Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Hywel Dda University Health Board
Mrs A complained about the care given to her by Hywel Dda University Health Board (“the Health Board”). She said that the Health Board failed to identify her pulmonary embolism (“PE” – a blocked blood vessel in the lung) promptly. She also said that it took too long to diagnose her womb cancer, that it misdiagnosed the stage and type of that cancer, that it took too long to refer her to a specialist cancer centre (“the Cancer Centre”) and that it failed to support her after her cancer-related surgery. Another healthcare provider, which was not a Health Board, performed that surgery.
The Ombudsman found that the diagnosis of Mrs A’s PEs was not unreasonably delayed. She did not uphold this aspect of Mrs A’s complaint. She found that the diagnosis of Mrs A’s womb cancer was delayed by a relatively short period and that that delay caused Mrs A distress and uncertainty. She upheld this element of Mrs A’s complaint to a limited extent. She recognised that the Health Board did not diagnose the stage and grade of Mrs A’s womb cancer correctly. However, she did not determine that those diagnostic inaccuracies arose because the Health Board failed to provide a reasonable standard of care for Mrs A. She did not uphold this part of Mrs A’s complaint. She found that the Health Board took too long to refer Mrs A to the Cancer Centre. She considered that that delay meant that the revision of Mrs A’s cancer diagnosis was delayed and that a different Health Board was unable to provide the surgery that Mrs A required sooner. She upheld this aspect of Mrs A’s complaint. She found no evidence that the Health Board assessed Mrs A’s needs or gave her support after her cancer-related surgery. She considered that those omissions caused Mrs A distress and potentially resulted in Mrs A’s need for support not being met. She upheld this element of Mrs A’s complaint.
The Ombudsman recommended that the Health Board should apologise to Mrs A for the failings identified. She asked it to pay Mrs A £1,000 and £500 for the referral delay and the postsurgical support failing respectively. She recommended that it should revise its “Cancer Key Worker Guideline” to ensure that patients who receive treatment from an alternative healthcare provider are, where appropriate, assessed and supported by their Key Worker following the completion of that treatment. She also asked the Health Board to take action to ensure that referrals to the Cancer Centre are made as soon as possible. The Health Board agreed to implement these recommendations.