.”
Patient collapsed from malnutrition
The health board was also told to make changes in relation to a separate case in which someone was discharged from hospital without a necessary prescription.
Referred to in SPSO documents as A, they were prescribed thiamine – Vitamin B1 – for malnutrition and sent home a few days later.
Several weeks after, however, A collapsed and was readmitted to hospital with “confusion and reduced mobility”.
They were diagnosed with Wernicke’s encephalopathy, a life-threatening brain injury caused by a lack of thiamine.
The SPSO found NHS Grampian’s board had previously acknowledged A had not been given the prescription after the recommendation from its dietetic team.
Additionally, staff had implemented a new checklist to prevent reoccurrence.
But the watchdog said: “We were concerned that the board had not fully considered or accepted the potential impact of this failure.
“We considered that thiamine supplements may have at the very least lessened the severity of the Wernicke’s that subsequently developed.”
A spokesman for the health board apologised to A, and their sister who raised the complaint.