Decision Report 201402636

Summary

Mr A was referred by his GP to the ear, nose and throat clinic at Forth Valley Royal Hospital with a swelling below his left ear. This was found to be cancerous and Mr A was referred to another health board for surgery. This surgery resulted in extensive facial disfigurement and Mr A's daughter (Mrs C) complained that the board failed to explain the extent of Mr A's cancer and the impact the surgery would have on him. Mrs C also complained about delays following surgery in arranging onward referrals for Mr A to various specialists.

The board apologised that Mr A and his family were not adequately prepared for the life-changing results of the surgery, and they developed an improvement plan to address the concerns raised. They noted that their consultations with Mr A occurred at a very early stage in the process of preparing him for major surgery. They indicated that their role was to provide an overview and the intention was for a more detailed explanation to be provided by the board who were carrying out the surgery.

We took independent medical advice from a consultant maxillofacial surgeon (doctor specialising in the treatment of diseases affecting the mouth, jaws, face and neck). The adviser confirmed that the board carrying out the surgery were responsible for explaining the procedure and obtaining informed consent. He considered that the board had appropriately carried out their duties in this case. However, he noted that the communication between the two boards appeared to be lacking. He found no evidence of a formal referral to the other board having been made and he considered there was a lack of clarity regarding the respective role of each board. This also applied to the handover between the cancer nurse specialists at each board, which meant that relevant patient information literature was not given to Mr A. The absence of clear lines of responsibility also resulted in a delay in arranging relevant onward referrals following surgery. We accepted the advice we received and upheld the complaints, recommending that the board further develop their action plan in light of our findings.

Recommendations

We recommended that the board:

• develop their action plan further to take account of the failings this investigation has identified and the adviser's suggestions for areas of improvement.