Decision Report 201306238

Summary

Mrs C experienced numerous troubling symptoms over a number of years including impaired vision and muscle wasting. She underwent a range of investigations with the board's neurology department to establish the cause of her symptoms. Mrs C then complained about the standard of her care and treatment. She felt that, although her symptoms were getting worse, staff did not take her case seriously, dismissed her as anxious and provided contradictory information. Mrs C told us that she decided to have an MRI scan (magnetic resonance imaging scan: a detailed scan of her brain) carried out privately, which identified a small focal lesion (an area of tumour or other tissue damage) on her brain. She complained that this had been missed in scans taken by the board some years previously.

We took independent medical advice from a consultant neurology adviser, and we found that the focal lesion had been present in the earlier scans, but was not easily identified. MRI scanning technology advanced in the intervening period and the lesion was more readily identifiable in the more modern scan. It was only with hindsight and knowledge of its location that radiology staff could identify it in the earlier scans. We did not find the board's actions to be unreasonable in this respect and were satisfied that a number of relevant and appropriate investigations were carried out to establish the cause of Mrs C's symptoms. Ultimately, we found that the treatment she received was in line with that which would have been provided had her lesion been identified from the outset.

That said, we were critical of the board's handling of Mrs C's complaint and their failure to provide an independent review of her MRI scans, as had been promised during their investigation of her complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for their inadequate communication about her complaint;
• contact Mrs C as a matter of urgency to discuss possible further actions to be taken to review her MRI scans outside of the board area, or provide us with evidence that this has been addressed; and
• review their handling of Mrs C's complaint to ensure that action points from meetings are properly recorded and followed-up and that the NHS complaints handling procedure is properly followed.