Summary
Ms C complained about the care she received from Grampian NHS Board (the board). As Ms C was experiencing post-menopausal bleeding, her GP urgently referred her to the gynaecology service of Aberdeen Royal Infirmary.
Ms C's referral was downgraded from urgent to routine by the gynaecology service. She was offered an appointment six weeks after her GP referral. Her GP contacted the gynaecology service on two occasions to request an earlier appointment but was told it was unnecessary for Ms C to be seen any sooner. When Ms C contacted the gynaecology service, they agreed to bring her appointment forward by a week. Given her concerns, Ms C was told that a consultant gynaecologist would look at her ultrasound scan report. Ms C received a phone call from a non-clinical staff member reassuring her that she did not need an urgent appointment.
When Ms C attended her appointment at the gynaecology service, an endometrial biopsy was carried out. When the results were issued, Ms C was diagnosed with endometrial cancer.
During our investigation, we took independent advice from a consultant gynaecologist and from a consultant obstetrician and gynaecologist. We found that Ms C's referral should not have been downgraded to routine and she should have been seen by the gynaecology service within two weeks of her GP referral. We found that the target for the treatment of Ms C's cancer was missed by 19 days. We found that Ms C should not have been given reassurance about the findings of her ultrasound scan report as they could have indicated cancer. We also found that this reassurance should not have been given to Ms C by a non-clinical staff member. We upheld Ms C's complaint.
Redress and Recommendations
The Ombudsman’s recommendations are set out below:
What we are asking The Board, to do for Ms C:
|
Complaint number |
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|---|
|
(a) and (b) |
There was an unreasonable delay in giving Ms C a gynaecology appointment and a delay in treatment after her diagnosis. Ms C was given inappropriate advice about her ultrasound scan results by a non-clinical member of staff |
Provide a written apology which complies with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance |
A copy of the apology letter. By: 2 October 2017 |
We are asking The Board to improve the way they do things:
|
Complaint number |
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|---|
|
(a) |
There was an unreasonable delay in the gynaecology service offering Ms C an appointment |
Patients with postmenopausal bleeding should be offered a gynaecology appointment in line with the NICE guidelines [NG 12] |
Documentary evidence of the steps to being taken to prevent similar failings in future cases, such as an action plan, instructions to staff, revised guidance By: 30 October 2017 |
|
(a) |
There was an unreasonable delay in treating Ms C's cancer |
In similar cases, patients should receive treatment within 62 days of referral as per the Scottish Government targets |
Documentary evidence of the steps being taken to reduce waiting times for treatment By: 30 October 2017 |
|
(a) |
The Board’s vetting guidance on endometrial cancer is incorrect |
The guidance should be updated urgently taking into account NICE guidance |
New or updated guidance, highlighted to show the changes and/ or additions By: 2 October 2017 |
|
(b) |
Ms C was given inappropriate advice about the ultrasound scan results |
Staff should reflect and learn from the adviser’s comments in relation to the ultrasound scan results |
Documentary evidence that this decision has been shared and discussed with staff. This could, for example, include minutes of discussions at a staff meeting or copies of internal memos/emails, or notes of feedback given about this complaint By: 30 October 2017 |
|
(b) |
Ms C was given clinical advice by a non-clinical member of staff |
The Board (including staff) should reflect and learn from the adviser's comments about the inappropriateness of non-clinical staff giving clinical information to patients |
Documentary evidence that this decision has been shared and discussed with staff. This could, for example, include minutes of discussions at a staff meeting or copies of internal memos/emails, or notes of feedback given about this complaint. By: 30 October 2017 |