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Appointments/admissions/discharge and transfer procedures : Cardiff and Vale University Health Board

Report date

14/05/2021

Subject

Appointments/admissions/discharge and transfer procedures

Outcome

Upheld in whole or in part

Case ref number

201905157

Report type

Non-public interest report issued: complaint upheld

Relevant body

Cardiff and Vale University Health Board

Mrs M complained about the care provided to her son Mr D, who sadly died of cancer in April 2020. In relation to the Trust, she complained that:
• A consultant clinical oncologist had not communicated Mr D’s prognosis appropriately and had not offered to obtain a second opinion.
• There was a failure to manage Mr D’s care appropriately.

In relation to the Health Board Mrs M complained that:
• A multi-disciplinary team (“MDT”) meeting decided not to offer cancer surgery to Mr D and this decision was not reviewed.
• Mr D was not offered appropriate cancer surgery and had no option but to undergo surgery privately.
• The clinical management of Mr D’s care and handling of an Individual Patient Funding Request by a hepatobiliary and pancreatic surgeon was inadequate.

The investigation found that the Consultant Clinical Oncologist communicated Mr D’s prognosis reasonably and that it was not inappropriate that she did not seek a second opinion of the MDT meeting decision. The investigation found no evidence that the care provided by the Trust was inadequate. Accordingly, the Ombudsman did not uphold the complaints against the Trust.

In relation to the Health Board, the investigation found that the MDT decision should have been reviewed and that this failure caused Mr D to lose confidence in the local Surgical Team; this complaint was therefore, upheld. The investigation found that in response to a privately obtained second opinion, the Health Board offered appropriate liver surgery. Accordingly, this aspect of the complaint was not upheld. In relation to the third complaint, the investigation found that the Health Board should have sought the input of a stereotactic body radiotherapy specialist and that it was an injustice that Mr D did not get to consider this advice. This aspect of the complaint was therefore upheld.

In response to the Ombudsman’s investigation, the Health Board agreed to apologise to Mrs M and to pay her the cost of the private consultation to obtain a second opinion. It also agreed to make a financial redress payment of £500 to Mrs M to reflect that its failings deprived Mr D of the opportunity for a better-informed discussion of his treatment options. Finally it agreed to share the report with the Hepatobiliary and Pancreatic Surgeon and to develop a policy to define when MDT meeting decisions should be reviewed.

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