Cancer patient was ‘failed’ before death
Health chiefs issue apology to family for errors
Top brass at East Ayrshire health and social care partnership have apologised to the family of a cancer patient who died after ‘failings’ were made during the control of their treatment at a local medical practice.
The Scottish Public Services Ombudsman (SPSO) upheld a complaint brought against NHS Ayrshire & Arran by the spouse of the deceased patient.
Now bosses at the partnership have admitted they ‘did not meet’ the high standards they ‘strive for’ in relation to the tragedy, which saw blood test results ‘outwith the normal range’ go ‘unrecognised.’
Essentially, earlier action should have been implemented when the blood test results were known, then compared to the patient’s history – and symptoms.
The patient, known only as ‘A’ and their spouse, known only as ‘C’ have not been identified.
The location of the medical practice has not been disclosed but it lies within the Ayrshire and Arran NHS boundary.
In its report, the SPSO said: “C complained that the practice did not take reasonable action in response to their late spouse (A)’s symptoms and condition.
“’A had a long history of degenerative disc disease affecting their spine (when normal changes that take place in the discs of your spine cause pain) and a history of stomach cancer.
“A visited or contacted the practice several times over three months regarding pain in the neck and shoulder, numbness in the right hand and jerking of the right leg.
“Tests were undertaken, medication and therapies prescribed and a referral to an orthopaedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system) was made.
“Following a fall at home, A was admitted to hospital where a spread of cancer to A’s spine was diagnosed.”
The report goes on to say that the patient died, prompting a complaint from their spouse in relation to the medical practice’s response to A’s symptoms and condition over the previous months.
The report states: “In response, the practice recounted the actions they had taken in response to A’s visits and contacts in their final months, highlighted blood tests whose results did not indicate any significant abnormality, or spread of cancer and explained that A’s symptoms were relatable to their ongoing diagnosis of degenerative cervical disc and spinal stenosis (a condition where the space around the spinal cord narrows, compressing a section of nerve tissue).
“The practice advised that a significant case review had been carried out. This had highlighted that A’s orthopaedic referral could have been upgraded to urgent when it was clear A’s symptoms were not being controlled, but stated that it was doubtful this would have had any impact on the outcome. C was unhappy with this response
and brought their complaint to this office.”
During the SPSO’s investigation, they took independent advice from a GP.
An extract from the report says: “We found that the practice took reasonable action in response to A’s symptoms and condition – until a point.
“However, when it was clear that A’s symptoms were not being controlled and began to worsen, the practice’s actions were unreasonable.
“We found that the potential significance of test results reported to the practice and the potential link with A’s symptoms were not reasonably recognised by the practice until they reviewed A’s care and treatment as a result of our investigation of the case.
“Therefore, we upheld C’s
complaint.
“However, while we noted that earlier action by the practice may have led to an earlier admission to hospital, it was extremely unlikely to have prevented A’s death.”
The medical practice at the centre of the case has now been told to ‘review’ how it deals with blood samples that are ‘significantly outwith the normal range.’
Craig McArthur, East Ayrshire health and social care partnership director, said: “I am sorry that we did not meet the high standards of care we strive for in NHS Ayrshire & Arran for this patient, and offer my deepest condolences to their family.
“In addition to a formal apology to the spouse of A, I can advise that the GP
practice has fully accepted all the recommendations in the Scottish Public Services Ombudsman (SPSO) report.
“The GP practice has addressed the issues highlighted and made the appropriate changes in terms of ensuring that all blood results are efficiently communicated to patients, record-keeping and required follow up actions are completed to the required standards and reviewing home visiting polices which have been updated in line with required guidance.”
He added: “In order to ensure learning across the organisation, we will share the findings from the report with staff and assurance to our clinical governance teams that the necessary actions have been completed.”